If I pay out of pocket, is the ins co responsible for anything?

[mmarsh]

I have a question and I'm not sure if anyone knows the answer. Help out if you can, please. If I pay for my ADR out of pocket, what responsibility does the ins co have after the surgery? Let's say I have a post-op infection or if I need more surgery down the line, what is the protocol?

M-

[locorebob]

thats a great question. I am also curious of the postop implications when having non FDA approved procedure done overseas (e.g., two level cervical ADR).
Bob

[Terry]

Blue Cross/Blue Shield of Michigan has paid for my multi-level ADR surgery and has covered me for all of my spinal related issues since surgery. I had a long history prior to my going to Germany for the surgery and I still have issues since.

BC/BS has been very good to me http://adrsupport.org/groupee_common/emoticons/icon_biggrin.gif. That said I know that it is not that way for everyone and I wished that they would develop some consistency. That is what makes health care so maddening in this country.

Terry Newton

[Liz]

i tried to get in writing from my insurance company what they would cover post-op for a procedure they were not authorizing but they wouldn't send me anything and they were very vague on what would be covered post-op, always telling me it would depend on the situation. one of the reasons i think it's very important to obtain authorization for surgery (besides the cost of surgery) is that the cost of uncovered complications can quickly become astronomical.

what i discovered from the California Dept. of Managed Healthcare was that my insurance company was required to pay for any post-op infections i received in the hospital. they gave me the example that if someone had a facelift (usually not authorized by insurance!) and that person received an infection that insurance would be required to cover those costs.

when i spoke w/my insurance company they informed me that if i needed to revise to a fusion in the future they would pay for it but if i needed to revise to another disc replacement they would not pay for it until they changed their policy to cover disc replacement. for all other post-op treatments (PT, x-ray, doc appts, injections) i was told to rely on what was in my Plan description.

hope this helps... be sure to check with your insurance company though as everyone's policy is different. During my appeals process United assigned me a nurse case manager who proved to be somewhat helpful. good luck.

also, i noticed you are in CA so depending on your policy you may be able to appeal to the CA Dept. of Managed Healthcare for an independent review by their physicians. If they grant it, your insurance company is required to pay for it. B/c my policy was self-funded through my employer unfortunately I was unable to do this.

Liz

[mmarsh]

Liz

Thanks for the info. I was thinking that cosmetic surgery was the perfect example. Did you speak to anyone specific at the state level? Who at your ins co did you speak with?

M-

[Liz]

i'll try and dig up my contact person at DMHC but anyone at DMHC should be able to help you. since they are a gov't agency they also disclose all of their cases and decisions online. see http://wp.dmhc.ca.gov/imr/results.asp?id=6468&optFormat...ails=artificial+disc (http://wp.dmhc.ca.gov/imr/results.asp?id=6468&optFormat=html&cboDetermination=0&cmdSearch=Search&cboMC=0&cboTreatment2=0&cboDiagnosis2=0&cboDT=0&cboType=0&txtDetails=artificial+disc)

if this link doesn't work i can PM it to you. i think it's interesting to see what they are upholding and what they are overturning.

re a contact w/my insurance co, United assigned me a nurse case manager whom believed in my case but ultimately my surgery was never authorized. perhaps you could request that a case manager be assigned to you as well.

[mmarsh]

Liz

It looks like the DMHC never overturns anything! What is that about? Thanks for info.

M

[Liz]

i know... not encouraging... i did this query specifically for disc replacement last year when i was fighting for coverage. if you read some of the cases sometimes one of the three reviewing physicians will deem ADR appropriate for the patient's condition and recommend overturning the Health Plan's decision but if the other two don't it's majority rules and the denial is upheld. the two cases i had emailed myself were EI06-5974 and EI06-5652. i'm sure there are more by now. i think the more people that request the IMR (independent medical review) that qualify the better.

[mmarsh]

To all: spoke to a representative at my insurance broker's office and she said if I go ahead with an "unauthorized" procedure, the ins co is NOT liable to cover any expenses. I've decided that this is too big a risk for my family's financial future. If something goes wrong, we could lose everything we've worked for over the years.

M-

[Terry]

They are trying to scare you. I would go see an attorney. You had a condition that has been treated previously by your insurance company. They cannot decide to all of a sudden not cover you anymore just because you do not listen to them. You are the consumer and have a right to make your own decisions concerning your care. See a good attorney.

As I said earlier; my insurance company has covered my spinal issues for years and continues to cover my issues after ADR surgery.

Hang in there.

