Guest guest Posted December 22, 2006 Report Share Posted December 22, 2006 I agree also, because we are one of those centers that have been turned away as a COE based on volume. Kim Bentley, Office Manager Kidney Transplant Program Baptist Health Medical Center - Little Rock Medical Towers 2, Suite 800 Little Rock, Arkansas 72205 phone: or Toll Free: fax: email: Kim.Bentley@... >>> " Tyler, A. " 12/21/2006 5:03 PM >>> I think this is an excellent suggestion. ________________________________ IMPORTANT NOTICE - The information (both of the message and any attachments) contained in this message is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient or an agent responsible for delivering it to an intended recipient, or has received this message in error, you are hereby notified that we do not consent to any reading, dissemination, distribution or copying of this message and any such actions are strictly prohibited. If you have received this message in error, please notify the sender immediately and destroy the transmitted information. ochrane, Barbara E Sent: Thursday, December 21, 2006 2:46 PM & Program Committee: I have a topic suggestion for the next TFCA workshop. It might be interesting to have a panel of Transplant Directors/Case Managers from the larger commercial insurance companies present and be available for debate/questions about benefits, the authorization process, the centers of excellence (COE) concepts, etc. Those of us who work at transplant facilities that are not affiliated with major/university-based medical centers frequently come up against a brick wall when we have a patient who has insurance coverage that mandates use of an out-of-state transplant center. Oftentimes, going out of the patient's state of residence proves to be too much of a hardship and patients are not offered any alternatives; they often opt to wait out the 30-month COB period and return for evaluation and transplant under their Medicare coverage. Even then some insurance contracts do not provide secondary coverage outside a COE network. There are excellent, high quality transplant centers throughout the U.S. that have no hope of ever qualifying for a COE network based on volume. It could prove to be an interesting session............. Barbara Cochrane, MSN, RN Transplant Financial Coordinator Transplant Services Department Mercy Medical Center-Des Moines, Iowa Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 22, 2006 Report Share Posted December 22, 2006 This a great idea. ljm in okc -----Original Message-----From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ]On Behalf Of Tyler, A.Sent: Thursday, December 21, 2006 5:03 PMTo: TxFinancialCoordinators Subject: RE: 2007 Workshop I think this is an excellent suggestion. From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Cochrane, Barbara ESent: Thursday, December 21, 2006 2:46 PMTo: TxFinancialCoordinators Subject: 2007 Workshop & Program Committee: I have a topic suggestion for the next TFCA workshop. It might be interesting to have a panel of Transplant Directors/Case Managers from the larger commercial insurance companies present and be available for debate/questions about benefits, the authorization process, the centers of excellence (COE) concepts, etc. Those of us who work at transplant facilities that are not affiliated with major/university-based medical centers frequently come up against a brick wall when we have a patient who has insurance coverage that mandates use of an out-of-state transplant center. Oftentimes, going out of the patient’s state of residence proves to be too much of a hardship and patients are not offered any alternatives; they often opt to wait out the 30-month COB period and return for evaluation and transplant under their Medicare coverage. Even then some insurance contracts do not provide secondary coverage outside a COE network. There are excellent, high quality transplant centers throughout the U.S. that have no hope of ever qualifying for a COE network based on volume. It could prove to be an interesting session…………. Barbara Cochrane, MSN, RN Transplant Financial Coordinator Transplant Services Department Mercy Medical Center—Des Moines, Iowa Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 22, 2006 Report Share Posted December 22, 2006 I'm sure they would be very reluctant to discuss " how " patients might be steered away rather than toward the COE! Still could be a good topic, but a panel might have to be made up of TFCs! We have a process in place; draft of " 3 -example " appeal letters and a page of discussion points, etc... that we share with patients immediately and assist them with their appeal. Generally only works when there are at least OON benefits - but sometimes we are successful getting the exception in any case. We are in some networks for some of our programs - so we still frequenty encounter this and it's so frustrating for all concerned. Would sure be good to share information on this issue if possible. Craycraft Transplant Financial Coordinator University of Kansas Medical Center Fax lcraycraft@... >>> 12/22/2006 7:00 AM >>> The only way that would happen is if they ins carriers we've approached for the last 2 yrs ( & I know who you're talking about, Barbara, & we've contacted them MULTIPLE times) could bring themselves to even answer our requests, much less accept it, but so far, the only 'response' we've ever gotten is resounding silence! J. Aguiar Beth Israel Deaconess, Boston ________________________________ From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Tyler, A. Sent: Thursday, December 21, 2006 6:03 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop .. <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m sgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 22, 2006 Report Share Posted December 22, 2006 What has people’s experience been for patients with out of network benefits with such insurances utilizing COEs? Have centers been able to work patient specific contract closer to in network expenses? At least one insurance has mentioned 2 categories of centers available – one being such as center of excellence (for in network benefits) and one being hospitals they have contracts with (where patients can use out of network benefits)? Unclear as to the “qualifications” or “guidelines” for contracted hospitals vs. COE. Would be interested in a copy of “the page of discussion points” form Kansas if such can be shared. Best wishes for the holidays to everyone! Daryl Battin, LICSW Financial Coordinator/Social Worker Lahey Clinic Kidney Transplant Program 41 Mall Road Burlington, MA 10805 781 744-7166 RE: 2007 Workshop .. <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m sgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> Express yourself with over 10,000 FREE Email Smileys - click here! See our web page at http://www.lahey.org for a full directory of Lahey sites, staff, services and career opportunities.THIS MESSAGE IS INTENDED FOR THE USE OF THE PERSON TO WHOM IT IS ADDRESSED. IT MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW. If you are not the intended recipient, your use of this message for any purpose is strictly prohibited. If you have received this communication in error, please delete the message and notify the sender so that we may correct our records. