So You Found a Pilonidal Specialist but He is Not in Your Plan?


Pilonidal treatment center of NJ.

So You Found a Pilonidal Specialist but He is Not in Your Plan?

Patients are generally unclear about the forces that drive a physician to non-participation with major insurance plans.  The most simple explanation is an economic one.  For many solo and small group physician practices, the reimbursement rates offered for services and surgeries are prohibitively low.  Surprisingly, an unfair playing field exists with this.  As an example, the payment offered a solo physician for a pilonidal cystectomy is dramatically lower than that negotiated by a large hospital on behalf of their employed physician for the identical procedure.

Thus it stands to reason that when a private surgeon acquires a unique skill, such as the ability to perform the cleft-lift procedure, plan participation no longer makes sense.  Rather, the physician provides the sought-after care, and is free to arbitrate with the insurance company for a more commensurate payment, not bound by a pre-contracted fee schedule.

So where does this leave you, the pilonidal patient?  Social media abounds with testimonials regarding superiority of the cleft-lift, and the critical factor of surgeon experience.  Yet, the surgeon is “not in your plan”, and you have no out-of-network benefits.  Fortunately, some insurance payors are beginning to make an exception in this scenario, making a payment agreement with an out-of-network specialist despite lack of this benefit.  We facilitate this at PTCNJ with a well-crafted correspondence letter to the payor, speaking to the challenges of pilonidal surgery.  Perhaps these payors are beginning to see the morbidity and excessive costs of traditional pilonidal surgical approaches.

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