A Knee Injury Benched Jack, but Florida Blue Helped Keep His Wallet in the Game

Posted on Mar 25th 2019 by Florida Blue

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It started out as a normal Saturday. Jack met a few friends at the neighborhood courts for a pick-up basketball game. About 20 minutes into the game, Jack went for a lay-up. When he landed, he turned sharply and twisted his knee. First he heard a loud popping sound. Then his leg buckled beneath him.

It wasn’t the first time his knee hurt after playing, so Jack used what he always had— ice packs, over-the-counter pain meds, an elastic knee-support sleeve and sports creams. But this time, they didn’t seem to help with the pain. He tossed and turned night after night, and he had a hard time getting around. He even borrowed a cane from his dad.

Finally, Jack realized this time was different. His knee wasn’t getting better with rest and over- the-counter pain medications. Jack asked his friends and coworkers if they had a doctor they would recommend.

Jack’s co-worker Ellie had a knee replacement the year before. She suggested Jack see her doctor, who was part of their company’s health plan network. Ellie told Jack, “He was great to work with. We talked about the best treatment for me. I was concerned about the cost, but he consulted with the health plan to make sure the approvals were in place and my services would be covered.”

Jack and Ellie aren’t alone. More than 600,000 knee replacements are performed each year in the United States. This number is expected to grow to 3 million by 2030. Ellie was right to be concerned about the cost involved. Knee replacement in Florida averages $36,919, which includes a pre-op visit with the surgeon, the surgery itself, 12 physical therapy sessions after surgery and two post-op visits with the surgeon. It makes sense (and cents) to maximize benefits for your care and costs.

“When your doctor works with our medical team to discuss and agree on a course of treatment beforehand, you'll be sure to get the right care and will have the peace of mind to know that your procedure will be covered,” says Senior Medical Director Dr. Samuel Young. Here are some steps to follow if you need a service like a knee replacement done.

  1. Find a doctor or verify yours is in the network. To do this, log into your member account. Florida Blue can help you compare your options, plan ahead to maximize plan benefits and help you feel more confident about your health care decisions. Our customer service team can be reached by dialing the number on the back of your member ID card.
  2. Check to see if you need an approval for the service by clicking on floridablue.com/checkfirst. Some non-emergency services that need to be approved before you get the service include hip and knee surgeries, advanced imaging and cardiology services.
  3. Log in to your Florida Blue member account and visit our cost estimator tool to see your anticipated cost share. Check the status of your preapproval by going to “Authorizations” on your member account homepage or by calling the number on the back of your member ID card before your scheduled visit.

So, what about Jack?

The doctor suspected that Jack had torn one of his knee ligaments, which wouldn’t show up on an X-ray. Since Jack had been using a cane and other treatments for weeks with little or no improvement, his doctor submitted a preapproval request for Jack to have an MRI. The MRI showed that Jack’s knee was in worse shape than the doctor initially thought, so he submitted the request for Jack’s knee replacement. Jack’s doctor reviewed his treatment plan with Florida Blue, and Jack was approved and scheduled for surgery. Florida Blue was also able to recommend a high-quality, lower-cost place for his physical therapy.

The day after surgery, Jack was wobbly, but on his feet. Within six weeks, he was back at work and participating in low-impact activities. Jack appreciated Ellie’s encouragement and direction about care for his knee. The need for preapprovals for his diagnostic tests and surgery worked in his favor. He knew what to expect throughout the process and wasn’t surprised when he received the bill from the doctor.

If you find yourself in need of services like knee or hip replacement, a call to Florida Blue to check first could save you from receiving an unexpected bill for the full amount after treatment. There is no need for preapproval in emergency care situations.

Jack and Ellie are fictitious characters compiled from research and stories of members who have had knee replacement surgery.

Resources: anationinmotion.org, pricing.floridahealthfinder.gov

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