Patient Assistant Line (PAL) & Advocate
 

Has anyone used PAL or an advocate to help with their appeal?
And has anyone had success?

Ive tried to look at past threads on here but couldn't find anything.

My neurosurgeon has set me up with the Patient Assistance Line (PAL) who helped me get an advocate (Lindstrom) to help with my appeal/denial.

Once UHC denied my claim, PAL started gathering info for the appeal right away, we had to wait over a month for UHC to fax over the denial letter, they kept claiming that they faxed it, but nothing was ever received, then they claimed that it was never generated.... a bunch of lies!

On Tuesday (night) September 6, 2011 I received a UPS package that was left on my doorstep regarding the appeal. it was all my medical records, doctors notes and other insurance things... THEY LEFT IT BY MY FRONT DOOR UNDER A MAT! I mean come on! I have had to sign for things that you wonder why do I have to sign for this, and something that has personal info in it is just left on the front door for the whole neighborhood to see and possibly take!

I WAS PISSED TO SAY THE LEAST!

The package we got on Tuesday night stated that there would be a conference call that next monday (September 12, 2011) So I had 5 days to figure out what I wanted to say or do, and if I wanted to be apart of it I had to call in and give them my phone number. Thankfully I had Lindstrom Advocacy helping me out. I thought that the call went pretty good but I guess it didn't because they sent a letter either that day or the next day that the decision was being upheld.

So Im thinking they didn't even listen to what I had to say or what Lindstrom had to say and just kept the decision of the previous decision. It seems like to me that they left the call and all said "denied" "yep, yep, yep" and then that was it, they didn't put any thought into it. But what do i know I'm only the one LIVING IN PAIN, and the one that is trying to maintain my active lifestyle.

We found out later that the "expect" that made the decision graduated from medical school in 1961, and he's a pediatrician.

sorry for the long post I am just so frustrated (like everyone else that is on here dealing with the evil insurance company)

Becky, you have every reason to be upset -- there are so many absurdities in your situation. Is PAL a company or a division of a company? Keep fighting. If you can hire a lawyer, that will help...if you can afford it.

If I understood it correctly... PAL is a part of Synthes (Pro Disc-L) My doctor's office knew that UHC would deny the claim, so they started the process with PAL as soon as I decided that I wanted to have the surgery. We got all the info together to get ready to fight the appeal. (denial was upheld so we are starting with an independent reviewer to make the final decision). Again if I understand it correctly Synthes (Pro Disc) has a hotline to help patients get the procedure covered. I look at it as its considered "new" and "un proven" so if Synthes can help people that need the procedure then they get paid so it benefits them and the patient. (but then again I'm not exactly sure)

Since I wanted to have ADR I wanted to get the process rolling and a few days after my doctor filed his surgery orders to UHC all my info was sent to PAL and with in a day or two a representative called me to get my approval to have PAL represent me. They have been nothing but great. I work with Amy from PAL and I shoot her an email and by the end of the day she gets back to me, even if it "I'm not sure but ill get back to you asap."

PAL gets the info ready to go towards the advocacy (in my case it is LindstromAdvocy) I did some research on him and his company and he graduated from law school and advocates for people that are fighting insurance companies to cover procedures that are considered "experimental' or "unproven"

here is the link that I found that gives more of a description on what PAL is and how it works

http://www.synthes.com/MediaBin/US%2...cC-LJ8699B.pdf

Mary Jane Stull, The Patient's Advocate fighting the Insurance Nightmare and Providing Medical Claims Assistance., has helped Laura and I with a number of items; not ADR but other spine procedures and knees, SI, and other areas. We didn't head down the appeal route with those but she was able to drag money out for procedures that we'd never have been paid for otherwise. She is, though, expensive if you need to pay her by the hour.

gymnast - do you qualify for a clinical trial? i would think that's your best bet if you don't have any litigation involved and are willing to be in a trial.

