Why Provider Participation Status With Insurance Shouldn’t Matter When Contemplating Hip Arthroscopy

I know what you’re probably thinking. You read this article’s title and immediately wanted to call my bluff. How dare I suggest that insurance doesn’t matter, especially in the case of an expensive procedure such as hip arthroscopy?

Bear with me.

First, keep in mind that I am referring to provider participation status, which means the surgeon is either in or out of the patient’s insurance company’s network.  The reason this shouldn’t matter is because regardless of the provider participation status, your insurance company should pay for this surgery if you have properly met all diagnostic criteria and failed to achieve a satisfactory resolution via conservative treatment.  If you are contemplating hip arthroscopy, you need to know that this surgery is not typically performed except as a last resort.  It is still a developing scope of practice. Not only is this procedure relatively new in the world of medicine, but it is also very technically challenging. Some of the best surgeons in the world will not consider performing it. It takes extensive training and loads of experience, and, even then, when performed on the wrong candidate, it can fail.  As a patient, I would only want the most experienced doctor with the highest level of training to perform this operation.

Back to insurance.  To be honest, insurance companies are still largely unfamiliar with hip arthroscopy and often hesitate to provide coverage because they do not understand what they are being asked to cover.  Once a case for hip arthroscopy and postoperative physical therapy is made, insurance companies will usually grant out-of-network benefits to their insured clients, but typically only if one of the best physicians available is performing the operation.  The obvious reason for this is to protect their clients, but also to ensure the most successful outcome the first time with the quickest, most reliable recovery so as to avoid unnecessary costs, including, but not limited to, repeated surgery, prolonged physical therapy, and excessive time off from work, which might lead to a short term disability claim.

Simply put, I am viewed by insurance companies as a good risk, mostly because my practice is now exclusively devoted to hip arthroscopy and I have a solid history of success.   Therefore, I have a pretty good history of success in getting out-of-network coverage approved for my patients.  The truth is, however, that the success rate of this surgery is highly dependent on both a skilled surgeon and a good surgical candidate.  Therefore, I work tirelessly with patients to make sure they are optimal candidates for this surgery.  When it is determined that they are, my office staff does a fantastic job of getting benefits approved.

2016-11-28T23:16:35+00:00