Negotiating insurance over MMA
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Negotiating insurance over MMA

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Posted by ejy2 on October 11, 2009 at 12:11:53:

I have not yet had an MMA, but it has been recommended to me by various Stanford doctors, and although I am still doing research, it appears that I may likely have an MMA done by one of the Stanford-affiliated surgeons in Palo Alto. Of course, as many people have discovered before me, many insurers consider these surgeons out-of-network, and therefore have either paid considerable fees out of pocket or had to appeal adverse decisions by the insurance companies.

I am planning on pursuing the latter course to bring my costs down as much as possible. As a result, I have reviewed as many postings on this topic as I can find (SeattleBill's postings on various sites have been particularly helpful), and the list below summarizes what I've learned (hopefully this will be a useful summary for others in a similar predicament):
1. Request pre-approval and a coverage estimate from my insurance carrier for MMA surgery with one of the Stanford surgeons.
2. Once I receive a decision giving a very low level of reimbursement (I have already received such an estimate orally, but I hope to receive an official one in writing), prepare evidence to submit to contest the decision. Such evidence may include:
a. letter from a doctor (hopefully my selected surgeon will agree to this) advocating the value of MMA surgery and its appropriateness for my condition
b. letters or other arguments indicating that the in-network doctors recommended by the insurer either have little or no experience performing MMA surgery for sleep apnea patients (so far this is definitely the case)
c. arguments that in the long run, having the surgery will be cost-effective for the insurance company
d. arguments that the surgery is medically necessary
e. medical literature indicating that the MMA surgery is a highly effective therapy for sleep apnea patients that are intolerant of or do not respond well to CPAP or an oral appliance.

Despite all of my research, two questions came up that I hope members of this forum can answer:
1. What is the basis (legal or otherwise) for arguing to the insurance company that they should cover an out-of-network surgeon at in-network rates? When I review my insurance policy, I actually do not see a clear statement saying, for example, "If the procedure is medically necessary and if a skilled practitioner cannot be found in the local area to perform the procedure, then the insurance company will cover the procedure at preferred rates," although I could be missing it or looking at the wrong document. When we are appealing adverse decisions by the insurer, are we making the appeal based on a particular official rule (e.g., state or federal law, or an insurer guideline) or is it more a general appeal for the insurer to treat their customer properly? I think knowing this would help me make better arguments.

2. Also, for those who have dealt with insurers and had MMA surgery, what insurers have up to now seemed most open to covering the fees charged by the Stanford doctors? I've heard good things about State Farm, are there others? (e.g., How are Blue Cross Blue Shield? United Healthcare? Aetna?) How much work was required in obtaining coverage?

Any other general comments about the topic of insurance and insurer negotiations would be really appreciated. Thank you for your help.

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