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 22, 2006 Report Share Posted December 22, 2006 Payers set up COE’s because they can negotiate better rates and control their costs. The provider is supposed to get higher volumes. So payers are reluctant to set up other patient-specific arrangements which cost them more money, unless there are other overriding issues. Unless the patient or the provider can present those overriding issues convincingly, the payers won’t budge. That has been our experience in a nutshell. Fred L. Forsthoffer, MBA Financial Analyst Banner Good Samaritan Transplant Services , , F- From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Battin, Daryl J. Sent: Friday, December 22, 2006 9:48 AM To: TxFinancialCoordinators Subject: RE: 2007 Workshop What has people’s experience been for patients with out of network benefits with such insurances utilizing COEs? Have centers been able to work patient specific contract closer to in network expenses? At least one insurance has mentioned 2 categories of centers available – one being such as center of excellence (for in network benefits) and one being hospitals they have contracts with (where patients can use out of network benefits)? Unclear as to the “qualifications” or “guidelines” for contracted hospitals vs. COE. Would be interested in a copy of “the page of discussion points” form Kansas if such can be shared. Best wishes for the holidays to everyone! Daryl Battin, LICSW Financial Coordinator/Social Worker Lahey Clinic Kidney Transplant Program 41 Mall Road Burlington, MA 10805 781 744-7166 RE: 2007 Workshop .. <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m sgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> Express yourself with over 10,000 FREE Email Smileys - click here! See our web page at http://www.lahey.org for a full directory of Lahey sites, staff, services and career opportunities. THIS MESSAGE IS INTENDED FOR THE USE OF THE PERSON TO WHOM IT IS ADDRESSED. IT MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW. If you are not the intended recipient, your use of this message for any purpose is strictly prohibited. If you have received this communication in error, please delete the message and notify the sender so that we may correct our records. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 22, 2006 Report Share Posted December 22, 2006 Sometimes the insurance has agreed to pay in-network rate but with no travel, etc.. like they would have going to COE. Our center also does a preliminary financial review to see if the patient would meet charity requirements - if they do , we generally allow them to proceed with transplant services based on their OON benefit (even if insurance appeal is still pending), knowing the majority of oop will be written off per our charity policy. I will attach the documents we provide to the patient for appeal - hope any of this information is helpful.. Have a great holiday! Craycraft Transplant Financial Coordinator University of Kansas Medical Center Fax lcraycraft@... >>> " Battin, Daryl J. " 12/22/2006 10:47 AM >>> What has people's experience been for patients with out of network benefits with such insurances utilizing COEs? Have centers been able to work patient specific contract closer to in network expenses? At least one insurance has mentioned 2 categories of centers available - one being such as center of excellence (for in network benefits) and one being hospitals they have contracts with (where patients can use out of network benefits)? Unclear as to the " qualifications " or " guidelines " for contracted hospitals vs. COE. Would be interested in a copy of " the page of discussion points " form Kansas if such can be shared. Best wishes for the holidays to everyone! <http://www.smileycentral.com/?partner=ZSzeb001_ZNxmk788YYUS> Daryl Battin, LICSW Financial Coordinator/Social Worker Lahey Clinic Kidney Transplant Program 41 Mall Road Burlington, MA 10805 781 744-7166 RE: 2007 Workshop .. <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m > sgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> ________________________________ Express yourself with over 10,000 FREE Email Smileys - click here! <http://www.smileycentral.com/> See our web page at http://www.lahey.org for a full directory of Lahey sites, staff, services and career opportunities. THIS MESSAGE IS INTENDED FOR THE USE OF THE PERSON TO WHOM IT IS ADDRESSED. IT MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW. If you are not the intended recipient, your use of this message for any purpose is strictly prohibited. If you have received this communication in error, please delete the message and notify the sender so that we may correct our records. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 22, 2006 Report Share Posted December 22, 2006 , If you are willing to share your sample appeal letters, I would be interested in utilizing some of the language in them. Can you forward copies to me? We don't often have this problem on our pediatric patients, but I can recall a few occasions over the last few yrs when I might have been able to use some helpful wording to accomplish this. Thanks, Sue Hogenmiller, Transplant Financial Coordinator St. Louis Children's Hospital email: skh4333@... phone: fax: > " Craycraft " 12/22/2006 10:24 AM >>> I'm sure they would be very reluctant to discuss " how " patients might be steered away rather than toward the COE! Still could be a good topic, but a panel might have to be made up of TFCs! We have a process in place; draft of " 3 -example " appeal letters and a page of discussion points, etc... that we share with patients immediately and assist them with their appeal. Generally only works when there are at least OON benefits - but sometimes we are successful getting the exception in any case. We are in some networks for some of our programs - so we still frequenty encounter this and it's so frustrating for all concerned. Would sure be good to share information on this issue if possible. Craycraft Transplant Financial Coordinator University of Kansas Medical Center Fax lcraycraft@... >>> 12/22/2006 7:00 AM >>> The only way that would happen is if they ins carriers we've approached for the last 2 yrs ( & I know who you're talking about, Barbara, & we've contacted them MULTIPLE times) could bring themselves to even answer our requests, much less accept it, but so far, the only 'response' we've ever gotten is resounding silence! J. Aguiar Beth Israel Deaconess, Boston ________________________________ From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Tyler, A. Sent: Thursday, December 21, 2006 6:03 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop .. <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m sgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 22, 2006 Report Share Posted December 22, 2006 I would like to add another side to this issue. I work for a large University based hospital that has contracts with most large payors. But, since our BMT program treats children with very, very, very rare metobolic conditions, we occasionally have the phsycian/family of a child with one of the few insurance companies we don't have a contract with, want to send a child to us for stem cell transplant, because we literally are one of the only places that the child may be helped. Believe it or not, I left for my Christmas vacation with 3 of these cases in the works. At this point I have one of the kids approved