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View Full Version : Ins approval-rescended a NEW way-Please Read


D. Coley
06-10-2007, 08:00 AM
I was approved by Blue Cross/Blue Shield March 2007 for the anterior Charite disc replacement at L5-S1 with a significant proven medical necessity. I scheduled the surgery in OKC for April 19th, 2007 with Dr Stewart Smith. I had a sinus infection therefore surgery was rescheduled for May 3, 2007. The sinus infection progressed to pneumonia therefore another re-scheduling for May 31, 2007.

I received a call from the neurosurgeons office on May 15th (2 weeks-2 days to go). They stated that there has been a "reduction in the surgeons reimbursement fee from $11,000. to $1,500.-$1,700." Of course I asked what the heck that it meant and what it had to do with me?? She stated that many of the major insurance carriers have gotten together and examined a determination of Medicare which decided that the surgeon's (one neurosurgeon and one general surgeon for the procedure) allowable fee is $1,500 to $1,700 for BOTH of their time in the OR. Insurance Cos have concluded that since Medicare decided that amount that they are only going to pay that much too. I CANT BELIEVE THIS!!!!!! My surgery has been cancelled until further notice. I immediately called Depuy/Charite Advocacy Group who knew me well as they had been ready to file appeal and fight if BC/BS did not approve me right from the start for the disc, they did not have any idea what I was talking about on the reduction of fees and immediately got in touch with the neurosurgeon's office to get the documentation from them. I called BC/BS in New York and they did not know of any problem with the reimbursement and said that it must be at the local level in Oklahoma (in-network ppo issue where all the bills for the surgery is submitted).

I went in for a follow up with Dr. Smith on May 22, 2007 and we talked about this situation, he is horrified at this development with the insurance companies!!! He explained to me that he could not work for that kind of pay which is alloted as $1500 to him and $200 to the general surgeon to open/close the patient. He said that NO general surgeon would work for that amount either. I completely understand!! This has been a long journey and I am SO mad at the insurance company that I pay $600. a month premium (by the way is on COBRA coverage and will expire at the end of this year).

I told Dr. Smith that I would wait a few weeks to give time for this nightmare to be worked out and hopefully get resolved but what are some other surgery options available EXCEPT regular anterior fusion???

Dr. Smith told me about a NEW alternative minimal invasive fusion procedure called the AxiaLIF which web site is Trans1.com. He said he had done six since the first of the year with GOOD results and said it was definately a "viable alternative to disc replacement". Has anyone had this done or know anything about it??? Please respond because I am climbing out of my skin with increasing pain and intend to call Dr Smith toward the end of this week and say "Set AxiaLIF Up for the end of the month, I can't wait anymore!!" Please help if you can.

36 year old female
5' 6" - very small framed
100# to 110# max

<LI>1990-Natural Child Birth (7# 6oz)
<LI>1994-Natural Child Birth (6# 13oz)
<LI>1989-2006 heavy lifting in career
<LI>2003-3/2006 constant Chiropractor Visits
<LI>7/2006 MRI of lumbar
<LI>8/2006- Physical therapy, cortizone injections, lots of pain
<LI>12/15/2006 Discogram of lumbar..ouch!
<LI>4/19/2007 Scheduled for Charite disc @ L5-S1
<LI>5/15/2007 Surgery cancelled for reduction of fee reimbursement

Harrison
06-10-2007, 08:16 AM
D.,

I am afraid that everything you stated was true – the insurance companies did get together a while ago and “colluded” to reduce the reimbursement fees for disc replacement. This is tantamount to eliminating the option for both doctors and patients! http://adrsupport.org/groupee_common/emoticons/icon_mad.gif

More on this in the Oprah post in the Big Bucket...

LBP
06-10-2007, 08:41 AM
Wow this is getting out of control....a story for Oprah?

I beginning to wonder if there's some kind of RICO law suit brewing. Relating to organized insurance fraud and embezzling our insurance premiums, mail fraud????

