My Dr is charging me $43k for one sided styloidectomy. Did anyone else have to deal with that who is has gotten a single case / gap insurance exception? I worked so hard to get it. The Drs office and hospital don’t trust that insurance will pay even though there’s a single case agreement. They said they will reimburse me if insurance sends them $. They need this in advance of surgery and paid in full. I’m hyperventilating here. Is this normal? Do they have the right to keep some $ if they’re unfaithful with how much insurance reimburses? Do they actually SIGN the single case agreement?
I would call your insurance company tomorrow & ask for a specific contact person for your case, whose name & phone number you give to the hospital billing department so they can confirm the legitimacy of your coverage.
I have never heard of a single case agreement, & perhaps the hospital/doctor’s ofc haven’t either which is why they’re being pushy regarding you paying them up front. I applaud you for erring on the side of caution as that’s a ridiculous amount of money to simply hand over to a hospital. Why would they expect you even have that kind of “disposable income”?! What are they thinking?!?!
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Hi! Thank you. I’ve already done all that. Two months ago. I have a case manager and an in with the gap exception woman.
They’re doing it bc they say they were burned before and ins didn’t pay.
Yes I’m waiting on a callback from my blue cross folks.
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You may need your Blue Cross case manager go to bat for you & have that person call the hospital to make reassurance of your coverage. Perhaps your caseworker can provide whatever “collateral” the hospital requires to prove that they will pay once the surgery is complete. I’m sorry this has come up for you in this manner. It’s not right. Seems the hospital is more interested in getting their money than in helping their patients.
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Yes I agree. I suspect and fear that it’s the drs office more than the hospital.
Makes me think they don’t want to do my surgery. I suspect it might be a way of weeding out people whose insurance won’t pay a lot.
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It’s all such a crazy minefield, I hope you can get this sorted 
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Thanks so much. Super crazy.
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It’s definitely important to find out (1) if they signed the single case agreement and (2) if the single case agreement limits them to accepting money from your insurance company only or if it allows them to balance bill you. Another important question: (3) is the hospital where the surgery is being done in network with your specific insurance plan. Will your insurance cover the associated hospital fees (anesthesiology, pre-op and post-op nursing care etc.)?
My experience with a SCA was this: my insurance company granted one but it limited the surgeon to a specific dollar amount and the amount was a fraction of the surgeon’s standard insurance payments. The SCA also specified that the surgeon could not bill me and would not be paid more if - for example - my surgery was more complicated than expected. Basically the SCA allowed for CPT codes associated with a tonsillectomy and adenoidectomy. (Side note: the scope of the surgery and relevant billing codes was detailed by the surgeon’s office in their documentation requesting the SCA out-of-network coverage so it was somewhat doomed from the start.) Needless to say, the surgeon declined to sign the single case agreement.
To the extent that it’s possible I would want answers to these questions in writing from sources authorized to guarantee them as accurate and factual before proceeding with surgery.
I’m sorry you’ve encountered another hurdle. I hope it gets resolved in a way that allows you to comfortably move forward with surgery.
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Thanks Kim, I was going to reach out to you and ask you, as I know you dealt with this. Very helpful response. My ins case manager said they were allowed to balance bill but she was oddly referring to the fact that they could charge me ahead of time. She reassured me that in the end I’d only owe my out of pocket max. So I have a few more questions for her now. The hospital is in a blue cross network but NOTHING out of state it covered so I don’t think it matters. The 43k included everything, I asked Dr. Annino’s office yesterday when they called to tell me I’d have to pay upfront and gave me that amount. Holy crap, I forgot you said that about Dr c… I really hope Dr Annino’s office won’t refuse to sign the single case agreement.
Tracy
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