for eval only(since we are in network for medical). If we want to proceed with transplant the fight will begin again, The process is frustrating and depressing. Especially when I think of agony of what these parents are going through waiting for the logistics to be worked out for their childs treatment. But, we are persistant, and I can think of only one situation to date that we were unable to overturn, and actually this child was misdiagnosed, so we didn't have to keep fighting. I know BMT varies greatly from solid organ, and many more centers are transplanting for solid organ than BMT (especially peds BMT), which probably makes the solid organ fight in this situation more difficult. I agree with that most insurance companies are not going to be willing to send reps to answer these questions. But the suggestion of a brainstorming session to discuss how these situations have been handled would probably be beneficial to us all. Thanks, Diane Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 22, 2006 Report Share Posted December 22, 2006 The thing is, the case managers really have little control over the decision making when it comes to COE OON exceptions. They can write a petition to the employer group who originally chose to use the COE restriction, but it is then in the hands of the employer group decision maker, not the case manager. This is true of all self-funded plans anyway. It is really the employer who is making these decisions when they write/chose the plan in the first place. By state law, once they allow an exception to one person, they have to consider that same exception for all persons under that plan. This essentially defaults the COE restriction making it a moot point, & in their mind, they lose (spend) money. There are 2 major reasons the employers write COE restrictions into the plan language: predictability of charges & benchmark “quality” indicators. We All know the quality benchmarks set by insurance/network companies are an arbitrary & often inappropriately measured concept. But the employers, who are not medical folks, don’t know that. They actually think they are doing the right thing. Another major component of the decision/ restriction to use COE’s is made by the reinsurers. They again, are after cost predictability & best outcomes predictability: they don’t want to lose money. That is all it is about. Having been an insurance case manager in my previous life, I can tell you, that the nurses in those roles have a very limited range of options. Most of them do want the best for the patient, and sometimes, they have studied the national stats/outcomes at various centers & are advising the patient to do the same. They have to work within the pre-written benefit plan. As transplant centers, of all sizes and specialties, we all struggle with the COE crap on a daily basis. But the COE concept is actually bigger than transplant, as it is utilized in cancer treatment, NICU, bariatrics, fertility, etc. I have no answers, but I do know that insurance companies will each argue that they are doing what is best for their members by getting the “highest quality of care with the most economical plan”. They will not be able to say anything else in a panel presentation as that is their mission. ~Sher Stirling-Burgin, BSHA, RN, CCM Transplant Financial Coordinator Clarian Transplant Liver/ Intestine/Multivisceral 550 N. University Blvd., Rm 4601 Indpls., IN 46202-5250 From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Sue Hogenmiller Sent: Friday, December 22, 2006 12:21 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop , If you are willing to share your sample appeal letters, I would be interested in utilizing some of the language in them. Can you forward copies to me? We don't often have this problem on our pediatric patients, but I can recall a few occasions over the last few yrs when I might have been able to use some helpful wording to accomplish this. Thanks, Sue Hogenmiller, Transplant Financial Coordinator St. Louis Children's Hospital email: skh4333bjc (DOT) org phone: fax: > " Craycraft " <LCraycraftKUMC (DOT) Edu> 12/22/2006 10:24 AM >>> I'm sure they would be very reluctant to discuss " how " patients might be steered away rather than toward the COE! Still could be a good topic, but a panel might have to be made up of TFCs! We have a process in place; draft of " 3 -example " appeal letters and a page of discussion points, etc... that we share with patients immediately and assist them with their appeal. Generally only works when there are at least OON benefits - but sometimes we are successful getting the exception in any case. We are in some networks for some of our programs - so we still frequenty encounter this and it's so frustrating for all concerned. Would sure be good to share information on this issue if possible. Craycraft Transplant Financial Coordinator University of Kansas Medical Center Fax lcraycraftkumc (DOT) edu >>> <LAguiarBIDMC (DOT) Harvard.Edu> 12/22/2006 7:00 AM >>> The only way that would happen is if they ins carriers we've approached for the last 2 yrs ( & I know who you're talking about, Barbara, & we've contacted them MULTIPLE times) could bring themselves to even answer our requests, much less accept it, but so far, the only 'response' we've ever gotten is resounding silence! J. Aguiar Beth Israel Deaconess, Boston ________________________________ From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Tyler, A. Sent: Thursday, December 21, 2006 6:03 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop .. <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m sgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 22, 2006 Report Share Posted December 22, 2006 This is a good synopsis of the COE issue. Well stated. Fred L. Forsthoffer, MBA Financial Analyst Banner Good Samaritan Transplant Services , , F- From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Stirling-Burgin, Sherry Sent: Friday, December 22, 2006 12:44 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop The thing is, the case managers really have little control over the decision making when it comes to COE OON exceptions. They can write a petition to the employer group who originally chose to use the COE restriction, but it is then in the hands of the employer group decision maker, not the case manager. This is true of all self-funded plans anyway. It is really the employer who is making these decisions when they write/chose the plan in the first place. By state law, once they allow an exception to one person, they have to consider that same exception for all persons under that plan. This essentially defaults the COE restriction making it a moot point, & in their mind, they lose (spend) money. There are 2 major reasons the employers write COE restrictions into the plan language: predictability of charges & benchmark “quality” indicators. We All know the quality benchmarks set by insurance/network companies are an arbitrary & often inappropriately measured concept. But the employers, who are not medical folks, don’t know that. They actually think they are doing the right thing. Another major component of the decision/ restriction to use COE’s is made by the reinsurers. They again, are after cost predictability & best outcomes predictability: they don’t want to lose money. That is all it is about. Having been an insurance case manager in my previous