f/u to Mirena with another (dumb) question

sistrkate

I contacted my health insurance company, and found out that the Mirena + insertion is fully covered under my medical plan, and I would only be responsible for a $10 copay.  The fine print is that it is covered when billed by a "participating physician".

The dumb question is, what is a "participating" physician?  If my OB is the one doing the insertion, is he not necessarily "participating"?

Sorry for the dumb questions.

Superchicy

Maybe they are talking about a doctor who is "in network"?  My PPO plan has "in network" and "out of network" physicians and charges can vary based on that.

sistrkate

Superchicy:

Maybe they are talking about a doctor who is "in network"?  My PPO plan has "in network" and "out of network" physicians and charges can vary based on that.

I think my OB is in network, because I never make more than a $10 copay for an office visit.  But I wasn't sure what they meant by "participating" in this case -- since my OB's office said the cost to me would be out of pocket.  I didn't know if there are MIRENA participating providers?

I guess I should just call the doctor's office back to see if they will bill it to the insurance co.

mrs.george2be04

Superchicy:

Maybe they are talking about a doctor who is "in network"?  My PPO plan has "in network" and "out of network" physicians and charges can vary based on that.

This is what I was thinking.  If the doctor is in network, I would think they would be a "participating" doctor.

And yay for it being covered!!

HrH33RN

I'm almost positive it means in network MD. At the MD office I use to work at- thats how it worked for us when precerting for mirena.

sistrkate

I just spoke to the doctor office.  They said that they don't actually stock the Mirena as a product, and patients who are wanting one actually purchase it through the company.  Nothing gets billed from or paid to the doctor's office except for the insertion.

I am waiting on a call back specifically from the nurse that I spoke to yesterday, but I think the way they are doing them is going to circumvent my insurance coverage.  So I'm back to being bummed.

There has got to be a way that I can get this thing, and have it paid for by insurance despite my OB's office being stupid.

Superchicy

sistrkate:

I just spoke to the doctor office.  They said that they don't actually stock the Mirena as a product, and patients who are wanting one actually purchase it through the company.  Nothing gets billed from or paid to the doctor's office except for the insertion.

I am waiting on a call back specifically from the nurse that I spoke to yesterday, but I think the way they are doing them is going to circumvent my insurance coverage.  So I'm back to being bummed.

There has got to be a way that I can get this thing, and have it paid for by insurance despite my OB's office being stupid.

That is such an odd way of doing it.  My OB office had to order my Paraguard since they didn't stock them but all was billed through insurance.  That really stinks!

HrH33RN

I remember talking to Dr Fleming nurse about the mirena 2 years ago, and she did say something about this now that you mention it. However, I had the documents showing my coverage etc, and she was going to order for me I believe, I was going to pay up front, then be reimbursed I think. But once Dr Fleming met with me and did my exam, he did not recommend the mirena for me. Have you talked to Fleming about it? (I believe he's your MD..if not forgive me)

sistrkate

HrH33RN:

I remember talking to Dr Fleming nurse about the mirena 2 years ago, and she did say something about this now that you mention it. However, I had the documents showing my coverage etc, and she was going to order for me I believe, I was going to pay up front, then be reimbursed I think. But once Dr Fleming met with me and did my exam, he did not recommend the mirena for me. Have you talked to Fleming about it? (I believe he's your MD..if not forgive me)

Yep, I just saw him last week.  He is completely on board with this for me, so that's not an issue.

I don't know if I can file a claim after the fact with the insurance company.  I will have to check.  What a giant PITA.

JLPT830

I would call your ins company, explain the situation, and ask what you have to do to have it paid for.  My ins company was very upfront with me about how to tell The Little Clinic to bill a vaccine so that it would be paid for.  Maybe if they need the office to do something specific you can ask Dr. F to take care of it.  Good luck!

Megs&Nick

I would definitely start with the insurance company.  Either ask them how to have the office bill it so that it is covered or ask them for a list of "participating" doctors.  You may have to have another doctor insert it or something stupid like that. 

I loathe insurance companies and medical billing.

kel716

If it were me, after talking to your ins company and finding out what you have to do, I'd call back the dr's office with explicit instructions.

If your dr's office is unwilling to cooperate, I'd find a new OB.  Seriously... that amount of billing headache is not worth it IMO.  And before I'd switch OB's, I'd tell them that because right now they know full well that you are more in charge of your dr's than ever before.