Maybe you should make a call to the district attorney's office? It just doesn't seem legal that insurance companies could get together and force policy this way. Private insurers are for profit...Medicare is a federal progam for elderly and disabled persons...the same standards should not apply. this just smacks of fraud and interferrence with free competition/commererce???? I don't know alot about this but if you got these kinds of facts, it's worth a phone call!

ZorroSF
06-10-2007, 09:16 AM
We don't know your condition precisely, so we couldn't recommend fusion over a motion control device like ADR. If your facet joints are bad, then receiving ADR will make them much worse as I have found out personally. However, if your spine is healthy and there are no other degenerating levels and you don't suffer from scoliosis or any other imbalance then ADR is for you.

It's almost better to just go through with the operation and get a laywer to file a greviance later. If you have a medical necessity and you don't receive treatment ASAP then you're degeneration will start moving up level by level.

I waited too long and now after the op it's moving up a level. Right now I am stuck with the $10,000 doctor bill, but the insurance did pay for most of the hospital bill.

Just an FYI, my doctor's office told me the op was covered and now insurance is telling me it's not. since my doctor's office has been negligent from the start, I'm going to have to believe my insurance company on this one.

I'm in for one hell of a greviance fight, just like everyone else here that can't afford this medical care. BTW I have blue shield of california and I pay $400/month plus deductables and co-pays. Probaably about $1000+/month and I get nothing out of it, but shrugged shoulders from doctors.

ZorroSF
06-10-2007, 10:29 AM
I just checked out that site on AxiaLIF. That looks like an interesting surgery. What is the material they use to replace the diseased disc with?

D. Coley
06-10-2007, 10:59 AM
It just indicates that it is a bone growth material is inserted in place of the nucleus?? I requested the free information and received it last week. WOW. Looks like an option.

My problem summarized on the MRI as:
L4-5 central canal stenosis and bilateral neural foraminal stenosis secondary to bilateral facet hypertrophy and broad based annular disc bulge
AND
L5-S1 disc desiccation, left neural foraminal stenosis secondary to bilateral facet hypertrophy, left greater than right.

I wonder if the report has the two descriptions reversed because they are worried about L5-S1 and discogram confirmed L5-S1 wouldn't hold any fluid. I know that I'm at the end of the road in tolerating the pain.

D. Coley
06-10-2007, 11:09 AM
LBP,
The surgeon is SO pissed. He was livid when I went in to see him and was dictating letters every direction. He copied all my documents and contact information for people I had talked to at Charite and at BC/BS. There were TWO people in his office working non-stop on this issue. I told them that I would give them a few weeks to try to get something done and/or for me to check on the AxiaLIF procedure. That has been since May 22, 2007 so I'm calling at the end on this week to schedule the other surgery. I can't wait anymore, I'm suffering too bad!!!

ZorroSF
06-10-2007, 11:46 AM
since you have stenosis, I'd get two or three opinions before you have surgery. I am no doctor, so don't believe anyone here over the advice of one. However, if you have a narrowing of the spinal canal, I am not so sure ADR would be able to fix that entirely. In fact I am not so sure fusion would fix that. it almost sounds like you need ADR and X-Stop. It really depends on how bad the stenosis it.

I know there are others here that have undergone that type of pain. I hope they see this thread and add some feedback.

LBP
06-10-2007, 12:02 PM
Coley,

with the news about the ins companies getting together and almost seeming to collude on how to create a new policy...I am wondering if there is anything rising to the level of criminal activity for a district attorney to investigate...not just an invidual civil lawsuit. Your facts are very unique. Do you have anything in writing about the reasononing? Like there was a meeting with out ins co to pay only what medicare is paying?

Re your pain and surgery. I am sorry for your pain and I don't know anything about the other procedure you mentioned. best of luck. I just find what happened to you so alarming for the future of ADR.

