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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 12-17-2006, 07:32 AM
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Harrison Harrison is offline
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Hello ADRSupport Friends.

Finally, some good news for people looking for assistance with their insurance coverage! For patients that are seeking insurance coverage for their one-level Charite disc replacement, a third-party can assist you throughout the entire process.

To start your appeal process, you need only call this number: 800-216-4154 (open M-F, 8:00 am to 5:00 PM). Your case will be “project managed” professionally by people that know the appeals process. There are little to no costs associated with the service.

Again, this program is for people for one-level Charite disc replacements at this time. I hope to see other support services in the future, but any progress is welcome in the meantime.

Good luck to all of you!
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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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  #2  
Old 12-17-2006, 09:22 PM
JFerg JFerg is offline
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Thank you for that lead, my good man!
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DDD diagnosis - denied disc replacement by United Health Care 3x's - Recently, Manipulation Under Anesthesia procedure - much needed relief from constant pain.
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  #3  
Old 12-18-2006, 04:23 PM
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J, you bet! I hope this program helps people get the most appropriate treatment for their condition.
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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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  #4  
Old 12-21-2006, 06:31 PM
Nairek Nairek is offline
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Harrison,
Thank you again for this information! I called the appeals provider on Monday & spoke to a reimbursement specialist there who explained the process to me. I received an enrollment form & HIPAA release form within 2 business days. Between all of the research I have already done and this, hopefully I can get the approval that I am looking for.
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----Karin----
Disc Bulge C4/C5, Disc Degeneration T11/T12, Bi-Lateral tears L5/S1, Diagnosed w/ Lumbar Disc Derangement w/ Radiculopaphy. Treatment: IDET, Percutaneous Discectomy, SI Joint Injection, Facet Block. All failed. Empire BC/BS Denied Coverage for ADR-lost all of my appeals. MVP also denied coverage.

ALIF/PLIF Fusion 1/20/09
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  #5  
Old 01-17-2007, 04:21 PM
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As brevity is key to organization, I deleted another topic to consolidate into this one topic. See below.
__________________________________________

Resources for Insurance Appeals

A constant problem for patients is the challenge of ADR coverage – some plans cover it and many do not. It seems unfair that there are such differences between plans. In reality, some people have been approved by the same carrier that has denied others!

This “rationing” of health care is the end of the road for many; but it need not be so! One can pursue many appeal options before throwing in the towel. For example, Depuy Spine has invested significant resources to the insurance problem and has rolled out useful infotools for ALL patients seeking ADR coverage. It may also be helpful to people seeking other (non-Charite’) devices, so these information services benefit the patient community at large!

Resources for Insurance Appeal

First: See the wide assortment of information resources available on Depuy Spine’s site: http://www.charitedisc.com/charitede...mbursement.asp There’s also an individual in each state that is chartered to help you – just use the locator!

Second: There are members of this community that are both lawyers and patients. A few of them can answer “quick” questions for you, and a few can represent you as a client. Email me and I’ll put you in touch.

Third: Members here have suffered through the appeal process, many have succeeded. Read through these previous discussions; feel free to PM or email any of these members. All want to help you, some are busier than others but will try to help you! See below.

Getting Insurance in US to pay for Disk Replacement
http://adrsupport.org/eve/forums/a/tpc/f/7701036081/m/9...961037081#9961037081

Anyone that has had 2 levels approved please Help!
http://adrsupport.org/eve/forums/a/t...1/m/1131077081

Medicare approval of coverage for Charite
http://adrsupport.org/eve/forums/a/t...1/m/9901008481

Anyone approved by UHC?
http://adrsupport.org/eve/forums/a/t...1/m/5491077081

Blue Cross of CA Approved!!!!
http://adrsupport.org/eve/forums/a/t...1/m/7801028081
___________________________________

fiddle
Harrison, I wanted to be sure to thank you for your very informative post about Resources for Insurance Appeals. I recently put together my appeal, and most of what I included came from your suggestions. The Depuy Spine's site was invaluable. I basically followed that outline step-by-step.

I appealed to my secondary insurance company. I didn't even bother with Medicare because when I called they told me they don't cover out of the U.S. unless it is an emergency just over the border.

My appeal included: 1) the original Letter of Medical Necessity; 2) My letter using the Depuy format giving history, experience, need, etc.; 3) The name and phone number of my primary MD for more consultation if desired (as well as the surgeon); 4) A picture and the name and brief literature about the Activ-L; 5) The generic informational approval letters from two other big insurance companies; 6) The Medicare approval of the Pro-Disc for the population under 60 years old; 7) A copy of a study (I think it was a letteski post of several studies to choose from). I chose the one that seemed to be a study about a NUMBER of studies, so it was more inclusive. I also sent along brief info about the AlphaKlinik where I had my surgery, and compared the two costs U.S. vs. Germany. All in all -- 39 pages.

For those who are new to this, I sent it certified mail with a return receipt. And when I filled out the address on the green certified mail slip, I also wrote the number of pages. That way, they can't say, "oh we didn't receive that part of it". I've learned this the hard way.

Wanted to share what I did in case others are looking for ideas. Good luck to all those who are requesting coverage. I will let you know my outcome.

P.S. They were close, but Germany came out $1000 less compared to a U.S. estimate for a one-level. This is calculated based on all medical needs, the surgery, the doctors, the tests, the meds, the klinik, the therapies, etc. This does not include the airfare, hotel, meal, expenses for a family member and all incidentals. Only medically-related.

