Less Breast = Fuller Life! -Insurance & Surgeons

Saturday, February 20, 2010

Today is actually Day 5 of my recovery.  But I want to tell the whole story, because I've been in active pursuit of this surgery since September 2009, and the insurance approval was a little bit of a bumpy battle.  This is a novel of a monologue, but for those seeking an insurance-covered breast reduction, I'm going to post it anyway.  The process of choosing a plastic surgeon, getting insurance approval, etc. etc.

While I had planned on having a breast reduction since I was a teenager,  I was still deciding if I wanted to breastfeed, etc.  I chose to be able to breastfeed entirely, and therefore not have surgery early, but that was easier said than done.  Alas, I have 2 little boys I dearly love, and was ready to take this step to my "Fuller Life."

I was scheduled for my consult appointment with Dr. P on October 9, 2009.  When I called to confirm, day of, they told me that he had an emergency surgery and I was rescheduled for the end of the month.  I was extremely late to that appointment, dragging my tantruming children with me, but they chose to see me anyway.  I got to sit on the "bed" they have in all clinics and be examined topless.  My wonderful children were not being so wonderful at the time, and the nurses, etc., were attempting to entertain them and keep them happy.  Dr. P assured me that he thought they were adorable and loved children.  That was a good step; people always like those who love their children...

Having done much research beforehand, I told Dr. P that I was open to a free nipple graft, because they could be done more easily and quickly, and because I had already had my children and saw no need to keep the blood supply and milk ducts intact.  He told me he would try very hard not to do that, and, upon examination, felt that he could take at least 600 grams out of each breast.  That's about 1 1/3 pounds.  My plan was to submit a request to my insurance company to cover the surgery for me.  I left having no idea what was to happen at that point.  Would they contact me?  Was I supposed to do something?  What happens from here?

Several days later, in my impatient excitement, I called the insurance company to see what to expect and if Dr. P's office had submitted my request.  They told me they had received nothing, but that the clinic would submit the request, and they would respond to them with four weeks, or so.  I immediately called Dr. P's office and spoke to Sue, who is responsible for billing.  She told me that she thought I was going to get her a letter from my chiropractor, and she was waiting to receive it before putting in my request.  I told her I would work on getting a letter, but was not sure if my chiropractor would be willing, and asked her to submit the request while I attained a letter.

7-10 days pass.  I've called my insurance company nearly every day because I cannot think of anything else during my free time (i.e., nap time).  No response.  I get a call from Sue saying that they need proof of my effort to alleviate back and neck pain using other methods.  I have my primary care doctor fax records that she prescribed me physical therapy 3 years ago (though, in all honesty, I never went.  I didn't want to, and soon got pregnant afterward).  After being annoyed with old chiropractors who did not see the need to help me, I found a new one and started seeing her regularly, with the understanding that she would write me a letter.  It worked.  Proof of physical therapy (wink wink) and a chiropractor's word that my pain would not leave until my large breasts did.  Things are looking up.

I'm calling every day again.  I would think Premera would approve my claim just to keep their phone lines free.  I mean really, there's a lot to be said for persistence.   And there's a lot to be acquired by using it. 

December 7th, 2009.  I called AGAIN, and was told that my claim was denied.  The only information they could give me over the phone was that the medical review board did not find the procedure to be medically necessary.  Devastated.  I knew insurance would fight it; I mean, who would pay 10 grand for something if they could get away with just saying no.  Nevertheless, it was quite a blow, and I have every intention of fighting it.  I was determined to get my way, and while there is a hopeless feeling with every initial failure, I was already researching how to write my letter of appeal.

But first things first.  The poor customer service representative that got to deliver this news to me told me that my Doctor had 7 days from the date of denial to have a "peer to peer review" with the physician of the medical review board.  He gave me a number for Dr. P to call.

Well, here goes.  I call the office and get to speak to my favorite Sue.  I tell her my claim was denied (why am I telling her instead of the other way around?), and her response is, "Oh yes, I think we got that fax."  I already wasn't too fond of her, and considering looking for another plastic surgeon because of her.  I was doing all the work to get insurance approval.  She hadn't taken pictures or sent any kind of documentation, but I was jumping through hoops to make this happen.  Well, she improved upon me still

After a brief period of silence, she says, "So do you want me to give you a quote of what it will cost?"