D. Coley
06-10-2007, 11:13 PM
LBP,
The surgeons office has the notification letter about the fee reduction so I believe it is in writing including the reasoning. I too am VERY appalled at the chain of events and like I said... I only have COBRA coverage until the end of the year and if I don't do something then I will fall under "pre-existing condition" if I try to get future coverage. I just can't believe this is happening!!!!! Last month I was thinking Option A is disc replacement and Option B is fusion if there were any problems. NOW the ins co has decided that I have to do Option B-Fusion and if there are problems then I'm SCREWED. I am SO VERY ANGRY that I pay them $600. a month to take away my choices and compare me to welfare and elderly coverage persons!!! I have nothing against those people but I am not getting anything for free http://adrsupport.org/groupee_common/emoticons/icon_confused.gif

LBP
06-11-2007, 10:43 AM
I was in a panic too when my COBRA was about to expire. I exhausted my Federal COBRA and then my State extended COBRA....but it was all over, I qualified for a state program. In Wisconsin it's called HIRSP. Under this program I qualified for insurance with no exceptions for preconditions because I had exhausted my Cobra and had applied for this new insurance immediately. Please look into your own state health programs. You might be able to find something. There are a variety of things here but some are based on income, whether you have a family or a single etc.


In any case PLEASE send your story to Harrison at info@adrsupport.org so he can forward it to Oprah!

D. Coley
06-11-2007, 01:48 PM
LBP,
Thanks for the information. I am trying to find out about the extension now. I didn't finish this post before they said OKlahoma does NOT offer anything except Medicare or SoonerCare. Just great http://adrsupport.org/groupee_common/emoticons/icon_mad.gif

I have already sent my stuff to Harrison and actually he called me yesterday to discuss a few things directly. I hope everyone else sends theirs because this is a great opportunity for everyone suffering!!

I spoke to the Charite group this morning and referred them to this site and referred to the submission that Harrison is putting together. Bill Milligan is the rep that I have been dealing with there and has promptly done everything he can for my case.

Oh by the way, I talked to Dr. Smith's office this morning and the x-stop procedures for stenosis were fantasically sucessful that they performed but ins co's cut the coverage for them in 2006. Their motto is "Lets not fix anyone!! Lets just take their money until their DEAD!!"

ZorroSF
06-11-2007, 02:09 PM
it really sounds like you need some more advice from doctors before you go back to blue shield to refute their dismissiveness. don't do the many operation routine. I'm in deep *$#@ as it is, and wish I had done much more testing pre-op. I probably should've had a fusion and ADR. Instead I am probably heading for more surgery as it stands.

LBP
06-11-2007, 07:23 PM
D Coley,

I went to the OK Dept of Ins and found the following link...http://www.okhrp.com/


This is comparable to what I have in WI. You might want to call them to see if you automatically qualify because your Cobra as been exhausted. (have you exhausted a state extended cobra beyond the federal cobra benefits?) You should receive a notice from your insurance company giving you this option with a very short and firm deadline to respond. I don't know if all states offer state extended cobra benefits.)

D. Coley
06-11-2007, 07:52 PM
I talked to the OK Insurance Dept earlier today. That program is called the Oklahoma High Risk Pool and is for persons that can't get coverage through a private carrier, very high premiums!! There is not any extension of COBRA at the state level for Oklahoma. I got that confirmed from the US Dept of Laber earlier today also.

LBP
06-11-2007, 09:48 PM
Sadly, their high premiums may be less than quotes you get, if approved with other plans. I am not working so I was able to get a premium reduction based on income for my high risk plan, plus the premiums were much more than my prior COBRA premiums.

Does Aetna offer individual plans in OK? They don't in WI, otherwise I would prob have been willing to pay a higher premium knowing I could get my surgery!

ZorroSF
06-13-2007, 02:49 PM
well after reading most of this book;

http://adrsupport.org/eve/forums/a/tpc/f/7701036081/m/8571067452


it alludes to most expensive surgeries being recinded after authorization. In most cases if they do approve the surgery, they turn around and then state they will only pay for $1500. This doesn't matter if you have a spine surgery or cancer surgery. The author tell you how the process works.

