Understanding Insurance as it Relates to Your Care & Treatment at the CEC

Please be sure to contact your insurance prior to your appointment(s) and/or surgery with the CEC to ensure that your policy is not a state-specified policy.

Claims such as “the CEC doesn’t take insurance…” are sometimes posted on certain social media groups in error. In fact, we do take insurance and always have, as an out of network provider like many other physicians. We have always worked with insurance on behalf of our patients since we were founded in 1991, ranging from the acceptance of out of network benefits to engaging in peer to peer requests to fighting high level appeals for our patients. As always, in addition to commercial insurance, we also accept CareCredit, Visa, Mastercard, Discover, and cashier’s checks if patients prefer. And of course, we also work with our patients individually on ways to try and accommodate their financial needs on a private basis to the extent possible, no matter their financial status or situation.

We recognize, of course, insurance can be a confusing issue and there may be significant misunderstandings about coverage and how it works with our Center, however. It is our hope that this information will clarify how we deal with your coverage; however, should you ever have any questions at all, do not hesitate to call us for help (770-913-0001). To expand on the above, however, please read on:

The Center for Endometriosis Care/Kenny R. Sinervo MD FRCSC, LLC is an out of network provider with all insurance companies. Despite confusion to the contrary, this does not mean we do not accept insurance and we are not ‘cash based’. This simply means, we will bill your insurance carrier at no cost to you, help with appeals and provide other customary and reasonable support,** but our services will process as an out of network (OON) practice. Seeing an OON Provider means you are seeking care outside of your insurance company's preferred provider network (as is the case routinely with other specialists); as such, they often pay for less coverage of related services versus going to an “in network provider” - who, while covered, may not be able to provide the focused and expert care for endometriosis that we do. We work for our patients, not the insurance companies.

Unless you are a ‘self-pay patient,’ we will file a claim on your behalf, as a courtesy, and appeal for coverage/reimbursement after the initial claim has been filed/denied. We will provide any other reasonable assistance required on a case by case basis in order to make your experience a smooth one and try to help you garner the maximum benefits from your coverage. Such service is just one more way that the CEC tries to help our patients. We can only do this, however, based on a proposed surgical plan for you, which is obtained only after you've undergone review with the CEC surgeon(s). Specifically: as an out of network provider, we do not accept assignment -- we bill the patient. Unlike many other Out of Network providers, however, once we have obtained the surgical plan from our surgeons, we will provide you with an estimate (and the patient’s max out of pocket figure they can expect) based on your personal surgical plan. This estimate is not based on patient insurance benefits, as out-of-network eligibility and benefits are not a guarantee of payment. We will not be able to tell you how much insurance is going to cover - but can best direct you on whether we think using your out-of-network benefits for our surgery will be the best financial option for you - or discuss other options that would better benefit you.

**Please note that patients with very high deductibles or who otherwise opt to come to the CEC as a "self-pay patient" in order to take advantage of our various discount or other payment options waive the ability to file with their insurance.

For information on “surprise billing” and “balance billing,” please refer to these articles from the US Centers for Medicare & Medicaid:

https://www.cms.gov/files/document/nosurpriseactfactsheet-health-insurance-terms-you-should-know508c.pdf

https://www.cms.gov/files/document/nosurpriseactfactsheet-final508.pdf

Self-pay/No Insurance:
Those who do not have any insurance, or who have no out of network coverage, are considered self-pay. It is recommended that you connect with your insurance prior to seeking care with our Center to understand your insurance policy and know if you have out-of-network coverage so there are no surprises. Please be advised, even if you have coverage, we cannot file insurance claims for patients who have asked to be treated as self-pay. Those with TriCare, Medicare and Medicaid, Kaiser, Ambetter and CHAMPVA (VA champ) are automatically considered self-pay with the CEC.

Although you may not have OON coverage for our surgeons, the hospital (which comprises the largest part of the costs of your case) and any associated providers may be still considered in-network, and you can still use your insurance policy to cover their charges. You will need to check with Northside Hospital directly.