life, I can tell you, that the nurses in those roles have a very limited range of options. Most of them do want the best for the patient, and sometimes, they have studied the national stats/outcomes at various centers & are advising the patient to do the same. They have to work within the pre-written benefit plan. As transplant centers, of all sizes and specialties, we all struggle with the COE crap on a daily basis. But the COE concept is actually bigger than transplant, as it is utilized in cancer treatment, NICU, bariatrics, fertility, etc. I have no answers, but I do know that insurance companies will each argue that they are doing what is best for their members by getting the “highest quality of care with the most economical plan”. They will not be able to say anything else in a panel presentation as that is their mission. ~Sher Stirling-Burgin, BSHA, RN, CCM Transplant Financial Coordinator Clarian Transplant Liver/ Intestine/Multivisceral 550 N. University Blvd., Rm 4601 Indpls., IN 46202-5250 From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Sue Hogenmiller Sent: Friday, December 22, 2006 12:21 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop , If you are willing to share your sample appeal letters, I would be interested in utilizing some of the language in them. Can you forward copies to me? We don't often have this problem on our pediatric patients, but I can recall a few occasions over the last few yrs when I might have been able to use some helpful wording to accomplish this. Thanks, Sue Hogenmiller, Transplant Financial Coordinator St. Louis Children's Hospital email: skh4333bjc (DOT) org phone: fax: > " Craycraft " <LCraycraftKUMC (DOT) Edu> 12/22/2006 10:24 AM >>> I'm sure they would be very reluctant to discuss " how " patients might be steered away rather than toward the COE! Still could be a good topic, but a panel might have to be made up of TFCs! We have a process in place; draft of " 3 -example " appeal letters and a page of discussion points, etc... that we share with patients immediately and assist them with their appeal. Generally only works when there are at least OON benefits - but sometimes we are successful getting the exception in any case. We are in some networks for some of our programs - so we still frequenty encounter this and it's so frustrating for all concerned. Would sure be good to share information on this issue if possible. Craycraft Transplant Financial Coordinator University of Kansas Medical Center Fax lcraycraftkumc (DOT) edu >>> <LAguiarBIDMC (DOT) Harvard.Edu> 12/22/2006 7:00 AM >>> The only way that would happen is if they ins carriers we've approached for the last 2 yrs ( & I know who you're talking about, Barbara, & we've contacted them MULTIPLE times) could bring themselves to even answer our requests, much less accept it, but so far, the only 'response' we've ever gotten is resounding silence! J. Aguiar Beth Israel Deaconess, Boston ________________________________ From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Tyler, A. Sent: Thursday, December 21, 2006 6:03 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop .. <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m sgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 23, 2006 Report Share Posted December 23, 2006 Exactly, Sher & Fred. Plus, don't forget, very few, if any, of the HR people buying these products EVER look @ what the tx coverage is or what it would REALLY mean to their employees if the situation ever arose. I can't be the only one who has ever had to explain to an HR person all the specifics of a policy he/she bought, especially the part that says the pt has to go across country for a procedure available literally in their own backyard. J. Aguiar Beth Israel Deaconess, Boston From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Stirling-Burgin, SherrySent: Friday, December 22, 2006 2:44 PMTo: TxFinancialCoordinators Subject: RE: 2007 Workshop The thing is, the case managers really have little control over the decision making when it comes to COE OON exceptions. They can write a petition to the employer group who originally chose to use the COE restriction, but it is then in the hands of the employer group decision maker, not the case manager. This is true of all self-funded plans anyway. It is really the employer who is making these decisions when they write/chose the plan in the first place. By state law, once they allow an exception to one person, they have to consider that same exception for all persons under that plan. This essentially defaults the COE restriction making it a moot point, & in their mind, they lose (spend) money. There are 2 major reasons the employers write COE restrictions into the plan language: predictability of charges & benchmark “quality” indicators. We All know the quality benchmarks set by insurance/network companies are an arbitrary & often inappropriately measured concept. But the employers, who are not medical folks, don’t know that. They actually think they are doing the right thing. Another major component of the decision/ restriction to use COE’s is made by the reinsurers. They again, are after cost predictability & best outcomes predictability: they don’t want to lose money. That is all it is about. Having been an insurance case manager in my previous life, I can tell you, that the nurses in those roles have a very limited range of options. Most of them do want the best for the patient, and sometimes, they have studied the national stats/outcomes at various centers & are advising the patient to do the same. They have to work within the pre-written benefit plan. As transplant centers, of all sizes and specialties, we all struggle with the COE crap on a daily basis. But the COE concept is actually bigger than transplant, as it is utilized in cancer treatment, NICU, bariatrics, fertility, etc. I have no answers, but I do know that insurance companies will each argue that they are doing what is best for their members by getting the “highest quality of care with the most economical plan”. They will not be able to say anything else in a panel presentation as that is their mission. ~Sher Stirling-Burgin, BSHA, RN, CCM Transplant Financial Coordinator Clarian Transplant Liver/ Intestine/Multivisceral 550 N. University Blvd., Rm 4601 Indpls., IN 46202-5250 From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Sue HogenmillerSent: Friday, December 22, 2006 12:21 PMTo: TxFinancialCoordinators Subject: RE: 2007 Workshop ,If you are willing to share your sample appeal letters, I would beinterested in utilizing some of the language in them. Can you forwardcopies to me? We don't often have this problem on our pediatricpatients, but I can recall a few occasions over the last few yrs when Imight have been able to use some helpful wording to accomplish this. Thanks,Sue Hogenmiller,Transplant Financial CoordinatorSt. Louis Children's Hospitalemail: skh4333bjc (DOT) orgphone: fax: > " Craycraft" <LCraycraftKUMC (DOT) Edu> 12/22/2006 10:24 AM >>>I'm sure they would be very reluctant to discuss "how" patients mightbesteered away rather than toward the COE! Still could be a good topic, but a panel might have to be made up of TFCs! We have a process inplace; draft of "3 -example" appeal letters and a page of discussionpoints, etc... that we share with patients immediately and assist themwith their appeal. Generally only works when there are at least OONbenefits - but sometimes we are successful getting the exception inanycase. We are in some networks for some of our programs - so we stillfrequenty encounter this and it's so frustrating for all concerned.Would sure be good to share information on this issue if possible. CraycraftTransplant Financial CoordinatorUniversity of Kansas Medical Center Fax lcraycraftkumc (DOT) edu >>> <LAguiarBIDMC (DOT) Harvard.Edu> 12/22/2006 7:00 AM >>>The only way that would happen is if they ins carriers we'veapproachedfor the last 2 yrs ( & I know who you're talking about, Barbara, & we'vecontacted them MULTIPLE times) could bring themselves to even answerourrequests, much less accept it, but so far, the only 'response' we'veever gotten is resounding silence! J. AguiarBeth Israel Deaconess, Boston________________________________From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Tyler, A.Sent: Thursday, December 21, 2006 6:03 PMTo: TxFinancialCoordinators Subject: RE: 2007 Workshop.