Have you been denied Health Insurance because of Uterine Fibroids?
By Hope Waltman

When women are diagnosed with uterine fibroids disease they are faced with two complex issues to research, treatments options and insurance coverage. Some women have even experienced being denied the right to purchase personal health insurance because their fibroids are considered a pre-existing medical condition.

To help Americans who are confronted with this issue State and Federal levels have implemented legislation as follows:

In some states, State Legislatures have created "High Risk Pool Plans" to help residences that are considered uninsurable or have a pre-existing medical condition. Each state has different rules, regulations, and health plans for their residents.

At the Federal level COBRA (Consolidated Omnibus Budget Reconciliation Act of 1996) was created to help people who left a company that hired 20 or more people. If the company you left had 20 or more people, it must offer you insurance up to 18 months (if you meet certain requirements). The individual would have to pay for the insurance premiums.

HIPAA (Health Insurance Portability and Accountability Act passed in 1996) is another Federal act that allows you to obtain group coverage from a new employer without having to satisfy a waiting period for pre-existing conditions. One requirement is that you've had 12 months of 'creditable coverage' and haven't been uninsured for more than 63 days. (Note: For HIPAA and COBRA research ALL the rules and regulations.)

Insurance coverage and 'pay her own way' issues to research.

What should a patient look at when deciding on a health insurance policy?

Paul Indman, M.D., FACOG, a Gynecologist who has a private medical practice in Los Gatos, California, replied,  "It is important to find a plan that has reasonable out of network benefits. Otherwise a woman may get a great bargain on a hysterectomy she doesn't need. Most of the MD's I know that contract with insurance do very little conservative treatment, since they are often reimbursed at less than the cost of providing the care. So if someone is caught in an HMO, it may be impossible to get coverage for anything but a hysterectomy."

Uterine Artery Embolization (UAE) is a fibroid procedure that is performed by an Interventional Radiologist. Does the Gynecologist or Interventional Radiologist start the pre-certification process for the UAE?

Robert Worthington-Kirsch, M.D., FSCVIR, an Interventional Radiologist who has a private medical practice at Roxborough Memorial Hospital, Philadelphia, Pennsylvania, said, "Unless a woman's insurance company has rules that state otherwise, it should be the responsibility of the Interventional Radiologist to obtain ALL insurance pre-certifications and clearances, and to assist with any or ALL appeals.

It is not the task of the referring gynecologist, primary care physician, or patient. I actively discourage patients from calling their insurance companies to check on or obtain clearances, since this requires some expertise in negotiating the health system. My staff has this expertise."

How does a physician bill a patient who has a health insurance policy, but the doctor doesn't accept the insurance plan?

William Parker, M.D., FACOG, a Gynecologist who has a private medical practice in Santa Monica, California, replied, "Some physicians' offices, who don't accept health insurance, will prepare all the paperwork and send the surgery bill to the insurance company. The patient will be billed for the balance. Also, some of the procedures, such as hysteroscopy and D&C, can be done in our office. This avoids the expense of going to a hospital and helps keep the cost down."

What should a woman 'paying her own way' consider when going for a fibroid treatment?

Dr. Worthington-Kirsch and Dr. Indman said the following should be considered:

1. The doctor's experience, training, expertise, and success rate with the fibroid treatment they perform.

2. Compare prices for the doctor and hospital stay in the area you are considering to have the procedure performed. Too many times women don't realize the doctor and hospital cost of a procedure may vary by thousands of dollars. One example of this is Uterine Artery Embolization medical costs. Some physicians quote $7,000.00 for the physician fee, UAE procedure, and staying overnight in the hospital. While other doctors, located in the same city, may quote as much as $16,000.00 for the same procedure and hospital stay.

3. When comparing prices, you should also think about value rather than just the dollar amount. A low-cost procedure you don't need isn't a bargain. Neither is a procedure that is poorly done, even though the cost of the treatment is cheaper. Doctors that have special expertise in fibroids may be somewhat more expensive than doctors with little experience (the money spent on an experienced physician is money well spent because the success rate of the procedure may be higher).

4. Ask about additional costs. MRI/ultrasound tests, anesthesia, pre-op tests, and physician consultations may not be included in the amount and are billed separately."

I asked Dr. Worthington-Kirsch and Dr. Indman, "What could Interventional Radiologists and Gynecologists do to help a patient who has to pay her own way?"

"Most physicians and hospitals are willing to discuss arrangements for patients who have to pay their own way," said Dr. Worthington-Kirsch.

"Although I don't contract with insurance companies, my office will bill the insurance company for the patient. I also do in office hysteroscopy, which is much less expensive than doing the procedure in a surgical center.

Many times hospitals are willing to give large cash discounts for patients without health insurance in whom the full amount would present a hardship. I often can get hospital services at a fraction of the regular rate," replied Dr. Indman, who is a Staff Physician at Good Samaritan Hospital of the Santa Clara Valley, San Jose, California.

High Risk Pool Plan information for all the states, examples of Appeal Letters, Self-Funded Insurance Plans information, and State and Federal contact information can be found at the following URL http://www.hopeforfibroids.org/insurance.html.

Uterine fibroids treatment options

The fibroid treatment options are the following: Hysterectomy, Myomectomy, Uterine Artery Embolization, medication-drug therapy, and watchful waiting/observation.

Depending on the physician's experience and training Myomectomy can be performed using a laparascopic, hysteroscopic, or abdominal technique. Hysterectomy can be performed laparascopic, vaginal, or an incision can be made in the abdomen. For women who are looking for a less invasive procedure there is Uterine Artery Embolization (UAE).

A more detailed description of the fibroid treatments is available in the "Fibroid Treatment Guide", which can be found at the following URL http://www.hopeforfibroids.org/faq2pg2-videoresearchandtreatments.html.

About the Author: Hope Waltman was diagnosed with uterine fibroids in 2001, and had the Uterine Artery Embolization procedure performed the same year. In 2002, she created the Hope For Fibroids Organization to help people with their uterine fibroid research. She has published several articles in magazines, and is Hope For Fibroids web site Webmaster. She can be contacted at the following e-mail address hopewaltman@paonline.com.

Reprinted by permission of Hope Waltman, Founder of the Hope For Fibroids Organization.