Out of Network

What that means for you

Dr. Arrington and EndoWest are out of network for health insurance companies. This means that, although we don’t have special contracts with insurance companies, we will work with them if a patient desires.

A little background information is important to help patients why this decision was made. When the government and insurance companies place a value on medical care, they typically focus on three main areas to assign value: Work, Malpractice risk, and Location. The two largest factors are Work and Malpractice risk. The current arrangement considers all endometriosis surgery to be equal. There is a single code that describes treatment for endometriosis whether it be burning, lasering, or excision. It sees deep and complex endometriosis the same as simple endometriosis. It also considers partial treatment and attempts at full excision to be equal without respect to the time invested by the surgical team.

A focus on full excision of endometriosis often requires additional procedures to be performed. This may include separation of advanced adhesions, removal of endometriosis from bowel, bladder, diaphragm and the appendix. Insurance companies often bundle everything together. This means that they include all the procedures on different organs into the same endometriosis code regardless of which organs are involved if the endometriosis surgeon is the one who performs the work.

At EndoWest, instead of Dr. Arrington using other specialties to do simple bowel excision, bladder excision, or ureter dissection, he prefers to perform these procedures as the trained endometriosis specialist. Other Gyn surgeons often call other surgeons to help with these common procedures. Insurance companies will always pay other surgeons when they are asked to help with a complex surgery, but they often deny coverage to a single endometriosis expert for the same work.

In focusing on the surgical care of excising endometriosis, Dr. Arrington takes the time to do a full abdominal and pelvic evaluation for even the most subtle endometriosis. This includes the diaphragm, large bowel, small bowel, appendix, and all the structures and organs in the pelvis. Taking to the time to look for disease is as important as knowing what to look for and how to treat it.

Endometriosis excision surgeries typically take longer than those performed by regular gynecologists that may only last a matter of minutes. The full evaluation and excision of even stage 1 endometriosis will often require an hour or more of surgical time. Compare this to the 15-30 minutes or other gynecologists to quickly glance at tissue and decide they don’t see anything or realize that it is far too advanced for them to treat.

With all this in mind, EndoWest has set up an out of network billing system that provides options to patients while offering protection against a high amount of additional expense beyond the original disclosure. This policy allows patients to choose between self-pay or to use their out of network health insurance benefits.

We have created three tiers of complexity based on RANZCOG (Royal Australian and New Zealand College of Obstetricians and Gynecologists). Using history preoperative evaluation, an expected level of complexity is assigned. Based on the level of difficulty, we discuss the expected level of surgery and its associated fee. Understanding that endometriosis can often be difficult to predict and additional procedures may need to be performed to fully address the endometriosis per patient consent, we have built in some protections to minimize any additional, unexpected direct patient cost. This policy is equally applied to the three levels of complexity.

Understanding that the financial burden is significant for many patients, we at EndoWest have worked to minimize the cost of practice overhead expense to lower the financial impact on patients seeking the highest level of endometriosis surgical care.

We develop a unique surgical plan for each patient based on a unique history and individual goals. With this in mind, the current policy will allow patients to know potential cost of care up front with options to use a self-pay program or to use their health insurance out of network benefits. We will work with patients to facilitate the financial arrangement they choose.