ADRSupport Community  

Go Back   ADRSupport Community > General Discussion > Insurance Hell

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.


Reply
 
Thread Tools
  #11  
Old 02-06-2014, 10:14 PM
bwink23 bwink23 is offline
Senior Member
 
Join Date: Nov 2013
Posts: 262
Default

Frank,

I'm picking up what you're laying down...brief, but detailed and easy to follow. Don't make a story out of it. Give them a patient history that leads to the surgical decision. Key words to them.....MEDICALLY NECESSARY. Show them you didn't just jump on surgery, and you should be fine. The doctor's letter of medical necessity should outline the fact that you do have a defect present that can cause your symptoms and the doctor's surgical treatment is what he performs to treat those symptoms.

You're saying to outline your conservative treatments prior to surgical intervention...but don't include all the extensive paperwork because they should have that on file ?? That's a good idea....the actual documented history would be more suitable for an appeal i believe as well.

I never really got any sort of official pre-authorization. I first confirmed that i do have BlueCard WorldWide coverage on my plan. I confirmed this with BCBS at home, and with BCWW ( both on voice recorder)...i couldn't risk dropping 63,000 bucks and then finding out, OOPS! You're not covered for that type of care outside the United States. Coverage can vary greatly, some people might only be covered for medical emergencies when traveling. I don't recommend anyone doing this without first verifying it. You don't need to go into specifics, just ask if all of your benefits remain the same if you were moving or traveling outside of the country.

Only this last call i made to BCWW did they issue me a case #. I called them to get a final decision on where i should send my paperwork, since i got 2 sides to the story before. I told them i had already scheduled a surgery date and made my self-payment in full. Pre-authorizations usually involve setting up direct billing with the hospital (which they DO with Quiron), but I let them know that i was instructed to make full payment prior to surgery and would need to submit for reimbursement. They were perfectly OK with that, and were adamant that the paperwork needs to go to them first. My situation feels more like a "pre-verification" than a " pre-authorization" since i had already scheduled the surgery and made payment. Whatever i have done, they will cover what they are going to cover, regardless if i kept my mouth shut and just laid the paperwork in their lap.



__________________
2013 - MRI and CT scan....DDD L4-S1
left side (where my pain is) interarticularis pars fracture/defect with Spondylolithesis L5 over S1 with 2MM anterior displacement

Feb. 2014 - Hybrid lumbar fusion(l5/S1), ADR(L4/L5)...2-level cervical ADR (C5/C6, C6/C7). Dr. Pablo Clavel of Quiron Hospital in Barcelona, Spain. All M6 implants (PEEK cage and plate from Medtronic at fusion level in lumbar.) SAME DAY OPERATION for both areas of the spine.
Reply With Quote
  #12  
Old 02-07-2014, 09:58 AM
FranklySir FranklySir is offline
Senior Member
 
Join Date: Jun 2013
Posts: 177
Default

B,

Exactly. Absolutely follow claim to BCWW as you already know.
The only adder I would suggest to the short and sweet is your reason for going abroad. The reason, if so, would be the experience of the surgeons as compared to here. It is factually correct regardless of what anyone says. They have just been doing it loonger. Unfortunately this doesn't help the docs here get the experience fast enough but neither does the FDA nor the lawsuit happy lawyers here. You cannot watch TV without seeing a commercial for a lawyer at least in my area.

Rest up B, you are going to need your strength for this party. Im 7 weeks out now and just starting to feel kinda normal.

Good luck and keep me up to date if you have the energy.

F
__________________
Lumbar issues 18 yrs
herniations lumbar L3-5 multiple Epis etc etc
Annular tears L3-5 cauda equina
Cervical herniation symptoms 2011
C5-7 M6C by Dr Clavel on June 5 2013
L3-5 M6L by Dr. Clavel on 12.18.13
Living life instead of living the condition
Reply With Quote
  #13  
Old 02-07-2014, 12:34 PM
2Confused 2Confused is offline
Senior Member
 
Join Date: Jun 2011
Posts: 322
Default

Frankly!
Excellent news! Hopefully we will continue to see people get reimbursed! Of course, I am a bit concerned as to what will happen in the near future as people are forced to transition into ACA insurance. BCBS sent me a letter recently saying I was grandfathered in through 2014.... what happens after??? I like my insurance and really dread the changes - will it also eliminate Worldwide Blue???

