I have a question and am wondering if anyone has experienced the similar problem.
I had an ADR/Fusion Combo by a very prominent East Coast surgeon. Prior to surgery, I had spoken with 6 of his patients, 2 of who also had Oxford.
As Oxford considers ADR experimental (their policy statement actually says not FDA approved even though it was 3 years ago), I had to have two separate procedures. I prepaid cash for the ADR at a rate comparable to what others have paid. The fusion was pre-certified by Oxford - however the insurance only re-imbursed approximately 25% of cost, leaving me with a $50,000 balance (in addition to the ADR).
This was NOT the case with the other individuals I had spoken to (same surgeon, same insurance, same procedure). Furthermore, the CPT codes that were on my precertification were DIFFERENT than what was submitted to insurance.
Does anyone have the Health Insurance Association Indexes that insurerers use to determine max allowable cost?
I was led to believe that the ADR would be the majority of my expenses (about 35K), and furthermore, do not understand how the same insurer can reimburse at different rates for the same surgeon and same procedure for different individuals.
Any advice would be appreciated ... please PM
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