Iām looking for advice on a site-of-service denial and whether switching insurance would make sense.
I had a breast reduction authorization submitted through my current insurance, Blue Cross Premera, at the end of May. Two days later, it was denied because of the site of service. My insurance wanted the procedure to be performed at an ambulatory surgery center (ASC) instead of a hospital setting.
When I contacted insurance, they explained that if the surgeon did not have ASC privileges, or if there was a medical reason the surgery needed to be performed in a hospital, the provider could submit additional documentation or appeal the decision. My surgeon doesnāt work out of an ASC, only a hospital so I thought a peer-to-peer could be done to reverse the decision. Iām young and healthy and donāt have any major health issues aside from the constant pain, strain, and recurring rashes caused by my breasts.
However, my surgeonās office was not willing to appeal, do a peer-to-peer review, or submit additional documentation. They instead provided an out-of-pocket quote, so I decided to move on and look into other options.
I have another consultation scheduled with a different hospital-based surgeon soon. I have found that this surgeon may perform surgeries at an ASC, but I am not completely sure if that would be the location used in my case. I was waiting maybe to see what would be said at the consultation before switching.
My employerās open enrollment is coming up soon, and I have the option to switch from Blue Cross Premera to Cigna. From what I can tell, Cigna has similar medical necessity requirements, but I have not seen the same ASC site-of-service issue.
Would you stay with the current insurance and see how the new surgeon handles the authorization process, or would you switch insurance to avoid potentially running into the same site-of-service issue again?
Iād appreciate any insight!