i haven't looked into a clinical trial but if i get denied again I'm going to have to do something so ill look into it. but i wouldn't even know where to start looking for that.

i just know that I'm in chronic pain daily and its just getting worse. the pain is stopping me from doing a lot of the stuff i want to do, like spot my gymnasts and or just function as a normal human being :P

found this via google... for freedom trial Freedom Lumbar Disc in the Treatment of Lumbar Degenerative Disc Disease - Full Text View - ClinicalTrials.gov

Doc,
I looked into it and my husband requested info and they emailed him back with in minutes to tell him that the trial is full and they are not accepting anymore patients :(

i know they are at Carolinas Neurosurgery and Spine - Dr Coric - if you can travel. others may still be recruiting too... but again, would involve travel. you MAY be able to arrange to do some of your follow-up locally if it's the same study just a different site. Dr Coric I know has a dedicated research nurse. they tried to recruit me, i didn't qualify b/c of pending legal issue mainly.

ill look into that. i really want to get this done if i can. im so ready for it

Dr Coric is quite highly regarded as an ADR surgeon, and I can vouch for him being easy to talk to and whatnot. Unfortunately, he can't help me b/c of the legal issue, and I'm not comfortable getting a Prodisc (that's the control in the study).

Good luck to you. I'm just 3 yrs older than you so I know how much this whole **** sucks at this age. You go to PT/clinic and most people are over 50 or so.

My whole life has basically been put on hold - I'm single and have more student and personal debt than most people have for a mortgage. I do, however, have quite a life and profession to return to WHEN I'm better.

Doc,
The doctor you suggested was the office that my husband emailed to get info, and they were notified that the trial is full and they are not excepting patients anymore.
on the website you gave me there are a bunch of email address so my husband is going to be making a bunch of emails tomorrow to see if there is a state taking patients..

do you know anything about trials? like do i have to pay for anything? like hospital stay, doctor fees, other things or is it all paid for? I'm new to all this so i have no idea.

hm that's weird bc they were trying to recruit me not 3 weeks ago.

i don't know a lot about what is or isn't covered in trials - my specialty/place of work does very very few true clinical trials because of issues with informed consent. the research nurse or whomever does the initial screening for a trial would be the person to ask.

i would say medical costs and followup yes, travel probably not beyond a certain amount if any. but, i really don't know. i've never been part of a randomized control trial, nor conducted one.

i would say that emailing all of the people on that list would be the best way to go. i [I]think that the Freedom trial is the only active lumbar ADR trial in the US.

given that your level of involvement is L4/5, i would be pretty persistent about ADR. don't know your financial situation, but 1 level ADR with Boeree or Clavel is about $30k plus airfare/food/incidentals.

my medical situation is a little less clear since it's L5/S1 - not very mobile typically so not as bad to fuse. still working on M6-L vs minimally invasive TLIF decision.

though, i have the flexibility of a gymnast even w/ back trouble, so mine is probably hypermobile. my sport is swimming - where flexibility is a plus as well, but in a different way. i was too tall in 6th grade to be a gymnast - my adult ht is 5'8".

thanks... i want to make sure i have a backup plan if my 2nd appeal is denied. but the clinical trials are at least giving me a little hope

Clinical Trials
 

has anyone ever been apart of a Clinical trial? im looking into it just in case my second appeal gets denied.

Freedom disc has been closed but one of the clinics that are doing the trial for Freedom gave my husband another trial to look into... anyone have any info on this one? here is the website...



http://clinicaltrials.gov/ct2/show/NCT00927238

i think that since your level of involvement is L4/5, you'd qualify and it would be a reasonable try. the only thing is, the control is fusion, not a different disc.

the freedom trial was freedom vs prodisc. this one is nuvasive XL TDR vs fusion.