<http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/msgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 26, 2006 Report Share Posted December 26, 2006 Yes, I recently had a case where the HR person spoke with me about verbage for coverage at our facility, then when the policy was purchased, the OON benefits were so small (only $100,000. per transplant) that the pt still had to go to the COE. Amellia Gay ETMC Tyler Texas >>> LAguiar@... 12/22/06 7:41 PM >>> Exactly, Sher & Fred. Plus, don't forget, very few, if any, of the HR people buying these products EVER look @ what the tx coverage is or what it would REALLY mean to their employees if the situation ever arose. I can't be the only one who has ever had to explain to an HR person all the specifics of a policy he/she bought, especially the part that says the pt has to go across country for a procedure available literally in their own backyard. J. Aguiar Beth Israel Deaconess, Boston ________________________________ From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Stirling-Burgin, Sherry Sent: Friday, December 22, 2006 2:44 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop The thing is, the case managers really have little control over the decision making when it comes to COE OON exceptions. They can write a petition to the employer group who originally chose to use the COE restriction, but it is then in the hands of the employer group decision maker, not the case manager. This is true of all self-funded plans anyway. It is really the employer who is making these decisions when they write/chose the plan in the first place. By state law, once they allow an exception to one person, they have to consider that same exception for all persons under that plan. This essentially defaults the COE restriction making it a moot point, & in their mind, they lose (spend) money. There are 2 major reasons the employers write COE restrictions into the plan language: predictability of charges & benchmark " quality " indicators. We All know the quality benchmarks set by insurance/network companies are an arbitrary & often inappropriately measured concept. But the employers, who are not medical folks, don't know that. They actually think they are doing the right thing. Another major component of the decision/ restriction to use COE's is made by the reinsurers. They again, are after cost predictability & best outcomes predictability: they don't want to lose money. That is all it is about. Having been an insurance case manager in my previous life, I can tell you, that the nurses in those roles have a very limited range of options. Most of them do want the best for the patient, and sometimes, they have studied the national stats/outcomes at various centers & are advising the patient to do the same. They have to work within the pre-written benefit plan. As transplant centers, of all sizes and specialties, we all struggle with the COE crap on a daily basis. But the COE concept is actually bigger than transplant, as it is utilized in cancer treatment, NICU, bariatrics, fertility, etc. I have no answers, but I do know that insurance companies will each argue that they are doing what is best for their members by getting the " highest quality of care with the most economical plan " . They will not be able to say anything else in a panel presentation as that is their mission. ~Sher Stirling-Burgin, BSHA, RN, CCM Transplant Financial Coordinator Clarian Transplant Liver/ Intestine/Multivisceral 550 N. University Blvd., Rm 4601 Indpls., IN 46202-5250 ________________________________ From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Sue Hogenmiller Sent: Friday, December 22, 2006 12:21 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop , If you are willing to share your sample appeal letters, I would be interested in utilizing some of the language in them. Can you forward copies to me? We don't often have this problem on our pediatric patients, but I can recall a few occasions over the last few yrs when I might have been able to use some helpful wording to accomplish this. Thanks, Sue Hogenmiller, Transplant Financial Coordinator St. Louis Children's Hospital email: skh4333@... <mailto:skh4333%40bjc.org> phone: fax: > " Craycraft " <LCraycraft@... <mailto:LCraycraft%40KUMC.Edu> > 12/22/2006 10:24 AM >>> I'm sure they would be very reluctant to discuss " how " patients might be steered away rather than toward the COE! Still could be a good topic, but a panel might have to be made up of TFCs! We have a process in place; draft of " 3 -example " appeal letters and a page of discussion points, etc... that we share with patients immediately and assist them with their appeal. Generally only works when there are at least OON benefits - but sometimes we are successful getting the exception in any case. We are in some networks for some of our programs - so we still frequenty encounter this and it's so frustrating for all concerned. Would sure be good to share information on this issue if possible. Craycraft Transplant Financial Coordinator University of Kansas Medical Center Fax lcraycraft@... <mailto:lcraycraft%40kumc.edu> >>> <LAguiar@... <mailto:LAguiar%40BIDMC.Harvard.Edu> > 12/22/2006 7:00 AM >>> The only way that would happen is if they ins carriers we've approached for the last 2 yrs ( & I know who you're talking about, Barbara, & we've contacted them MULTIPLE times) could bring themselves to even answer our requests, much less accept it, but so far, the only 'response' we've ever gotten is resounding silence! J. Aguiar Beth Israel Deaconess, Boston ________________________________ From: TxFinancialCoordinators <mailto:TxFinancialCoordinators%40yahoogroups.com> [mailto:TxFinancialCoordinators <mailto:TxFinancialCoordinators%40yahoogroups.com> ] On Behalf Of Tyler, A. Sent: Thursday, December 21, 2006 6:03 PM To: TxFinancialCoordinators <mailto:TxFinancialCoordinators%40yahoogroups.com> Subject: RE: 2007 Workshop .. <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m > sgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> =========================================================== This message is confidential, intended only for the named recipient(s) and may contain information that is privileged or exempt from disclosure under applicable law. If you are not the intended recipient(s), you are notified that the dissemination, distribution or