Patients having such large deductibles and out of pocket costs for OON care, even those with insurance, might also consider going 'self-pay' to the CEC. Doing so makes patients eligible for possible self-pay discounts or other possible considerations (though contracted payment will be expected in full at least 3 days prior to surgery and there are no guaranteed discounts). Northside Hospital (click link to see accepted plans) may also offer similar upfront discounts for self-pay patients; we can help connect you to their financial department as you plan your surgery.

Why We Elect not to Participate as an “In-network” Provider:

Insurance companies limit provider decision-making and impact the quality of care you receive. To stay within carrier contracts, we would be required to reduce the quality of care offered to our patients, which we are unwilling to do.
We will not compromise the quality of services we offer in order to stay 'in network' with insurance companies; participating as an out of network provider allows us to maintain autonomy and improve the quality of care our patients deserve. We believe your treatment decisions should remain between you and your physician, not a bureaucratic entity that does not understand the need for advanced, multidisciplinary expert care for endometriosis and pelvic pain. You can also click here to learn more about the excision/insurance provider aspect of care.

When you send your records in for our FREE evaluation and review, we also direct you to send your insurance information as well in your records package. Make a clear copy of the front and back of the card (you might need to enlarge it for legibility). This information will let us get some idea of your coverage levels. You can also call your insurance company directly anytime before even sending your records to us and find out what they offer for OON services.

Unlike many other endometriosis centers, the CEC staff will take the time to check your eligibility and benefits. We will then provide you with an estimate, based off your surgical plan - and will discuss in full detail at the time of surgical booking. Once you have a surgery date, we will then verify if an authorization is needed for your procedure codes. Authorization is not a guarantee of payment. We will also pre-certify you, if necessary, for your surgery. You will be asked to bring in a specific payment at the time of your pre-op. The amount depends on the specifics of your case. We try to work with all patients in any way reasonable to make excision with us a real possibility, regardless of your insurance coverage (or lack thereof), including making possible adjustments and working one on one with patients on each of their specific situations to the best of our ability.

We can only speak to our own surgical fees; all other (hospital, anesthesia, surgical assistants, etc.) should all be contacted directly for their specific information. Please note as well that travel and lodging are not part of our fee quote. Patients are responsible for their own transportation and accommodation costs.

Please remember, each patients' insurance policy is different. We could have Patient A with BCBS and Patient B with BCBS, and reimbursement on their claims may be totally different. Just like you should be your own patient advocate, you should also be your own advocate with your insurance company and be prepared to appeal on your own if our appeal is not successful.

Please note we do not file for in-network exceptions.

We are here to help. Call us anytime with general insurance and coverage questions at 770-913-0001.

Did you know…?

The CEC staff has presented to national legislators including in Washington, DC about the critical shortfalls in endometriosis care. Those efforts have included substantive discussions about the failed coding and reimbursement structure surrounding endometriosis treatments and poor disease guidelines, both of which pose significant barriers to accessing gold standard care for everyone seeking treatment. We are also represented on institutional coding committees seeking to make significant changes and ultimately recognize the subspecialty of endometriosis to remove those financial barriers for patients. Of course, we also donate a number of surgeries and work with our patients year-round to increase access to our own Center.

See also: excerpted from "Low payments for excision surgery frustrate physicians, patients" (previously featured on the Endometriosis Journey, a project of MDEdge) by the leading medical writer, Alicia Gallegos:

"Similar challenges are playing out in practices across the country as surgeons try to manage the relatively low insurance payments for certain complex endometriosis-related surgeries, as well as the often time–consuming paperwork demands that come with seeking appropriate payments and coverage for patients...A spokeswoman for America's Health Insurance Plans (AHIP) would not comment specifically on coverage for endometriosis excision surgery. Health plans generally have individual policies regarding how they handle such treatments, said Kristine Grow, senior vice president of communication for AHIP. "Typically, they evaluate requests for new treatments on a case-by-case basis in the context of an expert review of all available evidence to make a coverage determination," she said in an interview.

