A single moment can make your heart sink, and I never expected something like this to do it. I got off the phone and broke out in tears as I had just learned that my insurance denied the pre-approval for my excision surgery with the only excision Specialist in Houston. I also learned that if I wanted to go through with the surgery it would be entirely out-of-pocket and a minimum of $20,000. Since I absolutely could not afford that, I knew I would have to get my insurance to approve my excision surgery. Good thing my nursing experience had prepared me for this.
It was honestly a terrifying feeling. Not having the financial resources or savings to pay for this surgery, meant that I would have to wait at least another year or two to save up the money. And going through 1-2 years of the suffering that endo causes was definitely not something to look forward to.
I know I am not alone, as many expert excision specialists do not accept insurance or are out-of-network providers. This is why I want to share the process I went through to get my insurance to approve my excision surgery.
But First, A Disclaimer
Following my exact process does not guarantee you will have the same results. Endometriosis presents very differently for every individual and each insurance policy has its differences. However, I hope that in sharing my story, you may find additional ways to make your case against your insurance company.
Also, this post in NO WAY reflects my thoughts towards my current employer or past employers. employer. Additionally, this content reflects my thoughts alone and does not represent the thoughts of my employer or any organization I am affiliated with.
How I got my insurance to approve my surgery
1. Denial Details
My first instinct after receiving the news that I would have to pay out-of-pocket for my surgery was to call my insurance. I immediately dialed the number on the back of my insurance card. I followed the prompts until I was connected with someone. They don’t make this part easy, but I was determined to know why it had been denied.
Up until this day, I had full confidence that my surgery would be covered. I was within network. My doctor was within network. And the Hospital was within network. So, what was the problem?
Insurance Plan Specifics
Turns out that my plan is slightly different. Since I work for the hospital that provides this insurance, you would think I understand it. But many nurses don’t deal with the insurance aspect of care. Most nursing positions are focused on direct patient care. Unless they work in case management, a clinic, administration, or other similar setting, it is unlikely that a nurse will know everything about the restrictions of insurance.
I digress. Simply put, my insurance is under the United Health umbrella, but my specific plan prefers members to be seen within the hospital system I work for. The plan prefers members to stay in our hospital system, but they also advertise that any provider in the UH network would be covered. However, my plan specifies that some procedures and surgeries are not covered out-of-network.
Asking for an Appeal
And so, before I got off the phone, I asked the representative for information on filing for an appeal. I was told that my plan was “not set up that way,” and that there was no option to appeal the decision.
BULL SH**! I may not know all there is to know about insurance, but I did know this was total nonsense. I told the representative “There is no possible way that is true, and I know there must be a way to dispute the denial.”
Case Review
The representative then told me that they could do a one-time case review for one-time coverage of out-of-network benefits . . . which is basically an appeal. He explained that I would need to submit a letter from my surgeon and any relevant medical records. I was provided the fax number, case review number, and his name (as all documents sent would need to be to his attention).
It was sounding promising, as I knew I was armed with the knowledge to dispute why they should cover my surgery, even if it was just out-of-network benefit coverage.
Then He Laid Down the Law—Figuratively
He then explained that my chances of approval were very low. Why? Because if my plan found another surgeon who performed the same procedure within network and within 100 miles of me, then it would be denied. They would expect that I go to the in-network surgeon.
From this, my hope began to fade, as I know that there is a physician who claims to do the same procedure. I was his patient for many years. And there were many reasons why I chose to seek out a specialist elsewhere.
My gut, my endo knowledge, and some of his responses to my vetting questions told me that he was not a true specialist. And although some hope was lost in knowing it might be denied, this also gave me so much drive to state my case against my insurance company.
Insurance Summary:
What did I learn from this encounter with my insurance company? I learned not to back down! Had I accepted the fact that an “appeal is not an option.” then I wouldn’t have been given the additional info about a case review.
2. I Called My Surgeons Office
I spoke with the RN at my surgeon’s office and let her know that I was filing for an appeal. I explained that I would need a letter from my surgeon explaining the benefits of why surgery with him was preferred.
Not even an hour later, she called back and said that he would not be able to supply the letter. Per my doctor, he cannot give reasons why he should do my surgery over someone else. This was obviously upsetting, but I still did not lose hope.
You see, many physicians know each other well and do not like to talk poorly about one another. Knowing this, I decided that asking my PCP to write a letter was even more out of the question, since she practices within my hospital system. This would mean that she would have to go against the care that was offered by my previous “endometriosis specialist” (quotations added for a reason).
It became clear that I was going to have to write the letter myself and I was ready to pull out all the stops.
3. I Did My Research
Battling my insurance company was uncharted territory for me. Although I had just started a new job as a nurse in a clinic, I was still learning about the appeal process.