copying of this message is strictly prohibited. If you received this message in error, or are not the named recipient(s), please notify the sender and delete this e-mail from your computer. ETMC has implemented secure messaging for certain types of messages. For more information about our secure messaging system, go to: http://www.etmc.org/mail/ Thank you. =========================================================== Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 26, 2006 Report Share Posted December 26, 2006 You are right… it’s sad… but true. I work for a hospital that does not even allow its OWN employees to be transplanted here until they have coverage with our insurance for 2 years. We’ve had to tell several “newer” hospital employees over the years that they could not be transplanted here, even tho they work at this hospital and have the hospital’s own insurance. (unless they are healthy enough to wait for 2 years….) a From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of LAguiar@... Sent: Friday, December 22, 2006 8:41 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop Exactly, Sher & Fred. Plus, don't forget, very few, if any, of the HR people buying these products EVER look @ what the tx coverage is or what it would REALLY mean to their employees if the situation ever arose. I can't be the only one who has ever had to explain to an HR person all the specifics of a policy he/she bought, especially the part that says the pt has to go across country for a procedure available literally in their own backyard. J. Aguiar Beth Israel Deaconess, Boston From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Stirling-Burgin, Sherry Sent: Friday, December 22, 2006 2:44 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop The thing is, the case managers really have little control over the decision making when it comes to COE OON exceptions. They can write a petition to the employer group who originally chose to use the COE restriction, but it is then in the hands of the employer group decision maker, not the case manager. This is true of all self-funded plans anyway. It is really the employer who is making these decisions when they write/chose the plan in the first place. By state law, once they allow an exception to one person, they have to consider that same exception for all persons under that plan. This essentially defaults the COE restriction making it a moot point, & in their mind, they lose (spend) money. There are 2 major reasons the employers write COE restrictions into the plan language: predictability of charges & benchmark “quality” indicators. We All know the quality benchmarks set by insurance/network companies are an arbitrary & often inappropriately measured concept. But the employers, who are not medical folks, don’t know that. They actually think they are doing the right thing. Another major component of the decision/ restriction to use COE’s is made by the reinsurers. They again, are after cost predictability & best outcomes predictability: they don’t want to lose money. That is all it is about. Having been an insurance case manager in my previous life, I can tell you, that the nurses in those roles have a very limited range of options. Most of them do want the best for the patient, and sometimes, they have studied the national stats/outcomes at various centers & are advising the patient to do the same. They have to work within the pre-written benefit plan. As transplant centers, of all sizes and specialties, we all struggle with the COE crap on a daily basis. But the COE concept is actually bigger than transplant, as it is utilized in cancer treatment, NICU, bariatrics, fertility, etc. I have no answers, but I do know that insurance companies will each argue that they are doing what is best for their members by getting the “highest quality of care with the most economical plan”. They will not be able to say anything else in a panel presentation as that is their mission. ~Sher Stirling-Burgin, BSHA, RN, CCM Transplant Financial Coordinator Clarian Transplant Liver/ Intestine/Multivisceral 550 N. University Blvd., Rm 4601 Indpls., IN 46202-5250 From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Sue Hogenmiller Sent: Friday, December 22, 2006 12:21 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop , If you are willing to share your sample appeal letters, I would be interested in utilizing some of the language in them. Can you forward copies to me? We don't often have this problem on our pediatric patients, but I can recall a few occasions over the last few yrs when I might have been able to use some helpful wording to accomplish this. Thanks, Sue Hogenmiller, Transplant Financial Coordinator St. Louis Children's Hospital email: skh4333bjc (DOT) org phone: fax: > " Craycraft " <LCraycraftKUMC (DOT) Edu> 12/22/2006 10:24 AM >>> I'm sure they would be very reluctant to discuss " how " patients might be steered away rather than toward the COE! Still could be a good topic, but a panel might have to be made up of TFCs! We have a process in place; draft of " 3 -example " appeal letters and a page of discussion points, etc... that we share with patients immediately and assist them with their appeal. Generally only works when there are at least OON benefits - but sometimes we are successful getting the exception in any case. We are in some networks for some of our programs - so we still frequenty encounter this and it's so frustrating for all concerned. Would sure be good to share information on this issue if possible. Craycraft Transplant Financial Coordinator University of Kansas Medical Center Fax lcraycraftkumc (DOT) edu >>> <LAguiarBIDMC (DOT) Harvard.Edu> 12/22/2006 7:00 AM >>> The only way that would happen is if they ins carriers we've approached for the last 2 yrs ( & I know who you're talking about, Barbara, & we've contacted them MULTIPLE times) could bring themselves to even answer our requests, much less accept it, but so far, the only 'response' we've ever gotten is resounding silence! J. Aguiar Beth Israel Deaconess, Boston ________________________________ From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Tyler, A. Sent: Thursday, December 21, 2006 6:03 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop .. <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m sgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> ======================================================= The information contained in this message may be privileged and/or confidential and protected from disclosure. If the reader of this message is not the intended recipient or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the sender immediately by replying to this message and deleting the material from any computer. ======================================================= Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 26, 2006 Report Share Posted December 26, 2006 It is the “shock claims” they are trying to prevent. Anything over $25,000 at a single pop is a red flag for a place to cut benefit costs. Self funded plans are required by the state rules that govern them to keep enough $ in a fund to actually pay the claims for the amount of total member/dependent claims they may have to pay out in any given 3mo.period. They are required to have reinsurance w/variables as to when the reinsurance kicks in to take over on those shock claims. Reinsurance is very