Anyway - for now we celebrate!!
__________________
50 year old female
Rear-Ended in 2009
Disk rupture cervical 5-6 & 6-7
2 level M6 ADR, Dr. Clavel - Oct. 2012
Insurance paid
Not a day goes by that without me whispering a silent "thank you" to Dr. Clavel
Post Op 2+ years
Cross Fit 3-5 times a week
Running 5ks
Reply With Quote
  #14  
Old 02-07-2014, 01:17 PM
FranklySir FranklySir is offline
Senior Member
 
Join Date: Jun 2013
Posts: 177
Cool

2,

Thank you. I'm still shocked. Putting my other one together now since I'm feeling really good.

Well unfortunately these are the consequences of Voting. There was a system in place for those that needed help getting CARE. Well when you inject Gov into this they can do or make you do anything so it would not surprise me one bit that it continues to get worse. Its funny they now there is a line for smoking. No line for drugs or alcohol. That's next or should be. Then it'll be potato chips and soda like New York.

A friend of mine was given the option for a blood test to save 400$ per year on his insurance. What do you think they will do with that info??????

We were all warned whether you want to hear it or not! Some listened and most didn't.

We are all paying the price now for providing INSURANCE not care.

It is really sad since there could easily have been a stepped approach but that ship has sailed. Unless it crumbles we are gonna be stuck with it and it will get worse. My insurance DOUBLED across my whole company so how affordable is that? My people look at me funny when i say your raise is in your insurance and it was 4000/yr raise. Not so funny now huh!

Sorry for the rant. Thanks for the congrats and I wish others success as well!
F
__________________
Lumbar issues 18 yrs
herniations lumbar L3-5 multiple Epis etc etc
Annular tears L3-5 cauda equina
Cervical herniation symptoms 2011
C5-7 M6C by Dr Clavel on June 5 2013
L3-5 M6L by Dr. Clavel on 12.18.13
Living life instead of living the condition
Reply With Quote
  #15  
Old 03-07-2014, 07:30 PM
jheumann jheumann is offline
Junior Member
 
Join Date: Nov 2013
Posts: 5
Default Quiron or Mexico

I am attempting to set up payment to a Dr/hospital in Mexico using BC Worldwide. One particularly successful study for the M6 was published in 2010, and the study was in Mexico City, so I am looking into that resource for the M6 surgery. Mexico has at least 5 doctors that were in that study, so I am contacting them but Spinal kinetics already set me up pretty well with a very experienced surgeon there, Enrique Kleriga.

If anyone has input or concerns about my approach, let me know. I am certainly open to and am consulting with the ever-favored Dr Clavel, but the thought of flying 7 hrs vs. 26+ rounctrip for initial and any potential revisions makes me think Mexico is a good shot.
__________________
Headaches 2001/2
Upper back tension.
Cervical discs diagnosed DDD in Nov 2013.
Scapular nerve burn due to spasms starting 12/5/13, alleviated with massage, valium, creams.
Sharp pains in neck/shoulder area, alleviated with Tylenol4. Etodolac regimen start 4/21/14.
PT/steroids from 12/11/13 provides temp relief only.
3/3/14 Prodisc surgery denied by BC.
3/25/14 Mobi-c surgery denied by BC. Appeal approved (Prodisc).
5/27/14 ADR surgery with Dr. Bae scheduled.
Reply With Quote
  #16  
Old 03-07-2014, 07:54 PM
Jerry5 Jerry5 is offline
Senior Member
 
Join Date: May 2013
Posts: 363
Default Contact

jhuemann, I did not even know they did Spinal Kinetics in Mexico. If need be, send me a private message. I found some information, but it is all in spanish, can you send me the contact information. {side note-one doctor recommends I have a fusion, the disk is so degenerated?, received the email today} I refuse to fuse.
__________________
Jerry, Somewhere Ohio

L2-3 herniation, two days before Thanksgiving, 2012, Discectomy/Laminectomy, 3/13 Numbness in the right leg, lateral femoral, gone, July 10, 2014 L45 M6 ADR, July 15 PLIF L5-S1, Not able to access L51 Anterior.
Reply With Quote
  #17  
Old 03-07-2014, 07:57 PM
FranklySir FranklySir is offline
Senior Member
 
Join Date: Jun 2013
Posts: 177
Default

J.

