August 7, 2016

Dealing with Insurance for my Laparoscopic Bilateral Salpingectomy

The least fun part about getting spayed has been dealing with insurance.

Let's start with the end: I lost.

Backing up a bit, before you go and get this or any surgery call your insurance company and ask what your costs will be. First, get the precise codes from your doctor. Make sure to get all codes, all of the codes that each doctor will use (I had two), the code the anesthesiologist will use, the code the hospital will use, and any other code they might need. Second, tell that code to the insurance company, have them read it back to you so you know you're on the same page, and ask what your total costs will be. DO NOT ASK IF IT'S COVERED. "Covered" in medical insurance language does not mean the insurance company will pay for it, it simply means it's an approved procedure (wtf an unapproved procedure is I have no idea). This was mistake #1 for me. Third, before you actually go in for this surgery call your insurance company again and make sure they're giving you the same answer as before. If your plan suddenly changes and they don't inform you (cause they're dicks like that) you'll be on the hook.

Another important point: the Affordable Care Act states that all birth control costs are 100% provided by insurance companies, including female sterilization. HOWEVER,
 sterility is only a side effect of a bilateral salpingectomy. Fallopian tubes were historically removed as part of a hysterectomy in order to reduce the risk of ovarian cancer, and only recently are women turning to the procedure because of how effective it is at stopping pregnancy (no tubes, no babies). Compare this to a tubal ligation, which is only done for birth control purposes. This makes sterilization an off-label use of bilateral salpingectomy. Some insurance companies have this procedure labeled as sterilization because of its quickly growing popularity (up to 33% of sterilization procedures are bilateral salpingectomy), but mine did not. In principle I felt that insurance should have covered it because my primary reasons were for sterilization. 

Further, and this is an argument I had with many people at my insurance company over many months, is that even if laparoscopic bilateral salpingectomy is used for other things, I used it for birth control, as a preventative measure, so why isn't it paid for? The only answer I got was the code didn't specify either of those things.

What I learned is that there are generally two codes a doctor can use for laparoscopic bilateral salpingectomy: one that says it's birth control, and one that doesn't. There were two codes in my paperwork: one that described it as "female surgery" (no shit) and one that described it as a "medical procedure" (imagine that). The super weird thing was when I asked the insurance rep to read the codes back to me she said it "tubal ligation." Which would be paid for. When I asked why it said tubal ligation and they still weren't paying for it she said that's where that second code comes in, the one that called it a "medical procedure." Apparently, in order for Blue Shield to pay for this surgery, it would need to have a code that indicated it was a "preventative procedure." What differentiates a medical procedure from a preventative one is something I still don't know. 
Call your insurance company and find out what their rules are. If they consider it birth control, awesome. If they don't, do your best to find out what your costs are going to be when all is said and done (hospital fees, doctor's fees, anesthesiologists fees, medical waste fees, administrative fees, any and all fees they can throw at you). Honestly, I'm an educated person and am used to talking with medical professionals and I feel insurance is needlessly and possibly intentionally complicated so people will just pay to avoid the headache.

Since this was the surgery I wanted and I wasn't going to get a less-effective surgery with a longer recovery period and more potential for risk because it would be cheaper (some things you just need to pay for), I didn't try too hard to determine all these things. Plus, I knew my company would pay my deductible so my risk of actually paying anything out of pocket was pretty small.
I had my surgery in October and finally paid up in April. When all was said and done, it cost just over $2,000 (less than my deductible, which my employer pays as part of our medical benefits package). The upside was the hospital was very understanding and worked with me to try and get Blue Shield to reconsider. They resubmitted the paperwork twice, I talked everything over with both my doctor and the billing department multiple times, and they put several holds on my fees to give me time to get it sorted out. I still can't believe it took 6 months. 

Here's my six week update, the official "back at life" time for anyone currently considering this procedure and the recovery period. And here I am one year later. Good luck to anyone considering a salpingectomy! Despite the struggles with insurance, it has been 100% worth it.