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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 04-02-2007, 02:31 PM
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CindyLou CindyLou is offline
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Hi everyone,

Cindy here. Well, no news is good news I guess. My husband gave his boss the folder I had compiled all weekend for his review, and he said he wanted a couple of days to read the information, with the assistance of HR dept. head. He commented he was very interested in learning more and appreciated my organized data. (per my husband) I am trying to remain hopeful. I am choosing to believe I have some momentum working in my favor. The HR lady asked for the name and contact # of my assigned case manager thru HealthPartners (I had requested a case manager weeks ago to help advocate for me). My husband left for New York so he and the boss and HR have one final meeting on Thursday morning for review. I haven't received that package yet Harrison, that you recommended, on Long-Term Results of Lumbar Arthroplasty-Roundtables in Spine Surgery. Maybe if that shows up, I can drop it off at the company, for more information his boss can peruse. My stomach has been in knots all day. I feel like I am groveling for this surgery. I am groveling for it. update: QMP just called and are just now processing my order for that article, but I told them to go ahead and send it. Maybe I can get it in his boss's hands tomorrow afternoon. Does this still sound hopeful you guys? I need some confirmation that I still have a shot getting this covered. Hope I'm not deceiving myself. I'm just very anxious for an answer, one way or another. Sorry I'm blabbering.
__________________
CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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  #2  
Old 04-02-2007, 02:53 PM
Ilene Ilene is offline
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Unfortunatly, this is a big problem. My 5 level surgery in November cost 69,000 Euro's (just at ($90,000) plus airfare for my husband, father and myself, plus, plus, plus...We are still attempting to work this out with the insurance company but, now with the use of an attorney.
Good luck.
Ilene
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  #3  
Old 04-03-2007, 06:17 AM
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CindyLou CindyLou is offline
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Ilene, thanks for the response. What 5 levels did you have surgery on, and what surgeon? Most importantly, how are you doing? I hope you continue to heal well. On the insurance note: I had emailed my doctor here last night, asking if he would write a "no holds barred" letter stating his recommendations for my adr. He responded so swiftly last night (God love him), and composed a strong, I hope convincing, two paragraph letter. So, one way or another, I should have an answer by thursday. Good luck using the attorney...hope that bodes well for you! Cindy
__________________
CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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  #4  
Old 04-03-2007, 03:45 PM
kevin bosse kevin bosse is offline
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Join Date: Dec 2006
Posts: 33
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Hi Ilene (sweetcheeks)
I think persistence may pay off with the insurance end of things . We received monies from our insurance this week ,but not much .A total of 2,500 dollars .This was just some of the cost for anesthesia.We were denied our first claim,of $38,000 now my wife has a rep. from bcbs and we have a letter mailed to our state representative. We don't know where it is going to take us but a little money is better known
Someone one on the forum mentioned that the insur. co. don't have codes for a.d.r and my wife is using that info. to help us out .I'll let you know how we make out.
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  #5  
Old 04-03-2007, 08:02 PM
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CindyLou CindyLou is offline
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The publication that you, Harrison, directed me to, via QMP, titled RoundTables In Spine Surgery;Long-Term Results Of Lumbar Arthroplasty arrived today and absolutely exceeds my expectations. Have you seen this yourself? Likely. It's fantastic. If this, along with the Dr.'s letter, does not approve my surgery, I don't know what else I can do. It's hands down, the best thing I've read that supports long term results of lumbar arthroplasty. Thank-you for helping me get my hands on this. If this succeeds, any and everyone who is still trying to get covered or reimbursed should purchase this bound booklet. I guess we should wait and see. In any event, it is reassuring me of my decision to have adr two weeks from today, regardless of compensation. Thanks again. Cindy
__________________
CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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  #6  
Old 04-05-2007, 12:50 PM
chasswen chasswen is offline
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cindy
so whats the word are they going to pay?
chuck
__________________
ddd 1990
2003 mri,xrays,shots,emg
2004 discogram ouch pos l4 l5
facet block neg
lost all appeals BCBS 5 months of that
3 surgeons later
surgery with dr. bertagnoli aug 2nd 2006 in Bogen Germany Successfully ProDisc-L L-4 L-5
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  #7  
Old 04-05-2007, 06:04 PM
Ilene Ilene is offline
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Cindylou, my surgery in Stenum was after having had 4 previous surgeries in the U.S. I had 3 surgeries in Stenum (7 in all). My spinal issues started with a 12 cm mass at my L4 - L5 level and my last ditch hope for recovery was Germany! However, the doctors made me come over to their facility 1 week early so they could perform their own tests. They were not sure that they could help me up to that point. So, I went to Stenum with blind faith. Yes, they decided that they would do the procedures with reasonable belief that they could give me relief.

The 5 ADR were: C3-4, C4-5, L5 - S1, L3 - L4, L4 - L5, plus 2 cages, and refusions (3x) L3 - L4, L4 - L5, C5 - C6, C6 - C7.

Our 'argument' with the insurance company was many faceted:
1.) this was the 3rd time that I have had to have refusions. The fusions were not holding and were backing out. The first time that this happened one of the screws broke loose and backed down in to a major muscle (hip); and
2.) NO ONE in the U.S. was willing to handle my case. Mayo Clinic sent me around and around not knowing what to do with my case. Records documentation exist.
3.) Had other options been available to me in the U.S. I would not have gone to Germany. This was my last ditch effort to try and get any improvement with my spinal condition; and
4.) Our insurance company not only turned us down, but also stated that any subsquent medical claims related to my spine or medical issues resulting from the spine will not be covered. This is the biggest reason we are using an attorney. We cannot afford for me to be uninsured when insurance is clearly available to me.
etc., etc., etc.