Europe is the place and most experience. Your choice though. Five surgeons to choose. Clavel is good choice as well as others here. I say to heck with the long flight and it should not be part of your decisiojn.

F
__________________
Lumbar issues 18 yrs
herniations lumbar L3-5 multiple Epis etc etc
Annular tears L3-5 cauda equina
Cervical herniation symptoms 2011
C5-7 M6C by Dr Clavel on June 5 2013
L3-5 M6L by Dr. Clavel on 12.18.13
Living life instead of living the condition
Reply With Quote
  #18  
Old 03-07-2014, 08:03 PM
Jerry5 Jerry5 is offline
Senior Member
 
Join Date: May 2013
Posts: 363
Default Reimbursement

F, Having insurance problems, and I need to get this done, this is no way to live. If this surgeon in Mexico, has a few under his belt, I'm good. For me, I had a car drive earlier this week, about 6 hours, and I stayed home from work the next day, hard driving sometimes to work. So far, the most experienced is in Germany. But $$
__________________
Jerry, Somewhere Ohio

L2-3 herniation, two days before Thanksgiving, 2012, Discectomy/Laminectomy, 3/13 Numbness in the right leg, lateral femoral, gone, July 10, 2014 L45 M6 ADR, July 15 PLIF L5-S1, Not able to access L51 Anterior.
Reply With Quote
  #19  
Old 03-07-2014, 08:04 PM
jheumann jheumann is offline
Junior Member
 
Join Date: Nov 2013
Posts: 5
Default Mexico info

roberto@mkj-trade.mx is the email for Spinal Kinetics' distributor in Mexico. Roberto Ramirez. I understand the point above, I have a level of comfort in Mexico from my mother's side being there. I do want to do more research on "experience and succcess" for sure.

Frank, there are no docs here that do the M6, just to clarify that I have a surgeon here or the Mobi-C/ProDisc if I can and decide to go that route.
__________________
Headaches 2001/2
Upper back tension.
Cervical discs diagnosed DDD in Nov 2013.
Scapular nerve burn due to spasms starting 12/5/13, alleviated with massage, valium, creams.
Sharp pains in neck/shoulder area, alleviated with Tylenol4. Etodolac regimen start 4/21/14.
PT/steroids from 12/11/13 provides temp relief only.
3/3/14 Prodisc surgery denied by BC.
3/25/14 Mobi-c surgery denied by BC. Appeal approved (Prodisc).
5/27/14 ADR surgery with Dr. Bae scheduled.
Reply With Quote
  #20  
Old 03-07-2014, 08:13 PM
Jerry5 Jerry5 is offline
Senior Member
 
Join Date: May 2013
Posts: 363
Default Thank you

I will contact them and ask for some information. This is a very hard decision. Think of it this way, if they put in the disk and it works, all the better, if it doesn't then you can go the fusion route. I would take a Pro Disc over the fusion, but the M6 has graded resistance and more natural movement. I have been to another country and have had surgery, unfortunately, the FDA is still holding their hand. Cervical, have you looked at the Bryan? Thanks again.
__________________
Jerry, Somewhere Ohio

L2-3 herniation, two days before Thanksgiving, 2012, Discectomy/Laminectomy, 3/13 Numbness in the right leg, lateral femoral, gone, July 10, 2014 L45 M6 ADR, July 15 PLIF L5-S1, Not able to access L51 Anterior.
Reply With Quote
Reply

Bookmarks

Thread Tools

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off


Similar Threads
Thread Thread Starter Forum Replies Last Post
Aetna just paid 100% for my 2 level adr at Stenum gjmorse Insurance Hell 10 02-11-2014 10:22 AM
Insurance Paid - Dr. Clavel 2 level ADR 2Confused Insurance Hell 18 12-05-2013 11:21 AM
Won my Appeal with BCBS-TX Now TBI Drops BCBS twowheelyankee Insurance Hell 3 07-13-2013 11:23 PM
Need evidence that Medicare Advantage plan has paid for 2 level Lumbar ADR surgery Juli Ann Insurance Hell 1 12-24-2009 10:31 AM


All times are GMT -4. The time now is 01:36 PM.


© Copyright 2006-2017 ADRSupport.org All rights reserved.