The absence of a specific billing code for endometriosis excision contributes significantly to poor payment for the procedure, surgeons said. Currently, excision is generally billed under CPT code 58662, which refers to the destruction or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method. This means that insurers view a full and complex excision of endometriosis as comparable to a superficial ablation procedure, said Ken Sinervo, MD, medical director for the Center for Endometriosis Care in Atlanta, which operates on an out-of-network basis. "There's a huge difference between ablating something and excising something," Dr. Sinervo said in an interview. "With ablation, you can use many different forms of energy, most commonly cautery or laser vaporization. Unfortunately, those have about a 60%-80% chance of recurrence. Excision is a much more labor-intensive approach to completely removing all of the disease. What might take me 10 minutes to ablate could take several hours to excise."

At the Center for Endometriosis Care in Atlanta, staff members work with patients to minimize their out-of-pocket costs and also negotiate with insurers regarding coverage of procedures, said Heather C. Guidone, the center’s surgical program director. Center staff conduct insurance preauthorizations, research patients' benefits, process as much paperwork as possible upfront, and file claims with insurers, Ms. Guidone said. They also send appeal letters if patients are initially rejected for coverage and issue letters of medical necessity, if needed.

"We offer any assistance that they need throughout the process of care and thereafter," she said in an interview. "We really try to help maximize their benefits from their coverage. This helps not only educate the insurance company, but it helps advocate for the patient."...In some cases, insurers do change course and cover the procedure or surgery, Ms. Guidone said, but it may take several appeals. "I am encouraged every time I see an insurance company recognize that, 'Yes, this was an incredible increased degree of difficulty.' 'Yes, this couldn’t have been done at the local level.’ ‘Yes, we understand that endometriosis is a specialty disease that requires specialty care.’ I’m always heartened by that. I just wish it was on a broader scale," she said.

In order to improve the insurance landscape for physicians and patients, excision surgery needs to be more widely recognized as the optimal way to treat endometriosis, Dr. Sinervo said. This includes more education for gynecologists about excision and broader support for the procedure by the American College of Obstetricians and Gynecologists (ACOG). "It is very important that we try to train gynecologists to know what the most effective surgical treatment is," he said. "But there's a lot of resistance in the mainstream, with the American College, who aren't that interested in trying to demonstrate that excision is best way to treat [the disease]."

ACOG recommends a range of treatments for endometriosis, depending on the specific case. In a Practice Bulletin issued in 2010 and reaffirmed in 2016, ACOG noted that there was Level A evidence that "excision of an endometrioma is superior to simple drainage and ablation of the cyst wall" [Obstet Gynecol. 2010 Jul;116[1]:223-36]...A spokesperson for ACOG said that, over the years, it has worked diligently with representatives of the American Association of Gynecologic Laparoscopists to develop laparoscopic codes specifically for endometriosis surgery. For example, a new code proposal for laparoscopic excision of deep pelvic visceral lesions was submitted to the CPT Editorial Panel in February 2005, according to the ACOG coding department. That proposal was rejected by the panel, which concluded that "existing codes could be modified to reflect this service (e.g., 58662 with modifier –22)," according to ACOG.

"Attempts to obtain support from our colleagues in general surgery have been frustrating and challenging," the ACOG spokesperson said. "Without their support and buy in, we have been unable to get codes accepted by the [American Medical Association] CPT Editorial Panel. This has been an ongoing process, and we are currently attempting to engage with the American College of Surgeons to propose a set of codes."

"I truly believe that, if we don't make [patients] suffer for years before they have appropriate surgical excision [said Dr Arrington], we could prevent most cases of advanced-stage endometriosis that put patients at risk for opioid dependency, depression, and infertility. This disease destroys lives largely because it is inappropriately managed."