Health Insurance and Pilonidal Treatments
This section is also mostly for US patients dealing with an insurance system. The USA has taken the first steps towards a European-style universal care system, but it will be many years before we complete this transition. Even in a universal system patients still have to fight for their health care as managing costs is an priority in every system, there is no getting around it.
If You Have Insurance
Insurance companies are getting better about understanding that Pilonidals are best handled by specialists. Some still want to argue (we’re looking at YOU, Kaiser Permanente), but if you make a big enough ruckus and keep going up the food chain, you can win. Even in countries with universal care systems, patients still have to sometimes fight bean counters for quality care. You must be willing to fight for you health, that is the bottom line. You must be relentless in your demand for proper treatment from a provider who knows what they are doing. Nobody else is going to fight this fight for you.
Never take “no” from a front line person answering the phone. Ask for a supervisor, then ask for the supervisor’s supervisor, if necessary. Be nice, but firm and don’t give up. Keeping reminding them that YOU are PAYING them for coverage. Remind them that it is in their best financial interest to get your Pilonidal resolved the FIRST time, rather than the insurer paying for 4 additional surgeries.
There are a number of great articles on the web for taking on your health insurer, we link to a small sampling of them below:
http://money.cnn.com/2015/02/19/news/economy/health-insurance-bills/
https://www.healthcare.gov/appeal-insurance-company-decision/appeals/
Be wary of surprise medical bills even if you have coverage. A common practice has been for hospitals / insurers to refuse to pay for out-of-network providers like surgeons and anesthesiologists. Make sure everyone who is going to end up on your bill is in-network or you have a guarantee IN WRITING that there will be no additional out of pocket charge for an out-of-network provider. Get it in writing from someone official, you stand a much better chance on an appeal. You can also sign a petition for disclosure of out-of-network costs here.
Don’t immediately pay when you get a bill, sometimes hospitals and doctors send bills before they’ve filed with insurers. Wait until you get an “Explanation of Benefits” notice form your insurer which breaks down charges and what’s covered. Ask for an itemized bill of every charge and check for duplicates (Consumer Reports).
Also, medical billing errors are frequent. The codes for Pilonidal surgery are below, make sure this is what is being billed. If the billing code is incorrect, start working your way up the chain to get it fixed.
Getting Your Surgeon to Adopt Cleft Lift
Surgeons sometimes are hesitant to adopt advanced procedures because they don’t know how to bill for them (and billing is what drives much of modern medicine.) The CPT codes that apply to Cleft Lift are below, your doctor’s office will know what these are and what to do with them.
- 10080 Incision & Drainage of Pilonidal; Simple (Lancing)
- 10081 Incision & Drainage of Pilonidal; Complicated (Lancing)
- 11770 Excision of Pilonidal; Simple
- 11771 Exicsion of Pilonidal; Extensive
- 11772 Excision of Pilonidal; Complicated (Pit Picking)
Cleft Lift Codes
- 11772 Excision of Pilonidal; Complicated
- 14301 Cleft Lift (Adjacent tissue transfer or rearrangement)
If You Don’t Have Insurance
Self Funding –
- 1) Purchase insurance on your own. You are legally required to carry insurance now, you may have a 6 month waiting period before you can schedule surgery. You can also set aside a savings plan or think about one of the new medical savings accounts.
- 2) Take out a loan. Get your costs from the surgeon’s office and take out a small loan to cover them.
- 3) Charge it. Get a very low interest rate credit card to cover the costs – but don’t use it for anything else.
Income Qualified Funding – these are options available to patients that meet low-income guidelines.
- 1) Check the hospital. Most hospitals have funding available for uncompensated care, but you have to ASK for it and meet their income guidelines. Ask to talk to their patient advocate or social workers.
- 2) Check with your State’s Dept of Social Services. Sometimes they give people temporary coverage who need treatments but aren’t covered.
- 3) Check with the staff at your doctor’s office. They may know of programs available to patients of limited financial means.
- 4) Check into Medicaid.
- 5) Check with your county health department.
- 6) Check Dollar For, an organization that matches qualified individuals with debt forgiveness programs. Dollar For
- 7) Check to see if there is an HRSA Medical Center near you. http://bphc.hrsa.gov/about/
Related Links
The main overview page for our Treatments section where you can review surgery options, plan for surgery day.
Look for a doctor near you from our worldwide list of Cleft Lift surgeons and recommendations on our forums.
Controlling your costs starts before your surgery. These are the costs involved and where you can negotiate some of them
This page last updated: January 4, 2019