Um...catch my breath..."No, I was hoping to appeal it.  The gentleman I spoke to said that Dr. P has to call and schedule something called a 'peer to peer review,' and it has to take place within 7 days of the denial date."

Sue replies, "Well, Dr. P has other patients and surgeries scheduled, and he can't be expected to drop everything for one patient.  The insurance company needs to give him an appropriate amount of time."

I'm at loss.  I've got some choice words for her in my vocabulary, but I presume to be above posting them online.  I do wonder-to this day-who she is sleeping with to keep her position.  It certainly isn't a matter of her competence, and it definitely isn't because of her bedside manner.  Then again, perhaps that's exactly what it is...  SHE has ME call the insurance company again because she expects me to give her the exact name of the person Dr. P is supposed to call.  The number isn't good enough for her, either.  I do it, but this customer service rep gives me the same information and has no name for me to give her.  At this point, I am seething angry.  When I call her back, she gives me the same attitude and reminds me that the doctor doesn't have to call for me because he has other patients and no time to make this phone call.  I'm so done.  New doctor; new billing specialist.

Within the week, I have a consult appointment with Dr. L.  She spends much more time with me than Dr. P, and she gives tons more information.  For example, she takes all the pictures right there during my consult.  She explains that the free nipple graft is definitely necessary because of the amount of tissue I want removed.  She is brusque and unfriendly, but she listens to what I want and gives me blunt answers about what is possible.  I like that.  She explains to me that I'll need those letters, etc. I got before, and that we're going to start the process over again.  She seems much more competent, so I am pleased, but unlike Dr. P, she doesn't take well to my tantruming toddlers.  She tells them to stop doing stuff, too.  I don't like that.

Her before and after pictures really aren't anything spectacular.  They're mediocre at best, but her before and after pictures of breast reconstructions (after mastectomy) are fantastic.  I mention the latter, and she tells me that if I like the way a nipple reconstruction looks, as opposed to the free nipple graft, she could do that.  But I'd better be sure, because once she throws my nipples away, they're gone.  To have my nipple reconstructed merely means that instead reattaching my nipple elsewhere and hope that the blood supply takes to it, the nipples are removed altogether, and the skin will be sewn to look like a small nipple.  Later, 6-12 months post surgery, I can have the areola tattooed on, and it will look like a real nipple, but it's not.

I go home, preparing for starting over, and I start making phone calls again.  I call Dr. P's office first, and ask to speak to anyone but Sue.  The nurse, the doc, but not Sue.  The receptionist says that Sue is the only one who can help me.  Sue tells me that the Dr. P is scheduled to participate in the peer to peer review the following day.  Shocking.  I figured Dr. P would do it if he knew what was going on, but I couldn't ever get past Sue to tell him.  Next I call the insurance company...again.  When looking up my case, the customer service rep says that my peer to peer review has been cancelled due to new information, and the decision has been overturned.  Speechless and truly caught by surprise this time.  I'm approved.  I can have life-altering breast reduction surgery, and not pay for it!  In fact they had approved my claim that very day.  I decide to contemplate what I want to do.  I like Dr. P, but I hate his staff (or, at least, the only member of his staff I'm permitted to speak with).  I like Dr. L's professionalism, but I think she's cold, rude, and childless (usually not a crime, until you are mean to my babies). 

I'm thinking...a new Doctor.  Maybe in California.  After all, if you want new breasts, you go to California!  I have family there, and my insurance is still completely effective there.  But I have children and responsibilities.  Sue calls me immediately the next morning.  Apparently she found out about my claim's approval--it's no credit to her.  Funny, she never called me when I was denied, or when she so graciously scheduled the peer to peer review on my behalf.  But as soon as the promise of money is there, she calls me first thing!  I don't want to go to Dr. P on principle now.  I've done ALL the work, and she's taking the bows after putting me through HELL!  It's finally paid off, and I'm supposed to gratefully answer her calls?  No.  You can leave a message, my dear.  I have nothing to say to you.

**Abbi

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