Terry Newton

Terry Newton

[Kirk]

Ask yourself a question. Is there anything I would rather do with $X than get out of this pain I am in? For me the number was $42,000 to put out up front (I did get reimbursed). Like you, I am not wealthy, but there was nothing I could have done with that money, nothing, that would have made my family and I happier than fix my back. Not a car, house, retirement fund, college fund, nothing. All that stuff can get taken care of once you have your health. Your health is priceless!

Originally posted by mmarsh:
To all: spoke to a representative at my insurance broker's office and she said if I go ahead with an "unauthorized" procedure, the ins co is NOT liable to cover any expenses. I've decided that this is too big a risk for my family's financial future. If something goes wrong, we could lose everything we've worked for over the years.

M-

[Terry]

[QUOTE]Originally posted by Kirk:
Ask yourself a question. Is there anything I would rather do with $X than get out of this pain I am in? For me the number was $42,000 to put out up front (I did get reimbursed). Like you, I am not wealthy, but there was nothing I could have done with that money, nothing, that would have made my family and I happier than fix my back. Not a car, house, retirement fund, college fund, nothing. All that stuff can get taken care of once you have your health. Your health is priceless![QUOTE]

Excellent point! End of story. Without your health you have nothing.

Terry Newton

[Terry]

Kimmers:

I am so sorry for your situation. I got denied originally by Blue Cross twice but then they ultimately paid with no intervention from me. I suspect it was one of my Board Members, who sells Blue Cross Insurance, called them and put in a good word for me.

Don't give up and I encourage you to continue the fight. If enough people stand up to them it still won't mean anything, as it is a huge corporation, but they will at least get the idea that people are willing to blacken their eye. http://adrsupport.org/groupee_common/emoticons/icon_biggrin.gif

Hang in there.

Terry Newton

[phylly]

Kimmers,
I also appealed to the IMR and they all the physicians said the same thing-no evidence that ADR was better than a fusion. I would like to appeal further so where exactly do you turn evidence to the CA. regarding the Insurance companies, I would be very interested and have not given up yet either.
Phylly

[mmarsh]

Phylly

Do you have an HMO or PPO? Did you file with the DMHC like Kimmers? Apparently, the DOI (Dept of Ins) is for PPO's and the DMHC is for HMO's. My attorney told me that the DMHC is essentially a mouthpiece for HMO's while the DOI is an independent office. I will be filing my paperwork on Monday with the DOI. I'll let you know how it turns out.

Kimmers

Thank you again for the inspiration to keep fighting! Was ready to throw in the towel until our last conversation. Now I've got a second wind. Much of that is thanks to the encouragement you gave.

Missy

[phylly]

Kim,
I appealed to the IMR-Independent Medical Review and was denied, that was after my denial from Blue cross. I have a point of service plan, so I can use any part, HMO or PPO. I have not given up yet either, but I haven't heard of the DMHC. I will PM about the rally.
Phylly

[Terry]

I feel sorry for anyone who has to put up with insurance companies acting like God and determining our fates and financial future, all the while lining their pockets and paying their executives far too much money. It's bad enough having to heal from a major surgery let alone having financial stresses because an insurance company has determined what is best for you. Sucks Big Time!.

Do not give up fighting ladies! There are several of us behind you. http://adrsupport.org/groupee_common/emoticons/icon_smile.gif

Terry Newton

[mmarsh]

Terry

Thanks for the good words! Is there anyone with a brain working at these ins offices? My surgeon wants to do ADR which will cost $22K and they want me to get another fusion which costs $77K. Can anyone explain this to me? I've already figured logic need not apply, but my goodness, who's running this asylum anyway?

Missy

[FUZZDOG]

When my surgeon spoke with Cigna regarding my hybrid adr at l2-l3 fusion l3-s1..and explained there would be less recovery time and less cost than the fusion the independant medical review "guy" replied...and I quote.....
"that does not matter"
I wish you the best in your fight.
I ended up having a fusion l2-s1 4 level and it has been a long road but so far doing ok so there is life after fusion.
I was declined the adr due to the hybrid application and being outside the fda criteria since adr at level l2-l3.
The boss of my department was also going thru a similar appeal for a prestige cervical disk one level only and met all the fda criteria. He was initially declined. He had the VP of our company intervene after giving him a thourough report of the benefits of adr over fusion in his situation. He was ultimately approved and Cigna paid for a one level prestige device I believe c5-c6.
Just goes to show even the same carrier for the same employees can come up with a different decision based on the facts. Keep up the good fight.
Coll

[Terry]

Sadly, sometimes it's not what you know but, who you know.

It was that way in my case as I had already had two denials and it got paid without appeal. I had a little intervention help.

Terry Newton