Another "New" Insurance wrinkle

[randy leach]

After approval by Texas Back Institute for an ADR procedure, they submitted a package to my insurance company for a 'pre-cert'. It came back with the following reply:
"Colorado (my state of residence), along with 3 or 4 other states, have laws that make pre certification impossible."

They say that any pre-cert in Colorado is considered a commitment of payment by the insurance company, regardless of circumstances;i.e., I could stop paying premiums and they would still have to cover me for the procedure. So they say I must have the surgery and then hope that the insurance company would cover me. Any comments or ideas?
thanks
randy leach

[Harrison]

Randy, this seems a bit tricky and strange; but it involves states laws, health care and layers of bureaucracy so who is really surprised?!

I'll talk to some folks on your behalf, but thx for sharing this with the community. Perhaps other folks can shed some light on this situation and possibly some ideas or alternatives.

If you can cover the cash outlay for 3-6 months and you won't loose your house if they don't pay then go for it. Ins. has some strange rules but they may work in your favor. Read your policy rules on how many planned days you can stay in the hospital before you need their pre-cert. My policy said 3 or more scheduled days in the hospital required pre-cert. Most ADR patients can be out in 2 days. Don't plan on driving home then, just get a hotel room near the hospital and stay till your first follow up.


Tell TBI you want a cash package price for your planned 2 day stay since you are having to pay for it all yourself. Don't let on you are going to submit for reimbursment after surgery. You should be able to get a single level done for $35-$45,000. If the come back with $60-80,000 tell them you have been looking into going to Germany for under $35,000. If they are having problems getting insurance to pay or pre-cert others they will jump at the chance for a cash customer. Your Dr. office may also not know how to handle cash customers. If they don't, ask if they have an international patients dept. They will know how to get you a package deal.

After surgery request an itemized list of all your charges with ins. codes and then submit this to you ins. co. You can try to get the hospital to submit for you, but they sometimes won't do it for package deals. I don't think your ins. can or will deny an FDA approved procedure. If they do try to deny it then call your states insurance commisioner and tell them you have followed all your ins. co. rules for this FDA approved procedure and they won't reimburse you.

They are using the system to create this cash barrier without having to deny your pre-cert.

Good Luck and work the system to your advantage.

Pat

[Leanne]

Randy, I am sorry to hear you are having so much trouble with insurance. I am hampered by a complete lack of knowledge of Colorado law, but it seems to me that an insurance company must provide some information to you about whether a particular procedure will be covered, assuming all other conditions of insurance coverage are met.
I would suggest first contacting the company and asking if they give some type of conditional approval. My company (Anthem in Kentucky) gave a pre-cert approval with conditions -- we'll pay as long as you pay your premiums, etc. Something must be available because no doctor is going to perform an expensive procedure without knowing if insurance is going to cover.
Second, if your insurance company is unable to give you any helpful information, contact your state government insurance office and ask why pre-certification is unavailable and if the patient can obtain some kind of assurance a particular type of procedure is covered, assuming you continue to be a customer. Find out the exact procedure and get the state to help if they have some proceduer.
Insurance is a heavily regulated industry. The state will not allow an "illusory" contract -- that is, a contract where "we agree to pay your claim if we agree to." In essence, you would be paying for a promise that doesn't mean anything. Keep pushing.

[Paul]

I'm running the gauntlet now. TBI as well. They told me they submit to pre-determination and not pre-certification. Unsure what the difference is but apparantly there is one.

I have said this before on the site here but will sat it again. TBI told me that they have only had 3 procedures paid for by insurance. they have more success with WC. I remarked that "the remainder are paid out of pocket"? and she said yes. I was floored.

[annapurna]

Unless you're near retirement age, the most valuable financial asset you possess is your abilitly to work. That's probably the philosophy that many people are using to self-fund ADR (besides being tired of waiting in pain). I have and will use my "buy a house" money to fund several knee surgeries and possibly cervical ADR (if accepted by Bertagnoli) that my HMO would never think of covering. I figure that it's better to be able to work full-time in my chosen field and rent, than worry about having to quit work early and go on disability (which can still happen, of course - no guarrantees). This does not help those who can't scrape the $$$ together at all. Is TBI willing to give discounts and/or a payment plan?

[biffnoble]

US healthcare is scandalous! We, patients/suffers, run like rats through a maze, face bankruptcy or simply the denial of pain relief because of a system based on a fundamentallly inhumane and unsupportable premise. Privatization of health ins. along w/privatization of any "social good" functions, simply hollows the social structure out from the inside leading to eventual implosion at least for those in the middle and on the bottom.