Thursday, August 24, 2017

How we won the $12,000 insurance lottery

Max's double surgery is on Tuesday. He's chill. I'm anxious, even though I know he's in good hands. But this week brought financial relief when we got excellent news from the insurance company. (It's not often I get to use the words "excellent news" with "insurance company.")

One key lesson parenthood has taught me is that the squeaky wheel really does get oiled. My squeakiness has come into play when I've tried to score appointments with specialists who were booked months in advance, when I've attempted to get Max into programs, and when dealing with insurance companies. As any parent of a child with disabilities knows, sometimes the answer you receive from insurance reps depends on who you get on the line. This time, though, there was no room for error: we were juggling the costs of two surgeries, one to loosen up Max's foot, the other to reduce drool.

Press "1" if you tend to need a glass of wine after dealing with your insurance company.

The procedure for Max's foot is mostly not covered by insurance, as that doctor is out of network and there are in-network doctors who do it. That's the "cheaper" one of the surgeries. Last week, I was informed that based on a predetermination issued on June 21—the first we'd heard of it—just a small portion of the $12,000 drool reduction surgery would be covered by our insurance company. What?! That didn't make sense. The insurance company had already acknowledged that they couldn't locate another doctor in network who did the surgery. Why would we have to pay so much?

Press "2" if your insurance company makes you want to commit hara-kiri.

I emailed back and forth and back and forth with my so-called "customer service" contact, my final email asking upon what information the determination had been made. But then Dave stepped in, emailing them to note that there had been a mistake and affirming that since our doc is the only M.D. around doing this form of surgery, we shouldn't be responsible for paying for it.

Press "3" if on average you spend more time per week communicating with insurance reps than with your spouse.   

For 14 years now, I've been pushing and prodding insurance companies, which makes me a bona fide pro. Mostly, I've had to make the case for getting Max's speech, occupational and physical therapies covered. I write a pretty convincing letter, and I know what to tell doctors so that their supportive letters are persuasive, too. (In a nutshell: Make the situation sound as dire as possible, and invoke potential catastrophe.)

Dave got the you've-won-the-insurance-lottery call on Tuesday from the supervisor of operations, and patched me in. In fact, they will be covering the surgery. We already had to pay the entire amount last week, given that the surgeon requires payments two weeks in advance and doesn't deal with insurance companies, so we'll be reimbursed.

Yes, I'd like to know why the insurance company just figured this out a week before the surgery. Also: There's no reason we should feel like we've won anything when our family pays plenty for our insurance. We are entitled to all of the benefits. In the end, though, the big-bucks surgery is covered, and now I can settle down...and focus on freaking out about the anesthesia.

Press "4" if you'd rather have a kidney removed than deal with your insurance company ever again.

Press "5" to find out why the insurance company won't cover a kidney removal.

Also see:

9 hacks for getting insurance companies to pay for your child's therapies


  1. Oh insurance. I'm so glad they are covering it although it is crazy that it took them to the week before surgery to do so.

  2. Insurance is the worst. We had to pay $1600/mo for PT for our daughter after insurance for our "in network" provider, when there is a closer option to our house that is much cheaper ($100/visit), but our insurance wouldn't cover it because the closer place was out of network and the other place was in netowrk and within 35 miles from our house (but still an hour drive in atlanta traffic) so frustrating! We now pay out of pocket for the $100/mo since it's obviously still the better deal.

  3. Wow. I've never heard of a doctor requiring payment before surgery. One caution about insurance and out of network doctors. Years ago we used an out of network doctor for our son's scoliosis surgery. The doctor was willing to negotiate his fee, but we still did everything we could to get the insurance company to tell us what amount would be covered. In the end we paid nothing out of pocket. Then a year later, our insurance company said they processed the claim incorrectly and wanted us to pay them back $6,000....since it was an out of network doctor they hadn't paid him directly the first time...they paid us. The hospital filed an appeal for us and then the insurance company said, based on that information, they wanted $10,000 back. After my nervous breakdown, I appealed directly to my husband's union because they provide the insurance and have the last say. They sided with we didn't have to pay...But it was very unsettling to learn an insurance company can change their decision after such a long period of time. So, as always in the world of special needs, get everything in writing so you can fight any unexpected future fight.


Thanks for sharing!

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