BCBS 100% M6 C two level PAID
 

Just wanted to share my shock as my wife brought in the wet mail today including a check for 100% less $200 copay for my Two level M6 Cervical surgery with Dr. Clavel. Out of the gate and no appeal!!:puke:

There is a little unknown or obscure thing that Quiron hospital is a preferred provider for BlueCard Worldwide. Look it up if you have BCBS.

Now, I did put through my Broker and I'm not sure if there was any intervention by her but what I can say is WHOOOOOOP!!!!!:beer:

Time for the Lumbar claim now that this is done.

The only deductions were Hotel and the extra insurance.

Keep great records and write a full synopsis with facts and not feelings.

Heres hoping for more results like this for others to come..

That's AWESOME FranklySir....I have the BlueCard WorldWide, and they told me over the phone that "in-network" and "out-of-network" is based on what your home BCBS deems it. Do you have private insurance throught BCBS??

When i contacted BlueCard WorldWide, they told me to send all the reports and billing to them FIRST, which contradicted what my home BCBS providers told me. BCWW said many say that, but it needs to go to them first due to complexities and coding when dealing with foreign billing. I was even given a case number by them to hold onto. They said they are aware of Quiron hospital and have dealt with billing directly before with them. My surgery is Feb. 14th, and the representative of BCWW said they will contact Quiron to make sure everything was going fine, the procedures are medically necessary, etc. I opted for the bank wire transfer, because BCWW does the wire transfer directly to my bank account themselves, not my home BCBS provider ( I was told). I would like to keep home base out of this as much as possible. :D

I'm i the only one who contacted BlueCard WorldWide prior to surgery to get coverage confirmation?? I never told them what types of surgery i was going to get, only that it was spinal surgery.

FranklySir, if you pay for your own insurance (your own boss), i can see why you got 100% reimbursement. My "out-of-network" coverage is 70%....i hope somehow i can reclaim 100%, but 70% is better than 0%. There was 2 other posters here who went to Clavel and got reimbursed with BlueCard WorldWide. One was at 60%, and the other at 100%. Funny how the percentages vary, but it could in fact be solely based on what your BCBS representatives pay at.

That is GREAT NEWS and keep us posted on your lumbar reimbursement. Hopefully, it will go off without a hitch.

whats better than getting a life changing surgery, all your hard earned money back good to hear,love dr. clavel

B,

First.... I wish you the best on your journey to Spain. Feel free to PM me if you need any help or insights before you leave that you may not have thought of. Give Doctor Clavel a big Hug from me and tell him I'm doing great the big italian guy And Yolanda tell her Superman said hello and hugs as well.

Your gonna do great!!!!

I think is mostly due to Quiron being a preferred provider for BCWW. I towuld make sense that they would consider in network. It is only conjecture since I'm not gonna complain. It is nice to get this back and especially without a fight.
I do have a private group plan that is payed for by my company that I own.

I believe the better the record with all the backup made the difference. Secondly I think that the experimental investigational thing is out the window now since this is not so in Europe. It is a gamble however to do this out of pocket. I think you have the right idea going direct to BCWW. Others here say what I believe don't ask for permision but forgiveness later. It is really a hard call.

I just wanted to get fixed and fixed fast since I was losing muscle,feeling swallowing problems and speach issues. The money didn't matter at that stage but getting it back is all the sweeter and my neck is great!:wiggle:

Now 7 weeks out today from the double lumbar, I am feeling pretty darn good and this is bringing up my spirits even though I have miles to go. Hoping for the double bubble now. Can't see how they could say no after paying out for the neck. Nothing like having a precedent huh..:nono:

Wishing all well and peace of mind.

Frank

Frank,


You could be right about that "asking for forgiveness"....the others who got paid also did not contact BCWW prior to surgery. Jasonhhh got paid at 100%, 2Confused at 60%. These damn insurance companies don't seem to know how to be consistent. Looks like i'm gonna take the dive and be the first to get a semi "pre-authorization" for this overseas surgery. Although, i did schedule it before i made it known to them what my intentions were...the lady on the phone acted like it was no big deal and issued me a case #. STRANGE.

LauraB, who also has BCBS, was told by her insurance she shouldn't have sent her information to BCWW first. Why, i don't have a clue. They told me ANY foreign procedures done should go through BCWW first. i believe she did the right thing though. I'm not sure how BCWW works in conjunction with your provider. My provider didn't even know what i should do first, they said to send the billing to them. BCWW sounded way more convincing, and logically seems like the first place to send your foreign bills.

As far as "preferred provider", i asked BCWW about that, and they said it doesn't play a role when determining "in" or "out" of network, that's up to your insurance plan. BUT, if they do the international coding themselves, they may be able to wiggle the numbers to where you get a much healthier chunk of your money back, seeing as how much money your saving them vs. U.S.

I got an "out-of-pocket" estimate of $48,500 for a fusion/ADR for 2 cervical levels from a local surgeon. That is JUST the surgeons fee. My cervical by comparison overseas is around $16,000 U.S. dollars. Doing both procedures at once also saves a good chunk of change....Hopefully they will take these things into consideration....I will note of them in my cover letter when i submit my paperwork.

So what should be highlighted in your letter to BCWW ?? Cost savings? Preferred Provider hospital ?? Failure of conservative treatment? inability to work ?? Surgeon experience?


