Breast Reconstruction Out of Network Provider

Sue Koch · New User Joined: 13 Mar 2005 Posts: 5

Hello All,

Last April, I attempted to obtain permission to have a surgeon that performs Bilateral Breast Reconstruction using the S-Gap procedure. (taking tissue from the buttocks when there is not enough abdominal tissue) perform the Bilateral on me. There are only a few surgeons in the U.S. that perform the S-Gap procedure(one side done at a time requiring two operations) and even less that do the bilateral S-Gap where both are reconstructed at the same time.

The procedure is not considered experimental and my Insurance will approve having an in-network surgeon do the Unilateral S-Gap procedure which means two major surgeries, two anesthesia's, two hospital stays, two recuperations, etc. I cannot believe that an Insurance co. would not see the benefit of doing the Bilateral S-Gap. It is more cost efficient by the way.

The surgeon I would like to do the surgery pioneered the Procedure 10 years ago and has performed hundreds. The surgeon I went to "[in-network) at Johns Hopkins had only performed ten unilateral S-Gaps in the last seven years. My Insurance would approve this.

I appealed , even appearing in person and was still turned down as they said there were others in network I could see. No, they do not perform the Bilateral.

How can they justify me being a "guinea pig" by having the surgery performed by a Dr. who has only performed a few and also requires two surgeries, etc.? Has anyone encountered the same problem and successfully had the Insurance Co. cover the surgery? Also, this Dr. will work with the Insurance Co. as far as providing a compromise. He refuses to become an "in-network" provider because of Insurance Co.s preventing women from being able to have this procedure done. I do not want to have to visit the few Dr's on the list, up and down the East Coast. I live in VA. I teach school and don't have the time to drive all over creation, meeting with their doctors.

By the way, the Dr. at Johns Hopkins had a lousy bed-side manner. Did not want me asking questions, just leave everything to him. I took copious notes and presented the info. The review Booard understood why I did not want to have him do the procedure. However, because I haven't checked with other Dr's., no deal. Does anyone have any advice? I would be most appreciative of any help or suggestions.
Thanks so much.

Sue in VA

Richard Day Gore

It's a shame and I wish you well. Dealing with insurance companies is such a David and Goliath situation. They're businesses, and among the richest and most powerful in the country if not the world. And like any other business they are in it to make and save money and one of the main ways they do that is to stick it to the consumer.

Document everything from the the shortest phone call to the time, date and place of every conversation. It will at least make you feel like you're doing something for yourself. Any time you deal with a person, get their name right up front, and this goes for the person who answers the phone at the insurance company or hospital. People in general will at least be a bit friendlier and sometimes more accommodating when they know that you know who they are, and therefore they're accountable on some level.

In the meantime, complain to your congressman that you are sick of being enslaved by the healthcare/insurance system in this couintry, which has turned health itself from a right to an increasingly expensive and elusive consumer commodity. It's a long fix, which sucks for those millions of us who are sick NOW.

I'm sorry I can't offer more substantive advice, but hopefully someone else in the forum can!

You're in my prayers,
Richard Day Gore
_________________
Richard Day Gore

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