expensive, & the sooner it kicks in to protect the plan, the higher the reinsurance premiums for that given payer. Employers are looking to brokers & advisors for any legal means to reduce their health care expenses. Transplant has become so much more common & payers have to set aside a much greater % of their anticipated claims coverage, that this is one they are choosing to carve out or control by limiting access. I personally think they could be legally challenged on carving out particular treatments that are considered standards of care, but the problem is that more & more payers are going the route of self-funding in order to operate outside of insurance regulations. Self-funded plans are under ERISA & guidelines by the Dept of Labor are rather relaxed in the area of coverage requirements. a: one argument you might take to your administration folks WITHIN the transplant program, if you are needing to increase volume, is that any employee sent away, is one person lost from your list. Don’t know the size of your program, but every case is a case & endorsing/ advertising your own program internally can only benefit the program itself. ~Sher Stirling-Burgin, BSHA, RN,CCM Clarian Transplant Indpls, IN From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Summa, a Sent: Tuesday, December 26, 2006 10:28 AM To: TxFinancialCoordinators Subject: RE: 2007 Workshop You are right… it’s sad… but true. I work for a hospital that does not even allow its OWN employees to be transplanted here until they have coverage with our insurance for 2 years. We’ve had to tell several “newer” hospital employees over the years that they could not be transplanted here, even tho they work at this hospital and have the hospital’s own insurance. (unless they are healthy enough to wait for 2 years….) a From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of LAguiarBIDMC (DOT) Harvard.Edu Sent: Friday, December 22, 2006 8:41 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop Exactly, Sher & Fred. Plus, don't forget, very few, if any, of the HR people buying these products EVER look @ what the tx coverage is or what it would REALLY mean to their employees if the situation ever arose. I can't be the only one who has ever had to explain to an HR person all the specifics of a policy he/she bought, especially the part that says the pt has to go across country for a procedure available literally in their own backyard. J. Aguiar Beth Israel Deaconess, Boston From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Stirling-Burgin, Sherry Sent: Friday, December 22, 2006 2:44 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop The thing is, the case managers really have little control over the decision making when it comes to COE OON exceptions. They can write a petition to the employer group who originally chose to use the COE restriction, but it is then in the hands of the employer group decision maker, not the case manager. This is true of all self-funded plans anyway. It is really the employer who is making these decisions when they write/chose the plan in the first place. By state law, once they allow an exception to one person, they have to consider that same exception for all persons under that plan. This essentially defaults the COE restriction making it a moot point, & in their mind, they lose (spend) money. There are 2 major reasons the employers write COE restrictions into the plan language: predictability of charges & benchmark “quality” indicators. We All know the quality benchmarks set by insurance/network companies are an arbitrary & often inappropriately measured concept. But the employers, who are not medical folks, don’t know that. They actually think they are doing the right thing. Another major component of the decision/ restriction to use COE’s is made by the reinsurers. They again, are after cost predictability & best outcomes predictability: they don’t want to lose money. That is all it is about. Having been an insurance case manager in my previous life, I can tell you, that the nurses in those roles have a very limited range of options. Most of them do want the best for the patient, and sometimes, they have studied the national stats/outcomes at various centers & are advising the patient to do the same. They have to work within the pre-written benefit plan. As transplant centers, of all sizes and specialties, we all struggle with the COE crap on a daily basis. But the COE concept is actually bigger than transplant, as it is utilized in cancer treatment, NICU, bariatrics, fertility, etc. I have no answers, but I do know that insurance companies will each argue that they are doing what is best for their members by getting the “highest quality of care with the most economical plan”. They will not be able to say anything else in a panel presentation as that is their mission. ~Sher Stirling-Burgin, BSHA, RN, CCM Transplant Financial Coordinator Clarian Transplant Liver/ Intestine/Multivisceral 550 N. University Blvd., Rm 4601 Indpls., IN 46202-5250 From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Sue Hogenmiller Sent: Friday, December 22, 2006 12:21 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop , If you are willing to share your sample appeal letters, I would be interested in utilizing some of the language in them. Can you forward copies to me? We don't often have this problem on our pediatric patients, but I can recall a few occasions over the last few yrs when I might have been able to use some helpful wording to accomplish this. Thanks, Sue Hogenmiller, Transplant Financial Coordinator St. Louis Children's Hospital email: skh4333bjc (DOT) org phone: fax: > " Craycraft " <LCraycraftKUMC (DOT) Edu> 12/22/2006 10:24 AM >>> I'm sure they would be very reluctant to discuss " how " patients might be steered away rather than toward the COE! Still could be a good topic, but a panel might have to be made up of TFCs! We have a process in place; draft of " 3 -example " appeal letters and a page of discussion points, etc... that we share with patients immediately and assist them with their appeal. Generally only works when there are at least OON benefits - but sometimes we are successful getting the exception in any case. We are in some networks for some of our programs - so we still frequenty encounter this and it's so frustrating for all concerned. Would sure be good to share information on this issue if possible. Craycraft Transplant Financial Coordinator University of Kansas Medical Center Fax lcraycraftkumc (DOT) edu >>> <LAguiarBIDMC (DOT) Harvard.Edu> 12/22/2006 7:00 AM >>> The only way that would happen is if they ins carriers we've approached for the last 2 yrs ( & I know who you're talking about, Barbara, & we've contacted them MULTIPLE times) could bring themselves to even answer our requests, much less accept it, but so far, the only 'response' we've ever gotten is resounding silence! J. Aguiar Beth Israel Deaconess, Boston ________________________________ From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Tyler, A. Sent: Thursday, December 21, 2006 6:03 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop .. <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m sgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> ======================================================= The information contained in this message may be privileged and/or confidential and protected