Paying for ADR/fusion hybrid

[ans]

Hi. I might need, pending a discogram and more facet injections, at least a fusion at L5-S1 and ADR at L4-L5 - a place that makes me nervous in case of trouble.

At one esteemed LA spine surgeon's office, the insurance person told me that with my coverage of BC of CA and BC/BS of NY (weak policy), that if I bill only for the one level fusion, they can deny this if they find out I had an ADR paid out-of-pocket. In the States, even this is expensive. I could alternatively try to get the ADR hybrid in full approved which of course would be a "no".

So is this how things are? That a person with a hybrid must pay for all levels out-of-pocket as an ADR at one level can preclude payment at all? I find this to be shocking.

Europe's to expensive for me. I know there's Pimenta in Brazil but don't know about his facilities, exchange rate - or anything other than he's respected. I think they ignored one person's attempts to contact them.

Anyhow, I sound like I'm complaining.

Just checking if people are encouraged to pay out of pocket for ADR/fusion hybrids, in toto.

Thanks and be well. - Allan

[cathydownunder]

Allan, As you know I"m an Aussie so can't help you with the insurance part of things.
As a guide though I can tell you my health insurance fund paid out over $42,000 for my hybrid surgery 2 years ago. Interestingly, I've just looked up my recent 2 level fusion payout and it was "only" $25,000. Big difference!
Cathy
N.B. the exchange rate right now is almost equal.

[Terry]

I did pay for my entire surgery out of pocket. My lawsuit against the homeowner whose dog took me out covered it and then BC/BS of Michigan also reversed their denial and covered my surgery. I was thrilled.

Terry Newton

[ans]

Thank you for your replies. Cathy, great that you were covered, and Terry, glad you won the battle (but how?). Looks like it took a "pound of flesh" to pay for the out-of-pocket costs and that nasty looking pitbull in our building's looking better.

Heal well people. - ans

[kimmers]

Allan,

If you find an answer to get insurance to cover ADR, please tell everyone. I have Blue Cross of California and they are some unprintable name.
I can't believe insurance companies are so stupid.
I like my ADR and yet I continue to fight BC and tackle workers comp also.
I keep thinking what would have happened if BC just approved the ADR when we asked for it. I would probably still be employed.
A lot of times I have just wanted to throw up my hands into the air and say, "who cares. You bleeping Blue Cross."
With wc, I have to prove that lifting patients and heavy stuff, caused my DDD. To me it is a no-brainer, but I am the one who was going to massage therapy because my lower back was hurting more and more. I didn't have a clue about DDD.
I feel like nobody is cutting ADR patients a break. I mean nobody from the private insurance companies (other than Aetna, Cigna, Kaiser). Like I always say, what use is insurance if you cannot use it?
I would fight for every little thing. I don't think insurance companies can deny care because you self-paid for an ADR.
I think that is a scare tactic, but ask someone more knowledgible in insurance law.
Again, my two cents--for whatever it is worth.

Kimmers

[ans]

Kimmers: I agree with you and thanks for your response. I note that you, a nurse, got denied 3X. Now this is discouraging and if I do go for it, we should get a team to work together and fight. (I used to be a researcher-type). I take it that you used The Insurance Warrior's advice, etc.

I admire your guts and perseverance. Anyone know a person in network news who could cover your story? Shame on them - or, shame them.

Allan

[Juli]

My insurance company paid for the fusion and hospital stay and all. I just wrote a check to my doctor for the charite fee, 20k for two, and had to pay the out of network costs for the rest of the stuff.

[ans]

Juli, I"m glad you are feeling so well.

Did Bitan's people even mention that you were to get an ADR or did they mention only for the fusion part.

If you wish to keep this private, then please PM me. Btw, what insurance company did you have?

Thank you for your time. I hope that you've recovered most of your life back!

W/Regards, Allan

[Juli]

Hi ans,

I believe they did submit the whole thing though we knew upfront that they would most likely not pay for the discs. I have United Health Care.

Thanks, I feel fantastic, best money I ever spent.
Hope things work out for you.

Juli

[kimmers]

Allan,

Has Blue Cross budged?
I am so entirely pissed off at them. I got a denial the other day for a CT exam I had at my sinus doctor's office. Now, these exams are pre-approved before they are done.
There is no way I will pay for this.

Just another example of Blue Cross's idiocy.

I am praying that Anthem/Blue Cross goes out of business. It would be just desserts. I can tell you I saw recently in the newspaper that BC/Anthem was fined 11.3 million for approving surgical procedures and then rescinding the policies of people after the surgery was done.

And here we are looking at a $63,000 hospital bill for my ADR surgery. They have quite a racket going on, denying ADR.
I learned a few things about appeals so I can help, but you cannot reason with BC. They are like a dictatorship.
I am not kidding when I say they are evil.

Sure, I studied Laura's book and e-mailed her for advice.
All in all, I would have ADR over fusion and am pleased with the ADR results so far even if it is a roller coaster ride.

[ans]

Thanks Juli and Kimmers.

K: I"m waiting for them to approve a new MRI requested by Regan's office. I"m sorry about this; they certainly do suck. I'm going to get Laurie's book ASAP. I"m sorry you hit the wall but maybe you can appeal?

I have not formally requested that they pay for a hybrid surgery yet. Just trying to get the ducks in line.

I might consider paying for an ADR one level out-of-pocket that would seriously hurt me financially but the idea that Regan's office telling me that it may be wise to pay for both a fusion and ADR out of pocket is a good logistic move blew me away. That is, they would deny the fusion is I had an ADR/fusion and also if they found out I had an ADR with the fusion, they could later deny paying for the fusion. Crazy..