If anyone does know the name of a top notch spinal specialist - anywhere in the U.S. please let me know. I would feel better knowing that there is a doctor available to me in the event of an emergency within the continental U.S.

Ilene
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  #8  
Old 04-06-2007, 11:16 AM
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CindyLou CindyLou is offline
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Posts: 627
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So, here's the "official" scoop on my healthcare provider's decision, along with my husband's boss' input: trust me, it's convoluted, so bear with me. HealthPartners (HP from here on out) has "officially" turned down my second appeal, w/ exception being they will pay for the fusion part (this is if Dr. B. discovers he has to fuse my L6-S1, partially sacralized segment during surgery). Dr. B's office would have to break out costs associated with it, and HP stated by agreeing to pay fusion part (if needed) they will pick up costs of my hospital stay, the fusion, attending physicians, pt, any anesthesia, recovery in hospital, etc. And all we would have to pay would be for the ADR's themselves (what does a prodisc run? Anybody know? In Germany, not states.)and Dr. B's time on their implantation. (so of course, I'm thinking, fuse the son of a bitch)

Secondly, and I still can't wrap my head around this logic, but they decided (HP, the boss, and HR)that were the boss to decide to "over rule" HP's decision for denial, and make an exception, then this reimbursement of the procedure would be subject to IRS taxing and would have to be declared as income. (???) Is that a true statement, anyone? And if HP were to reimburse us it would establish a precedent and the boss does not want to set a precedent for other "unusual or extraordinary claims." that's a quote.

And finally, because the boss feels so bad about this (yeah, I can tell, the tears are running down his face already) and does not want us to have to bear this completely by ourselves, (even tho he explicitly told Rick the other day, he could pick up the phone and just tell HP to cover this for Cindy,if he wanted to, which was a "tease" to me) he has offered the following: 1. Pursue the MN Dept of Health option. If they direct HP to pay, it would be done on a non-taxable basis. (I told my husband I have run out of steam, and if he wants to pursue that avenue, go for it) 2. our medical expenses will be tax deductible for year 2007 (duh, not stupid Larry) and gov't will reduce our tax burden by 35-40% for our out of pocket. 3. lastly, (finally a bone tossed our way) the company will reimburse us for 50% of the costs that we have for out of pocket, meaning whatever the total bill is minus what HP chips in for the fusion (if performed) , the company will pay us a check , which still means it will be taxable income.

Whew. Better than a poke in the eye as they say. By my husband's calculations, between the amount that the medical deduction should save us on taxes (about 35% of the amount we pay), plus the 50% that the company will reimburse us for, we should eventually come out with about 85% of our out of pocket costs recovered. (by next year, of course, this time)

I am no accountant, so all I can say is, "I guess so." All in all, we are talking about not getting reimbursed for the tax deductible part until almost a year from now, if my calculations are right.

So you guys tell me.....a win or a lose? My husband thinks it's not a bad deal. I think it sucks, because I presented such strong material in favor of my adr procedure and adr in general, for you guys as well, who are fighting the fight too. The statistics I gathered were there. I honestly don't know, how in good conscience, they could turn it down as an "unusual or extraordinary claim." Where is the burden of proof there? Sorry this is so long. I cried and cried and cried some more yesterday. And how did I find out my disapproval? Through HealthPartners? No. An email from my husband!
They can all go to hell as far as I'm concerned. (sorry to whomever that might offend) I have it off my chest, and now I have to think good thoughts, feel at peace, all that good karma, because I leave in one week for my surgery. So, I ask you guys once again, what do you think, a win or a loss? (to me, big picture, it's still a loss, anyway you cut the pie)
__________________
CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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  #9  
Old 04-06-2007, 11:25 AM
chasswen chasswen is offline
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Join Date: Apr 2006
Posts: 627
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cindy
sorry to hear of the outcome but at least there going to help. as my boss told me they would help and poof no help.
i am selling my house to cover all the expenses and moving to sc
single prodisc-l in aug was 4500 euro about 5800.00 usd
chuck
__________________
ddd 1990
2003 mri,xrays,shots,emg
2004 discogram ouch pos l4 l5
facet block neg
lost all appeals BCBS 5 months of that
3 surgeons later
surgery with dr. bertagnoli aug 2nd 2006 in Bogen Germany Successfully ProDisc-L L-4 L-5
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  #10  
Old 04-06-2007, 11:42 AM
kevin bosse kevin bosse is offline
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Join Date: Dec 2006
Posts: 33
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Hi cindylou
We too ,my wife and i are fighting the insur. battle.We were denied our first claim, and have been in touch with our local congressman to start our second battle .We did receive some monies, but about 1% of total cost WOW!!!!
I had 3 levels done in germany , and like you the insur. company says it was unnecessary surgery.
since when did Blue Cross receive there doctorate degrees .From what I gather they do not have a CODE to put A.D.R under,I say put it under Fusion you morans.
We wrote a huge cover letter to the congressman who is going to see it gets to the correct people.It's not as if we have any clout,we're just regular joes who want to be compensated for a procedure that was deemed neccesary you insurance morans.Wow i feel much better
Let me know how you make out
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