At EndoWest we help patients work with their insurance companies to receive the coverage they deserve. After trying for over a year to negotiate appropriate payments for complex endometriosis surgery, we received little interest from the insurers. Due to this, we were forced to become an “out of network” provider. This means that we do work with and bill insurance companies but at “out of network” rates. This applies only to Dr. Arrington’s fees. Hospital and Anesthesia fees should be covered as “in network” services. As long as a patient has out of network benefits, we should be able to help each patient make sure she receives appropriate financial help from her insurer for her advanced endometriosis care.
Patients who do not have out of network coverage, will likely be responsible for all of Dr. Arrington’s fees. Again, by operating at both Mckay Dee Hospital and Ogden Regional Medical Center, we do our best to make sure that hospital and anesthesia fees are covered as in network services. Especially in advanced endometriosis, we can assist with appealing for insurance benefits to help patients. Many insurance policies and state laws require that insurance companies cover out of network services if those services cannot be found within their contracted physician list.
Endometriosis can be a very complex disease. Most patients have had numerous consults and many have had multiple surgeries that have failed to recognize all forms of endometriosis or have incompletely treated the endometriosis present. There are very few surgeons trained to perform these complex surgeries and most in network surgeons do not perform complete excision of endometriosis. Although it is not a guarantee, we can help petition for Dr. Arrington’s services to be covered at in network rates as there are rarely in network doctors who can adequately treat endometriosis. We are required, by law, to bill patients for any amount the insurance doesn't cover after we have exhausted all levels of appeal.
For patients who have out of network coverage and all patients, we do our best to estimate what will be necessary during surgery and estimate the patient’s expected portion. The extent of endometriosis can be very difficult to predict. Therefore, as we make a treatment plan, it is important to understand that more or less surgery may be required to completely treat the disease. Adjustments to fees will be made accordingly. If assistant surgeons are called in to help with the removal of disease, most of these will be covered at “in network” rates as most of our local surgeons are contracted with insurances.
In most cases of "in-network" and "out of network" coverage, there is an extensive surgical billing appeals process with the insurance companies. They, of course, want to minimize what they pay out. This appeals process may take up to 6 months or longer to finalize. Our goal with this appeals process is to petition the insurance company to cover all the procedures performed in order to minimize the residual payment that would fall to the patient. Any delay in reconciling accounts with patients is due to continued negotiations with insurers for the patient benefit.
We have also found that insurers only want to cover their "usual and customary" fees. During this appeals process, our aim is to show them that there is nothing "usual and customary" about this form of treatment. Their "usual and customary" fees are set for "usual and customary" surgery that involves quick 20-30 minute surgery to burn or laser what the surgeon can then stop. Excision is much, much more than the usual and customary approach that most gynecologists take toward endometriosis.
This policy has become necessary due to the insurance companies' failure to recognize the difficulty of adequate endometriosis surgery and the benefit of excising all visible endometriosis rather than just going in and “lasering” or “burning” a few areas after releasing adhesions. Insurances consider quick laser or ablation surges as equal to more extensive and time consuming excision surgeries that focus on cutting out all visible endometriosis, and have no problem paying for repeat surgeries and ineffective hormone treatments. When an endometriosis surgeon performs procedures that other surgeons would normally perform, insurance companies usually consider those as part of the routine endometriosis surgery and do not pay the gynecologist the same as they do consulting surgeons.
It has been a difficult decision to become an “out of network” provider, but we were forced to do this because of inadequate reimbursement for the work and risk it requires to appropriately treat patients with endometriosis. At EndoWest we have take great care to set our fees in line with other providers in our area for the procedures that are performed. By focusing on excision of all endometriosis, our goal is to break the cycle and expense of multiple surgeries that leaves disease behind and the need for expensive and prolonged medical therapies.
