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RPLND post chemo, out of network-help

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  • RPLND post chemo, out of network-help

    Hello all,

    I posted earlier in another section of the forum about my son Greg. Stage 2,w/ spot on the lungs. CT scan last week showed reduction in tumor size.He starts his 3rd round of 4XEP on Monday. so far, reaction has been good, he is exhausted during the long week and the next week after, but no nausea, good appetite, etc.

    I just left him this am (he lives in NYC, I live in WA state).

    My question is about insurance. Bear with me this may get long winded.

    His insurer is HealthNet. We got them to spring for consult w/ Dr Sheinfeld at Sloan. they have been great w/ Chemo.

    Sloan Kettering is not in HealthNets network. From all I hear re Sloan, they always recommend getting the RPLND after the initial chemo. For a variety of reasons, the rplnd is preferable to surveilance for Greg-he wants the surgery

    Health Net uses Cornell as the in network provider for rplnd surgery. If Dr Sheinfeld recommends the rplnd surgery, we are afraid HealthNet will refer us to Cornell for the procedure. Not to dis Cornell, but Sheinfeld is who we want performing the operation.

    If Healthnet trys to force us to cornell, can you tell me if we can negotiate with the Healthnet insurance company to pay whatever is reasonable and customary toward the Sloan bill, then we pay the rest?

    Has anyone gottton into this type of situation? How do you approach it?

    Thanks

    ProudDad (Tom)

  • #2
    Tom,

    You can always try to negotiate anything you want, but the problem with the insurance coverage is that it is a contract, a contract which only permits you to go out of network when there is no alternate available. Being NYC, there are at least two doctors that I know of that take HealthNet who do RPLNDs, so convincing them that you can "only" go to MSK is going to be an uphill battle. I'd argue that a post-chemo RPLND is not the same category as a "run of the mill" RPLND and thus, there is no comparable alternative to MSK. (No way to predict whether the carrier buys the argument, but you definitely won't get anything if you don't ask).

    What I can tell you is that I also live in NYC, have HealthNet, saw Sheinfeld for a consult (although HN only paid for about 50% of the total cost of that visit) and had my RPLND at Cornell (sans chemo though). I have nothing but good things to say about my surgeon at Cornell and have recommended both him and his practice to several people over the last year. As far as I've been able to tell, after Sheinfeld, he does the most RPLNDs in NY which means convincing HealthNet that there's nothing comparable to MSK may be tough. (BTW - even if your son 100% wants to stick with MSK, he should still get a second opinion, and doing it up the block at Cornell is an easy way to do it).

    As far as payment goes, again, you are free to argue for any arrangement you want. But carriers generally tell you its an all or nothing kind of deal. If HN refuses to cover MSK and you can't convince them to pay even a portion of the bill, what you can probably do instead is at least negotiate with MSK to only charge you the same rates that they charge the insurance companies (i.e. the "customary and reasonable" charges), as opposed to the full-price they would otherwise try to sock you with. This "discount" can be as much as 90% on certain things.

    Best wishes for you both.
    Let's Go Mets! sigh...

    Comment


    • #3
      Hey Russ,

      Thanks for your insight, its exactly what I was looking for. It is very early for us to have to make a decision, I just wanted to be prepared for possible options.

      Its also good to know Cornell is a viable option.

      tom

      Comment


      • #4
        I had concerns about Andy's thoracic surgery. His oncologist said his surgery can only be done by Dr. Bains at MSKCC. I tried to convice the insurance company, but they suggested two surgeons in network(who although did thoracic surgeries, never did any with GCT patients). Anyway after a lot of research I came across this site:

        http://www.patientadvocate.org/

        If your oncologist believes that MSKCC is the only place he can do his surgery, you can join the patient advocate group and they can help you fight with the insurance company to convice them.

        I started the process with the patient advocate gropu but then found out my husband didnt even need the surgery. They are free of charge.

        The key is to get the oncologist on your side and have them write medical letters that state why your son should use MSKCC. Hope this helps.
        -Husband-Primary Mediastinal GCT Choriocarcinoma , Stage 3-Diagnosed on Mar10 BHCG 35596
        -4 BEP Mar 15-Jun 10, BHCG down to 3
        -Jul 27, relapse BHCG 23
        -Brain Radiation 8/18-9/18
        -BHCG-4
        -12/21 BHCG12800
        12/22-5/7 TIP
        2/24-Stereotactic brain radiiation
        6/25-BHCG 46400
        7/4-Started hospice
        7/8-Passed Away
        R.I.P.-06/19/1974-07/08/2010

        Comment


        • #5
          Thanks again. Greg finished EP round 3 last week so will have the 4th round the week of 9/7.

          We are early in the process, but I wanted to get some ideas on how we should approach this and your comments are a great help. I figure once round 4 is complete the time will pass quickly--even though the insurance company is slow to make a decision.

          Tom

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