And so, I looked to a few of my favorite resources for information:
- Nancy’s Nook Endometriosis Education Facebook Page
- Center for Endometriosis Care
- The Resources pages of:
- Beating Endo: How to reclaim your life from endometriosis by Dr. Iris Orbuch and Dr. Amy Stein
- Stop Endometriosis and Pelvic Pain: What Every Woman and Her Doctor Need to Know by Dr. Andrew Cook
I printed examples of letters from the Files in Nancy’s Nook. And I printed journaled articles that would be sent with my appeal to help my case.
4. Gathering My Medical Records
The letter template provided on Nancy’s Nook is just a template, and I knew I would have to make the letter specific to my case. Part of that meant I would have to get all my medical records to help my narrative.
I needed medical documents that clearly showed why it was in my best interest to seek care outside of my medical system (the one I work for). Luckily, working within the hospital system where I received most of my care made it extremely easy to obtain my medical records.
The Medical Records I Pulled Together
- I gathered progress notes that helped me highlight areas where past physicians were lacking in experience and skill regarding endometriosis care. Underlining and starring the parts I did not want them to miss. I made sure to supply journaled articles to reflect these facts.
- Lab and Diagnostic Test Results. My previous physician would often use the patient portal to relay results to me. Even better, he would write a note to me when releasing the results. So, you better believe I printed those messages. Especially the one where possible thoracic involvement was dismissed after my MRI showed normal results. (NOTE: MRI is not an accurate diagnostic tool for endometriosis. Diagnostic Imaging scans can sometimes show very invasive disease, but endometriosis rarely shows up on MRI, CT, or Ultrasound.)
- Chronological Order. To help the narrative I would provide in my letter, I put all relevant medical records in chronological order. This way when they read the letter, they could see the medical treatment that led me to seek care elsewhere.
5. I Wrote My Letter
This is the part that I believe made all the difference. Keeping the template I had found in mind, I started to write my letter. But since I was not able to get my physician to write a letter, I used my own credentials to help my case.
I started my letter in first person, then went on to say that the rest of my letter would be written in third person and from the perspective of a practicing healthcare professional. And I signed the letter with all my credentials and professional contact information. Yup! I did the damn thing!
I realize that this may not help most endometriosis patients, but if you have a nurse or healthcare professional in your family (or group of friends), ask them for help. This may also give you the opportunity to really educate them on endometriosis.
I Got My Insurance to Approve My Excision Surgery
Submission of Case Review (aka Appeal)
When it was all completed and pulled together, my appeal consisted of 48 pages. When I tell you that I was pulling out all the stops, I meant it.
I called later that week to confirm that it was received and asked when I should expect a final determination. The representative I spoke with stated that it usually took 14-21 days to get a determination, but it may be longer due to COVID-19.
COVID-19
Due to COVID-19, my original surgery date of April 7th was postponed. This was the only time during this pandemic that I was thankful for delays in surgery. Although no one wants to continue to live in constant pain, the shutdown gave me that cushion of time to get my surgery approved, without losing my spot in line. While we waited on determination, I was tentatively rescheduled for June 24th (granted the pandemic did not postpone it again).
It Was Approved!
If you follow me on Instagram, then you saw the ball of tears I was when I had just received word that my surgery was approved. Twenty-Six days had gone by and the appeal had not been touched; I knew because I called often to follow-up on the status. But on April 29, 2020, that all changed. I started to received calls and emails about my claim.
First, it was a call telling me that they had passed the first level of approval, which was the approval for my preferred surgeon. The next step would be getting approval for surgery at the hospital he performs surgery at.
Within an hour of the first call, I missed a call from my insurance. The voicemail was not clear, so I called them back. And within minutes I was in a puddle of tears, as the representative explained that it had all been approved. I told the rep how thankful I was for her, as she had just given me news that will change my life.
Estimated Costs
Ultimately, I was approved for Tier 3 out-of-network approval (whatever that means). With this approval, I was expected to pay about $2,000 out-of-pocket. I was shocked. This is 10% of the original amount. Now that was doable!
NOTE: This did not include the anesthesiologist bill, and this was specific to my plan. Your costs may be higher or lower depending on your situation.
Summary: Insurance Approval for Excision Surgery
Overall, this process was extremely stressful and came with emotional highs and lows. It took a lot of work to send the appeal filled with my extensive letter, medical records, and journaled articles. About 1 month later, the approval had been determined. Even better, I was able to move my surgery date up to May 14th after obtaining my approval.
It took time and effort, but I would do it all over again. Because at the end of the day, I learned so much about myself. I am a warrior, a survivor, and my best advocate! Of course, having a good knowledge of endometriosis facts and myths helped me get to where I am today. I would never have been able to fight for myself effectively if I didn’t first learn about excision, the gold standard in endometriosis care. If you are in a similar position, please know that you are not alone. And let me know in the comments below if you learned something knew today.