I can tell you it ain't pretty. In fact I am so pissed after reading this book I just want to contact the attorney general's office to report this criminal behavior.

LBP
06-14-2007, 10:35 AM
Coley,

PLEASEEEEEEEEEEEEEEEEEEE send your story to harrison so it can be included in the first thread of the "big file"

Your insurance experience is HORRIBLE and needs to be heard

D. Coley
06-14-2007, 12:08 PM
LBP, thanks for your concern. I already submitted my story to Harrison on Sunday 6/10. He called me directly to discuss several details and said I was one of the first few responses that he received. I called the surgeons office today and am getting the AxiaLIF procedure authorized by the insurance co and getting a surgery date scheduled ASAP. I have waited as long as I can...

D. Coley
06-14-2007, 12:20 PM
Zorro, by the way... Dr. Smith is my third opinion to determine if surgery is appropriate.

I went to a woman neurosurgeon in the early fall of 2006 til the end of the year..she's the one that put me through all the physical therapy, pills (most of which I wouldn't take which pissed her off), injections and discogram. She would NOT do the disc replacement on me (not trained to do it-so I found out) and kept pushing me toward the traditional anterior lumbar fusion. I kept telling her that a regular fusion was NOT what I wanted and she wouldn't listen!!!!

The second opinion surgeon (Dr. Kelley) said "it's not bad at all..not even to justify taking pain pills and he would NOT operate on me". He was a snot nosed young rich kid that probably has never had any pain in his life and this is his first job. I thought my husband was going to whip him right there in the exam room.

Dr. Smith backs the first surgeon that ONLY surgery will fix it! Dr. Smith said that the discogram was totally unnessary because it is very clear from the MRI alone that the disc is TOAST at L5-S1!!!!

Funny part is that Dr Smith and Dr Kelley are in the same neorosurgery group and Dr. Smith is the chief honcho so I know there were some angry words spoken bewteen them when Dr. Smith found out what Dr. Kelley had said to me!! Ha HA Sure made me feel better..

LBP
06-14-2007, 12:43 PM
Best wishes to you in your upcoming procedure. Keep us posted!

epiphaknee
06-18-2007, 01:17 AM
This is a classic anti-trust case fact pattern. Insurance companies or any companies conspiring/colluding in an anti competitive manner to reduce competition (e.g. choices) for consumers/patients. State and federal Attorney General's should be interested in this bad behavior. Even Medicare wrote that denying claims for all ADR surgeries would have a cooling effect on this new procedure, due to their power and influence in the medical community. This may not rise to a RICO case, because in such a case we need a criminal enterprise, and anti-competitive actions may not rise to crimes. This would be a good story for an investigative reporter (60 Minutes or Anderson Cooper....)



Originally posted by LBP:
Coley,

with the news about the ins companies getting together and almost seeming to collude on how to create a new policy...I am wondering if there is anything rising to the level of criminal activity for a district attorney to investigate...not just an invidual civil lawsuit. Your facts are very unique. Do you have anything in writing about the reasononing? Like there was a meeting with out ins co to pay only what medicare is paying?

Re your pain and surgery. I am sorry for your pain and I don't know anything about the other procedure you mentioned. best of luck. I just find what happened to you so alarming for the future of ADR.

Ouch!
06-22-2007, 08:40 PM
D,
I am so sorry for your insurance problems. I hope you can get adequate coverage for this new proceedure you are considering.

Jane

D. Coley
06-22-2007, 10:06 PM
Update:

AxiaLIF fusion surgery is scheduled for July 23, 2007 @ 10:30 a.m. @ Northwest Surgical Hospital in OKlahoma City.

This is the quickest surgery date available because the surgeon will be out of town....oh well, I can't wait any longer for the disc replacement. Like the surgeon told me, it may take months or years for the insurance co's to agree to pay a reasonable amount for the surgeons services. If I try to wait, I may be bed-fast even on the pain pills.