payin in one and not the other

Nichole · #1 03-06-2005, 11:21 AM

Just FYI

My insurance is Regence BCBS. What I have been told about the insurance paying for one and not another is it is all based on state. If they have paid within your state then you have a good case against them. However if BCBS is paying in FL and not in your state then you dont have a case regarding that particular issue. Each BCBS is per state. I was trying to go along the same lines in my appeal and that was their answer.

cavalier · #2 03-06-2005, 11:48 AM

Thanks for the info Nicole - seems so odd. I will not make a big deal out of it - other than I still state they should pay for the surgery & NOT the disc as the surgery is the same as a fusion other than the device.

Jill

cavalier · #3 03-06-2005, 11:49 AM

My disc cost was only 3k of my 21,5K surgery so dont pay for the disc is what I say

Jill

spotty14 · #4 03-06-2005, 03:18 PM

Although I haven't had to approach insurance with an appeal yet for ADR, I done lots of insurance appeals. I would just continue to indicate why they should pay. Somebody has to be a first person to get approved within a state and it may as well be you. On the other hand, if several patients have been authorized in your state I would definitely mention that if there's a way to find out.

Patrick · #5 03-06-2005, 06:51 PM

Hi Nichole,

Nice to see someone else from the Seattle area.

I am sorry to hear BCBS denied your procedure. I also have Blue Cross but mine is Premera, not sure what the difference is.

Were you trying to get your procedure done within WA State? I am looking into going outside of the state and am wondering if that would make any difference to them or is the issue that our insurance is from WA State? Hope that wasn't too confusing.

DWebster · #6 03-06-2005, 07:41 PM

BCBS veries from state to state and one employer to another. An employer can tel the insurance companies that they do not want to pay for certian item. My insurance is thru my wife, but at were I work we have many differant policies to choose from, but all of them will on pay for half of any back operation. I am so glad that I dropped my employers insurance and got on my wifes. But I have still not recieved my letter of guarantee yet, I am hoping soon.

Nichole · #7 03-06-2005, 11:09 PM

Patrick,

Yes....ahhhh Seattle. I am actually having mine done here in Seattle. If and when they approve. I am very confident in my physician so have made the choice to have it done here. As far as having it out of state, my insurance will not pay for out of state benefits unless it is an emergency while out of town. I work in the health care field and believe that Blue Cross has the same policy. I have contacted Blue Cross for my patients that come from out of state for Physical Therapy and they will not pay. But I would pull out your contract and read it as well as calling Blue Cross and asking them.

Who do you see as your Orthopedic Doc? Beings that I work in the Physical Therapy industry I know alot of the Orthopedic doctors in the greater Seattle area.

cavalier · #8 03-07-2005, 10:19 AM

Nicvole - My BCBS policy has INTERNTAIONAL coverage & they do pay for overseas surgery just like they do for out of state & it does NOt hae to be an emergency - just they pay at a higer rate for instate - in International they only pay 60% but even then they are trying still to avoid paying anything of the 21,5 k of my operation. Crazy eh ?
I say if the disc is experimental then just pay for the surgery & not the disc that was only 3k of this operation. I had a case number assigned & was not turned down until after I was back home from the surgery.

Jill

Patrick · #9 03-07-2005, 10:38 AM

Quote:

Originally posted by Nichole:
[qb] Patrick,

Yes....ahhhh Seattle. I am actually having mine done here in Seattle. If and when they approve. I am very confident in my physician so have made the choice to have it done here. As far as having it out of state, my insurance will not pay for out of state benefits unless it is an emergency while out of town. I work in the health care field and believe that Blue Cross has the same policy. I have contacted Blue Cross for my patients that come from out of state for Physical Therapy and they will not pay. But I would pull out your contract and read it as well as calling Blue Cross and asking them.

Who do you see as your Orthopedic Doc? Beings that I work in the Physical Therapy industry I know alot of the Orthopedic doctors in the greater Seattle area. [/qb]

Nichole,

I have contacted my insurance just to get it straight about using PPO's out of state. They told me for an in patient surgery, they cover 100% minus a $250 deductible. I did not even mention the term ADR at this time

My orthopedic spine specialist is Dr. Carolyn Marquardt in Bellevue. I am very happy with her style. We have ran the guantlet of care from conservative to aggressive and it has come time to hand it off to a qualified surgeon.

I have seen Ortho surgeon Wally Krengle in an office visit but he has no more experience with ADR than the initial model instruction. That is just not enough to make me feel confident. In fact after doing some research, I could not find anyone in the Seattle area who has anymore experience with it than the initial training. I am curious to find out who you have lined up to do your surgery.