They got back to me and it seems that it would NOT be fusion!!!!! :) she stated that there is no control arm

so the way it sounds is that everyone in the study would be receiving the disc but then again i could be wrong

but my issue now is... that we would not be able to get pregnant for 5 years after the surgery :( which is a big concern to me considering i really really really really want to have a baby but then again whats another 5 years if i can get ADR and not have to do fusion!

decisions... decisions...

someone want to make the decision for me???? please!!!!!!!

a clinical trial inherently has a control arm, and the patients have to be randomized to exclude bias as to who they would "pick" to get fusion vs this new adr.

i would double check about this.

and yes - from what i've seen, most studies will tell you not to get pregnant for x number of yrs. 5 is on the high end.

Omg
 

UHC HAS BEEN OVERRULED!

i just got a letter in the mail today from UHC stating that my claim for ADR has been APPROVED!!!!!!!!!!!

Becky,

CONGRATULATIONS!!!! I'm so happy for you! What is your next step?

Good luck, Jeff

I guess my next step is to schedule the surgery. Once I opened the mail and got the letter yesterday... I kind of jumped up and down for a while screaming :P and then called the doctor but it was almost 5pm when I called so now its another wait to hear back from his office to get in and schedule the surgery!

I have been waiting for this for almost 8 years!

Im terrified and yet extremely excited to finally getting this done!

UCH can suck it
 

Ok so my surgery was approved November 1 and I had my surgery November 22

we fought with UHC lost and then fought again and lost the appeal then an IRO got brought in and made the final decision and it was approved November 1

well now UHC is trying to screw with me (excuse my language) but they are trying to deny the surgeons that worked on my case. I had 2 surgeons a general surgeon and my neurosurgeon and apparently UHC has decided that they will and have paid for all expenses for ADR but won't pay the doctors.

anyone else have this issue?

Becky, this is absurd -- but somehow not surprising. I am so sorry. I have seen every flavor of rejection from insurance companies since my own in 2004, so nothing would surprise me. Keep fighting or get a lawyer, or both. They expect that you will give up. They are preying on your weakness.

I hope I can turn this into a positive -- I'll say a prayer for you tonight. Turn "preying" into "praying" so to speak. Who is the patron saint of insurance appeals?! ;)

Harrison
 

Oh i have lawyers on my behalf (PAL set me up with Lindstrom advocacy) his group is an advocate on medical procedures... so from the very beginning i have had lawyers doing the appeal process for me.

all i have had to do through the whole process is sign papers and such. Lindstrom's team put together the appeals and did all the leg work. and i have been told by PAL that I have nothing to worry about because the ADR was approved and i will not owe anything no matter what and if it comes to it Lindstrom will get involved again and fight it. but to my knowledge ( but then again who knows if I'm right ) but this is all between the doctors offices and UHC but again it could all be a mix up and someone that didn't know it was approved sent out the message.

but i do appreciate the prayer. ill take anything I can get!

so someone explain this to me
 

so I've been looking into the reason why they denied my claim after an IRO overturned the claim and approved it, UHC PAID for Anesthesia, Hospital stay, Radiology but they won't pay for the surgeons... um what the heck!

on my online benefit explanations of claims paid the two things that are not paid are both surgeons so to me I could have the procedure but I couldn't have the two people who know what they are doing put it in? does this sound strange to anyone else?

here is what they state for why they are denying to pay the surgeons...
we went through this and it was approved so I'm really confused.

ANYONE ELSE HAVE THIS ISSUE?




*Remark Code PE: Based On The Information Provided, This Service Is Unproven And Is Not Covered. Therefore, No Benefits Are Payable For This Expense. In Order For This Service To Be Considered For Coverage, Scientific Evidence Must Be Submitted, That Meets The Standards Described In Your Benefit Plan Language, That Demonstrates The Safety And Effectiveness Of This Service For Your Particular Condition. If The Service Was Received From A Participating Provider, The Provider May Not Balance Bill For The Service Unless The Member Has Given Pre-service Written Consent To The Ordering Or Rendering Provider To Be Billed.