This message has been edited. Last edited by: fiddle, September 27, 2006 11:18 PM
November 21, 2006, 02:07 PM
______________________________________

Harrison
Just a reminder that each state has its own procedure to encourage patients to appeal insurance denials. E.g., the state of Mass. spells out their process and provides applications for appeal here:

http://www.ago.state.ma.us/sp.cfm?pageid=1137

888-830-6277

Of course, there is also the Mass. Division of Insurance, Consumer Hotline (617) 521-7794.
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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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  #6  
Old 05-20-2007, 10:37 AM
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As you all know, medical insurance issues about within our community. Insurance companies wield considerable influence in our personal lives, on Capitol Hill and especially with hospitals. Most of us here have gone to bat (battle?) against insurance companies for coverage for our surgical procedures. It’s terrible, and I fear, getting worse.

Enter the “empress of insurance appeals,” or more popularly known as “the insurance warrior,” Laurie Todd. Her expertise is shaped by her own personal experience -- and successes -- as a cancer patient; she now helps patients from all walks of life win coverage for their treatment. Her record to date helping patients is flawless – and I’ve warned her about the lackluster results we patients have experienced! Nonetheless, here are some ideas for patients to consider:

1. Read the book she wrote: Fight Your Health Insurer and Win. You can order this book on her website; perhaps you could request it from your local library. Her site is: http://www.theinsurancewarrior.com/ Laurie was kind enough to offer a chapter of her book, which is attached.
2. Listen or call in to the June 2 Boston show; or maybe you could even hire her for your appeals.
3. Look for her in a future Q & A column in the Cutting Edge forum.

And no, I have no business affiliation with Laurie. I am just trying to help you folks get the treatment you need. There will always be new treatments that are considered “experimental,” so we may need an army of Lauries….

Laurie, knock ‘em dead! I hope this post helps all involved.
__________________
"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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  #7  
Old 05-22-2007, 09:46 AM
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CindyLou CindyLou is offline
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Harrison, thank-you for that information. I am going out today and buy that book!
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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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Old 05-23-2007, 04:49 PM
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CindyLou CindyLou is offline
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Harrison, can you only purchase this book from her website? Not available at Borders or Barnes & Noble? I stopped at one local bookstore yesterday, and their search on the computer brought up nothing. (gotta get my hands on this book!)
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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 05-23-2007, 06:42 PM
Nairek Nairek is offline
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CindyLou,
This book hasn't been published yet according to Barnes & Noble.Com. I should be released on July 28 according to their website. You can pre-order the book from the site as well. Here is the link: http://search.barnesandnoble.com/booksearch/results.asp...Win&z=y&cds2Pid=9481

The ISBN # is ISBN: 0979143500

Hope that helps!
__________________
----Karin----
Disc Bulge C4/C5, Disc Degeneration T11/T12, Bi-Lateral tears L5/S1, Diagnosed w/ Lumbar Disc Derangement w/ Radiculopaphy. Treatment: IDET, Percutaneous Discectomy, SI Joint Injection, Facet Block. All failed. Empire BC/BS Denied Coverage for ADR-lost all of my appeals. MVP also denied coverage.

ALIF/PLIF Fusion 1/20/09
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  #10  
Old 05-23-2007, 09:28 PM
The Insurance Warrior The Insurance Warrior is offline
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Hi, new ADR friends. The Insurance Warrior is in the house.

I published the book myself, I have 4,500 of them right here on the premises, and I sell it from my website www.theinsurancewarrior.com

Borders, Barnes & Noble, Amazon are all pretty much money pits for authors. They are not much interested in self-published books unless the author is hooked up with a major distributor, and major distributors take another huge cut, and aren't much interested in self-published authors.

If I sell the book to you directly, I get to keep $14.95. If I sell it through a major chain with a distributor involved, I would be lucky to clear about $1 to $1.50 per book.

I fervently desire to continue being the Insurance Warrior, keep raising these issues publicly, keep helping folks to win their appeals. So, for now, I keep it all simple and cost-effective.

These appeals are not won because we prove that our cases are just, and they are not won because we provide the best information. They are won by intimidation! It is pretty much a huge bluff-down, designed to make the insurer suspect that we might be a lawyer, know a lawyer, or have a lawyer hiding in the woodpile.

Standing strong, hanging tough, being the alpha dog ... that is how we win. We don't take it personally. We are peaceful warriors. We understand that it is their job not to pay, and our job to make them pay.

I had a metastasized abdominal cancer, and my oncologist said, "There IS no treatment for your disease. And, even if there were, they wouldn't pay for it." My written appeal was the only thing standing between me an certain death.

I spent two months researching, reading lawsuits, scoring all the free legal advice I could score, and turning myself into the finest lawyer that money could buy.

I had no money, I had lost my business, I had no influence. I had to win big, which I did. When I got done with them, they eagerly paid every penny.

I underwent a second massive surgery, from the world's expert on my appendix cancer. And made them pay every penny of it, including the deductible and out-of-pocket. Must have scared them really, really bad.

Obviously, I am not dead. I am exceedingly alive. I see no doctors, I take no medication ... I am fine. Thus far, I remain cancer-free. Plus, I have gone on to help people win over twenty of these cases. Since insurers always present the same objections -- in the same order -- every time, it's really fairly simple.

Until now, the appendix cancer people have been the only ones to have their very own Insurance Warrior. Between speaking and helping and shipping books and scratching my head in amazement at All This, I don't have time to participate in a lot of online communities.

So, ADR folks, you are the second ones.

My best to you, I will weigh in from time to time with a radically different approach to making insurance do our bidding.


Laurie the I.W.
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