One more thing, i have an app on phone that lets me record any conservation i want and sends it to dropbox....so if the insurance tries to backpeddle on me, i have evidence of their approval recorded that i will use in my defense if need be. I have recorded conversation with BCWW and my BCBS rep who gave me the go-ahead and confirmed my WorldWide coverage. Just for back up, i highly recommend the app. (InCall Recorder)

Here is a description of BlueCard WorldWide from a website i found called EAST COAST HEALTH INSURANCE:

Attachment 470






It describes the process of getting overseas coverage. One line to pay particular attention to when trying to maximize your reimbursement....


"Once you have gone through the verification and appointment setting processes, the way you receive international in-network care should be identical to how it works at home."


Frank, according to this document, it seems that the "Preferred Provider" role of Quiron Hospital perhaps does play a strong part in getting in-network coverage. The way everyone has been doing it fits the bill of "out-of-network" type transactions. Unfortunately, due to past experiences with international patients and health care, Clavel's office only accepts full payment out of pocket at this time. Maybe one day in the near future, the bugs will get worked out and the need for that will no longer be necessary.

I will be sending in this document with my papers(along with a print out of the webpage that states Quiron Hospital is a Preferred Provider and my case #), and highlighting this particular area, citing this document as a source of reference going through this process. Doing all that can be done to maximize reimbursement.

B,

When you look at percentage realize one thing. Insurance will not cover travel, meals, hotel and flights which is common sense. They wouldn't do it here nor will they anywhere. This is exactly what they removed from my bills. Hotel after care and the insurance for Clavel just in case you need intervention. I still think its a good idea to get that insurance.

Second, remember one thing. It is all green to them. It's just business regardless of how much it is personal to you. SO when you do or if you even need to do a synopsis keep it impersonal to 95%. the last part of the Document hsould be about getting back to taking care of your family or business and short and sweet. They will make the decision regarding the cost benefit when they audit the claim.

When I get some time I will post what I put together as a template.

Again if you need any advice on what to take or do while there just PM me.

F

Yes, i didn't expect my BCBS to pick up travel expenses. Were you given a choice on the aftercare insurance from Clavel ? It was included in my quote. Posting your template would be beneficial for future posters to see....If i'm successful the first time in getting reimbursed, i also will post how i went about putting together my paperwork for others to consider. I don't feel it necessary to treat the first go-around like it's the appeal process, because what information do you have left if they turn it all down? I could be wrong.

I plan on doing what you pretty much suggest. Keep it simple, don't overwhelm them with unnecessary literature and medical history to start.

1. International claim form (Case number if it applies)
2. Brief patient history with the condition your having treated.
3. All medical reports, invoices, and itemized billing from hospital.
4. Proof of wire transfer or receipts that payment was made by you to the hospital.
5. Copy front and back of your insurance card may be optional. International claim form has a spot for you I.D number, that could be sufficient.
6. Finally, STATE YOUR CASE....In short, let them know why you did what you did. You should be able to articulate yourself to them in such a way where they know you made an informed decision based on extensive research.
This part should not be long and drawn out. Keep in a "Matter of Fact" type tone.

If there is anything else that can be added or modified, i'd like to hear it.
I'm not sure i believe including any vast medical history evidence of conservative treatments prior to, is necessary to obtain coverage. Or that you need to include multiple surgical opinions in writing...that information sounds more like "appeal process" information. The "letter of medical necessity" from your surgeon should take care of all that...it is a big part of your claim...In my talks with insurance reps, they always bring up the terms "medically necessary".

B,
after care insurance was optional on the first surgery. I think you can opt out but on my lumbar it was on the quote probably so two quotes don't need to be generated but not sure. For me it was peace of mind and would still do it and did on the second surgery as well.
I agree with all of your list. I would however list the conservative or the treatment path in a general sense not as in like legal ease.
Only in the event that you are NOT seeking Preauthorization. You are seeking preapproval with BCWW so the Letter of necessity should suffice if they authorize up front. the conservative listing works when asking after you have paid without approval.

You are right IMO that hold some back just in case you need to appeal but too much that it has to be appealed. Fine line.

Mine was 11 documents plus the synopsis. Card copy like you said not needed/ just your member number.

Like this: synopsis but leave wiggle room as in from memory on some items. remember they have access to most of your records if you have been with them. short enough to get them to actually read it and long enough to cover the points.


July 2013
PCP ordered MRI
PCP Or surgeon course of oral steroids
Attended PT ordered by Surgeon
Pain Management by PCP or orhto list meds

August 2013
Oral steroids
COntinued PT and pain management
Surgical appointment
Surgeons assessment fusion and get opinion on ADR
Met with PCP to discuss ADR and he/she agrees that I would do well blah blah

Laying it out like this shows you have exhausted all conservative treatment
backing up medical necessity without saying it.

So we shall see since i will submit in the same fashion as before. not sure really what the magic was but being matter a factly mostly and lastly humanize yourself I think was key. The rest is just numbers and billing factual info. Complaining and making it a bad read turns these guys off and they just put it down. Iwould be careful not to put in their face their own documents. It shows you read them and the wording can trip you up especially given your case that your are getting a Preauthorization. Its either yes or no. Or am i wrong?

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