Thanks for your reply. You reply raises some interesting points:
#1 - The actual # of plans that Oxford offers in NY is very limited. My plan is the most generous. The payment amounts are based on a "percentage reimbursement that the group purchased * the Health Insurance Association Index" . This formula is common across all plans. Our % is very close to 100%. So proving reimbursement levels for a given CPT code would be relatively easy. The only real underlying issue is correlating a CPT code (same procedure Patient A and B) with an Index level (same level Patient A and B) and then applying a percentage. The deductible amounts would have a negligible impact given the magnitude of the total claim (in my case less than 1%). So - Yes - I think I can prove this.
#2 - I had 2 separate procedures. The other patients had the ADR/combo done in one shot, but only the fusion was reported to insurance (I would be interested in seeing how the Op reports were done). Apparently, Oxford found out about this and took some kind of action. So the other patients definitely will NOT let me use this information for fear that Oxford will come after them for fraud.
#3 - Your comment "would pay for a fusion but when in combo with an ADR would pay little" - this was precisely the reason the surgeon wanted to do 2 separate procedures in the first place - and it turns out that those who had the surgery in one shot paid very little out of pocket. I was quoted a $ amount to have the entire procedure done outside of insurance in one shot, and it was very close to what I am looking at now - and now I am potentially going to lose my job because FMLA only covers 12 weeks (had procedures spaced 1 month apart) - had I had the procedure done in 1 shot, I would have probably been able to return to work in 8 weeks.
#4 - The other issue is that the hospital (Lenox Hill) disclosed info about my ADR to Oxford without my consent (I specifically wrote "Do not disclose to Oxford" on my Financial Agreement Form for the ADR and they did so anyway). So I am wondering if this is a retaliatory action by the insurer.
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