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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File.


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  #1  
Old 06-23-2007, 04:33 PM
traderoil traderoil is offline
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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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Old 06-23-2007, 07:48 PM
LBP LBP is offline
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You raise some interesting issues. The first question is whether these other people with the "same" insurance really have the "same" plan. I'm assuming these other people on Oxford work for different companies... that's sort of their out...if you work for different companies...it's hard to prove that all of you have the exact same plan with each respective company. There are so many combinations depending on size of employer and what kinds of options are selected by the employer, i.e.; hmo, ppo, open access, hsa, self-insured plans, etc, amount of premiums, deductibles, and perhaps even coverage differences???

As far as reimbursement for the surgery...I was told that my insurer would pay for a fusion but when it's a combo with ADR...there's very little they would cover.

Now I don't understand why the preauth codes are different than the codes on your bill? Have you asked your dr's office about this?

seems like you need to fight this a little further. Do you have documentation from these other people that shows Oxford paid for a larger percentage of surgery? will they let you use their statements to fight your claim? Maybe you need to see an attorney.

Also...have you sent your story to Harrison (email address deleted by Harrison) this is another insurance problem that should be included with the rest of our stories!

best of luck..sorry I can't help you with more specifics.
__________________
Injured 9/01
Annular tears L4/5 & L5/S1
denied adr by insurance for 2 level charite as well as hybrid fusion at L5/S1 with Charite at L4/5.

New ins paid for 2 level lumbar prodisc surgery on 4/7/08 (at age 39) with Dr. Westerlund, at Core Orthop
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Old 06-23-2007, 08:29 PM
traderoil traderoil is offline
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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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Old 06-23-2007, 10:11 PM
LBP LBP is offline
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I had heard rumors about people getting ADR paid for under the fusion cpt codes. some I thought were before proper ADR codes were created but some may be after and that would likely be fraud.

Did you have fusion 1st or the ADR first? If you had fusion first...are they not paying for the entire surgery and then you pay for the entire and separate ADR surgery? When you say separate I understand that to mean 2 different hospital stays and 2 separate discharges. just trying to clarify.
__________________
Injured 9/01
Annular tears L4/5 & L5/S1
denied adr by insurance for 2 level charite as well as hybrid fusion at L5/S1 with Charite at L4/5.

New ins paid for 2 level lumbar prodisc surgery on 4/7/08 (at age 39) with Dr. Westerlund, at Core Orthop
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  #5  
Old 06-24-2007, 01:41 AM
traderoil traderoil is offline
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I had 2 separate hospital stays. one month apart. ADR first and then fusion. I paid cash for the ADR and nothing was submitted to the insurance. The fusion was pre-certified.

As recently as 10 months ago same surgeon was for same insurer (Oxford) doing ADR/fusion combo in one shot - but only submitting for fusion.
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