But what matters is that you (and Juli- hi) are doing well and happy with your decisions.

I am afraid that they are here to stay. This business of demanding pre-authorizations and denying payment for particular things not ADR related seems new to me.

We must have Warren Buffet or Bill Gates adopt us.

You take care. - Allan

[Terry]

I have never had any spinal problems not covered by my insurance company after I had 4 level ADR. I had facet injections and epidurals every three months for the first year after my surgery. I also had a couple of neuro-surgical consultations to make sure the discs were installed correctly and had not subsided further.

I have Blue Cross of Michigan which has been absolutely superb to work with for my care. Not all Blue Cross is created equal. Ours is a non-profit organization that operates in the State of Michigan.

I do not believe they can deny care just because you went against them but I could be wrong. They do have a lot of power and need some Federal Regulation that will prevent some of the rampant abuses that are occurring.

Terry Newton

[LBP]

Allan,

If I understand your post correctly, I would not mess with trying to pull one over on your ins company by paying for the ADR level and ONLY submitting a claim for the fusion level. That could be deemed insurance fraud, and if by chance something bad happens during your recovery, and they realize you have a hybrid you could be in trouble.

After being denied a 2 level Charite, I tried to submit a claim for hybrid (1 level fusion/ 1 level Charite) and I was denied the whole procedure because of the one level Charite. UHC/PacifiCare point blank said they would pay for a 2 level fusion but would not pay for anything if any part of my surgery involved an ADR. It seems ridiculous but it's a reality.

[ans]

I"m glad LBP that you were able to have your desired surgery.

Thanks for your advice folks Terry and LBP.

I am too chicken to pull a fast one. It's unreal that they would deny the hybrid portion.

Be well, ans

[kimmers]

Allan,

You have to be real careful on how you deal with Blue Cross/Anthem. They can collect on a bill after they already paid it, three years after the fact.
See cbsnews.com/stories on July 4, 2008, our esteemed Dept of Managed Health Care, the supposed over seer of HMOs in California, did not collect on the 1 million dollar fine against Blue Cross/Anthem.
That is one of the appeal processes for Blue Cross. They overturn something like only 20 percent of the appeals sent to them.
We don't have a chance in hell. Another fact, if you have a company policy instead of individual an attorney won't touch you (that is on a contingency basis).
If you have an Erisa policy, fat chance too (only,for a large fee (":30-45K") and at least 18 months to get a hearing, I was told).
People told me, why cannot you pay for the discs and they pay for the surgery since the approach for ADR and fusion are the same? Blue Cross won't consider it.
Other insurances, maybe.
I have heard of too many people getting fusion instead of a desired ADR, because of Blue Cross/Blue Shield/Anthem.
Several in my doc's office, because I was told, "they were just worn out from the pain".
You have to fight them at the ground level. One of the things I was told, if my husband had been part of a large group policy (more than 50 employees), i might have gotten some help.
With my policy, I think you can go to arbitration, which I haven't done. The language is very confusing.

You have to know too that my surgery was preauthorized. That does not mean anything to Blue Cross/Anthem.

I have a whole laundry list of what Anthem/Blue Cross, etc... is doing to rake in more money. They stopped paying for any surgeries in which the surgeon made a mistake, they stopped accepting transplant patients at UCLA.
UCLA is one of the best known heart transplant centers in Calif and the US. They are also a top liver transplant center, etc. Blue Cross will not take patients from there.
They signed up people for a policy supposedly for young people without health problems. They even say they will take care of the bumps and bruises, but not the major problems.

The easiest way to get ADR is get another insurance company involved. Aetna and Kaiser are two.
I have been told by my sources that the health editor at the LA Times just gets a massive amount of letters regarding insurance denial and rescision (sp?).

When I went up to San Francisco in June to protest the health insurance companies, I met a lady who because she had the misfortune to get cancer, stage 4, Blue Cross rescinded her policy.
If they can do that to cancer patients, what do you think they will do to us?

I have seen evidence if you are younger, under 30??, they might be more preferential to your plight.

The problem is Allan, is that they are so big, they get away with everything.

Feel free to PM me. I believe there are ways to beat them and I for one, don't think I will ever give up. I do believe they will go out of business. Look at Enron, and others.

You just have to really think out your strategy. Don't settle for a surgery you do not want.

Kimmers

[ans]

Hi Kimmers,

Now that's chilling. You were pre-authorized and they can collect after they paid? Now that's a new one for me!

I am in my mid-50s. Nobody likes us old codgers. http://adrsupport.org/groupee_common/emoticons/icon_smile.gif

Thank you for your time and I shall PM you.

My very best ~ Allan

Postscript: I called an insurance person at another respected LA spine surgeon's office. You're so right!! They can authorize, then deny, and yes, ask for the money back! I was told there's a 50/50 chance that they'd even pay for the hybrid part. K: You operate on me. http://adrsupport.org/groupee_common/emoticons/icon_smile.gif

[gwin]

HI All:

I don't mean to butt in, but I am in a rather departe situation putting together an appeal to Blue Cross (Using Laurie's book and advise) for denial of a 2 level fusion.

I need to find other people that Blue Cross has approved for fusion that either had no documented spinal instability or severe pain alone was reason for approval of fusion.

I was set for a 2 level bi-lateral decompression and fusion of L1,2 and L2,3 plus laminectomy of L3 and L4, but the evening before surgery was notified by my doctors office that Anthem Blue Cross of CA had denied coverage. "Not medically necessary" because there in no clear indication of "spinal instability". 24/7 severe pain from L1,2 and L2,3, bone on bone.

I would really appreciate anyone who has been approved by blue Cross for fusion feedback. Thanks.