Insurance Approval

[Terry]

I just received notification of the following:

Blue Cross paid for my 4 level ADR Surgery in Germany. I just received notice that the amount billed was $61,860.57 by the hospital and that was the amount paid by Blue Cross Michigan.

The hospital I went to wired me the refund yesterday as I had paid cash for the surgery.

I never appealed Blue Cros's original denial so I am shocked that it was paid. They originally denied it claiming it was investigational.

I am a health care provider and understand Blue Cross terminology very well. Blue Cross does not pay claims unless they determine medical necessity. My belief is, after looking at my medical records, they determined, in my case, that the procedure was the best course of action and medically necessary.

I am very happy with the money and it will go in to the Terry and Elizabeth Newton retirement fund.

This is proof that some get paid and there is no reason why this technology is not getting covered regularly. I hope all are as successful. For the ones that have not been I will be glad to lend my name in your appeals to help yours get approved.

Terry Newton

[Can\'t_Sit]

Congrats, Terry!

You still had to pay a deductable, especially since it was out-of-network, right?

I think my deductable/co-insurance annual maximum is $2,500, which isn't cheap but better than paying for the entire two level ADR myself. Since the discogram already cost me $600 out of pocket, I've used up some of that co-insurance already. So, if I am thinking this thru right, I should only have to pay about $1900 for this surgery.

[Terry]

No deductible as my yearly deductible was met and they did not seem to care about being out-of-network since no one is doing a 4 level in the States that I am aware of.

I am waiting for them to call me and say it was a mistake and demand the money back .

Especially since I signed an agreement in my lawsuit that I would not appeal their denial and they would waive a 28K Lien .

Too Late!!!!!!!!!!!!!!!!!!!!Money's in the bank . Betsy and I can have a little better retirement . Us in Florida or someplace warm for the Winter .

Proof to all.......Never Give Up!!!!

Terry Newton

[chasswen]

listen Mr HAPPY PANTS
CONGRATS. i am still holding my breath waiting on blue crap.
chuck

[Abbe]

I am in the waiting stages here and have been denied twice but did get some encouraging news today that Motion Picture asked for some more documentation from the people at Prodisc. Prodisc has an advocacy type program where they will act as your agent and help you with appeals and the insurance company. They have been very helpful so far (I think) and as with everything in this process you have to be very persistant.

Hoping for good news!
Abbe

[Judy]

Just curious can they come back for the money? I won my appeal and then 6 months later they said they overpaid me by 10K and wanting there money back but could not provide any documentation on how this happened.
As far as I was concerned I gave them 3 invoices and they paid all three invoices and the money did not exceed the amount I paid it actually was short by about 5K but was happy with the amount I received.
I am just curious that was almost a year ago and when I asked for documentation to provie they over paid me I never heard another word from them. I don't know if there is a certain time that they have and of course I surely don't want to call and find out if they are going to pursue this.
Anyone know if there is a certain timeframe they have?

Thank you
Judy

[Jmbeam]

Terry,

I dont mean to be obtrusive but since I found this site and read your many replies especially this last one regarding having the procedure coverd in Germany I have had goosebumps up and down my arms. I would do anything to get the three level ADR that the Stenum Hospital recommends for me. I have been liquidating many of my assets but still have a long way to get the $55K that may be needed. I was told that my surgery may be more because they are not sure how bad the ankylosis is on one level. If it has fused(they will only know when the cut me open) they I will need a fusion to repair it and then hav a two level ADR.

[Terry]

JMBeam:

I am reading more and more about S1/L5 being OK to fuse as it does not have as much motion as discs above. Patients are then having ADR on top of that which seems to prevent multi-segment disease. This is due to the discs carrying load vs. locking things in place causing the above discs to support your weight. Some insurances seem to be approving the hybrid surgery that I just mentioned.

It's fair to warn you though that I am the Executive Director of our company that pays for health care for our employees, spouses, and all children living at home. I don't mean to sound like I am that important as I believe I am about as expendable as anyone. A board member of mine who handles a lot of Blue Cross insurance called on my behalf and asked them to review my case. I would like to believe that they saw how few of options were available to me as I had 4 discs needing to be replaced. My surgery alone was far cheaper than anything I could have gotten in the States. If you would like to talk to me about my case I would be happy to talk to you. My personal e-mail is tnewt@freeway.net. I'll give you my telephone number if interested and discuss it with you.

Terry Newton

[Dom]

Dear Terry,

A bit late reply(and question -_-

Did you get that blue cross insurance before your laminectomy in 1995 or after?

As far as I know, no insurance company will cover existing conditions.

I had my discectomy in 1999 and now considering ADR in Germany. I'm still shopping for insurance company and my worry is that whatever insurance company I choose here in Europe will deny my claim for ADR coverage cuz I previously had disc discectomy which is an existing consition.

Originally posted by Terry:
I just received notification of the following:

Blue Cross paid for my 4 level ADR Surgery in Germany. I just received notice that the amount billed was $61,860.57 by the hospital and that was the amount paid by Blue Cross Michigan.

The hospital I went to wired me the refund yesterday as I had paid cash for the surgery.

I never appealed Blue Cros's original denial so I am shocked that it was paid. They originally denied it claiming it was investigational.

I am a health care provider and understand Blue Cross terminology very well. Blue Cross does not pay claims unless they determine medical necessity. My belief is, after looking at my medical records, they determined, in my case, that the procedure was the best course of action and medically necessary.

I am very happy with the money and it will go in to the Terry and Elizabeth Newton retirement fund.

This is proof that some get paid and there is no reason why this technology is not getting covered regularly. I hope all are as successful. For the ones that have not been I will be glad to lend my name in your appeals to help yours get approved.

Terry Newton

[Terry]

Dom:

Blue Cross does not exclude coverage for pre-existing conditions. You may have a waiting period after your insurance becomes effective due to the preexisting condition but then they will pay. If a true preexisting clause was in place hardly anyone would be covered for anything.

I got Blue Cross from my company when I started here in 1990. I had the hemi-laminectomy in 1995 and the ADR surgery in November 2006.

I still believe my board member's influence helped my case get paid. I may never find out why I got covered but I am eternally grateful.

Good-luck to you. Check the policy well to find out about a waiting period for a preexisting condition. Sometimes it is six months, sometimes it is one year. It all depends on the company.

The motto with insurance companies is; "Illegitimi non Carborundum" or "Don't Let The Bastards Grind You Down".

Terry Newton