from disclosure. If the reader of this message is not the intended recipient or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the sender immediately by replying to this message and deleting the material from any computer. ======================================================= Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 27, 2006 Report Share Posted December 27, 2006 Amellia: It’s very frustrating. We had a case where the broker argued w/us & the patient, stating they COULD come here, the broker “knew” this. He was VERY wrong. Turned out the patient was the owner/ president of this small self-funded company & ended up suing his broker for misadvice. Sher Stirling-Burgin, BSHA, RN, CCM Clarian Transplant Liver/ Intestine/Multivisceral Programs 550 N. University Blvd., Rm 4601 Indpls., IN 46202-5202 desk FAX sstirlingburgin@... From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Amellia Gay Sent: Tuesday, December 26, 2006 9:05 AM To: TxFinancialCoordinators Subject: RE: 2007 Workshop Yes, I recently had a case where the HR person spoke with me about verbage for coverage at our facility, then when the policy was purchased, the OON benefits were so small (only $100,000. per transplant) that the pt still had to go to the COE. Amellia Gay ETMC Tyler Texas >>> LAguiarBIDMC (DOT) Harvard.Edu 12/22/06 7:41 PM >>> Exactly, Sher & Fred. Plus, don't forget, very few, if any, of the HR people buying these products EVER look @ what the tx coverage is or what it would REALLY mean to their employees if the situation ever arose. I can't be the only one who has ever had to explain to an HR person all the specifics of a policy he/she bought, especially the part that says the pt has to go across country for a procedure available literally in their own backyard. J. Aguiar Beth Israel Deaconess, Boston ________________________________ From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Stirling-Burgin, Sherry Sent: Friday, December 22, 2006 2:44 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop The thing is, the case managers really have little control over the decision making when it comes to COE OON exceptions. They can write a petition to the employer group who originally chose to use the COE restriction, but it is then in the hands of the employer group decision maker, not the case manager. This is true of all self-funded plans anyway. It is really the employer who is making these decisions when they write/chose the plan in the first place. By state law, once they allow an exception to one person, they have to consider that same exception for all persons under that plan. This essentially defaults the COE restriction making it a moot point, & in their mind, they lose (spend) money. There are 2 major reasons the employers write COE restrictions into the plan language: predictability of charges & benchmark " quality " indicators. We All know the quality benchmarks set by insurance/network companies are an arbitrary & often inappropriately measured concept. But the employers, who are not medical folks, don't know that. They actually think they are doing the right thing. Another major component of the decision/ restriction to use COE's is made by the reinsurers. They again, are after cost predictability & best outcomes predictability: they don't want to lose money. That is all it is about. Having been an insurance case manager in my previous life, I can tell you, that the nurses in those roles have a very limited range of options. Most of them do want the best for the patient, and sometimes, they have studied the national stats/outcomes at various centers & are advising the patient to do the same. They have to work within the pre-written benefit plan. As transplant centers, of all sizes and specialties, we all struggle with the COE crap on a daily basis. But the COE concept is actually bigger than transplant, as it is utilized in cancer treatment, NICU, bariatrics, fertility, etc. I have no answers, but I do know that insurance companies will each argue that they are doing what is best for their members by getting the " highest quality of care with the most economical plan " . They will not be able to say anything else in a panel presentation as that is their mission. ~Sher Stirling-Burgin, BSHA, RN, CCM Transplant Financial Coordinator Clarian Transplant Liver/ Intestine/Multivisceral 550 N. University Blvd., Rm 4601 Indpls., IN 46202-5250 ________________________________ From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Sue Hogenmiller Sent: Friday, December 22, 2006 12:21 PM To: TxFinancialCoordinators Subject: RE: 2007 Workshop , If you are willing to share your sample appeal letters, I would be interested in utilizing some of the language in them. Can you forward copies to me? We don't often have this problem on our pediatric patients, but I can recall a few occasions over the last few yrs when I might have been able to use some helpful wording to accomplish this. Thanks, Sue Hogenmiller, Transplant Financial Coordinator St. Louis Children's Hospital email: skh4333bjc (DOT) org <mailto:skh4333%40bjc.org> phone: fax: > " Craycraft " <LCraycraftKUMC (DOT) Edu <mailto:LCraycraft%40KUMC.Edu> > 12/22/2006 10:24 AM >>> I'm sure they would be very reluctant to discuss " how " patients might be steered away rather than toward the COE! Still could be a good topic, but a panel might have to be made up of TFCs! We have a process in place; draft of " 3 -example " appeal letters and a page of discussion points, etc... that we share with patients immediately and assist them with their appeal. Generally only works when there are at least OON benefits - but sometimes we are successful getting the exception in any case. We are in some networks for some of our programs - so we still frequenty encounter this and it's so frustrating for all concerned. Would sure be good to share information on this issue if possible. Craycraft Transplant Financial Coordinator University of Kansas Medical Center Fax lcraycraftkumc (DOT) edu <mailto:lcraycraft%40kumc.edu> >>> <LAguiarBIDMC (DOT) Harvard.Edu <mailto:LAguiar%40BIDMC.Harvard.Edu> > 12/22/2006 7:00 AM >>> The only way that would happen is if they ins carriers we've approached for the last 2 yrs ( & I know who you're talking about, Barbara, & we've contacted them MULTIPLE times) could bring themselves to even answer our requests, much less accept it, but so far, the only 'response' we've ever gotten is resounding silence! J. Aguiar Beth Israel Deaconess, Boston ________________________________ From: TxFinancialCoordinators <mailto:TxFinancialCoordinators%40yahoogroups.com> [mailto:TxFinancialCoordinators <mailto:TxFinancialCoordinators%40yahoogroups.com> ] On Behalf Of Tyler, A. Sent: Thursday, December 21, 2006 6:03 PM To: TxFinancialCoordinators <mailto:TxFinancialCoordinators%40yahoogroups.com> Subject: RE: 2007 Workshop .. <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m <http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/m > sgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> =========================================================== This message is confidential, intended only for the named recipient(s) and may contain information that is privileged or exempt from disclosure under applicable law. If you are not the intended recipient(s), you are notified that the dissemination, distribution or copying of this message is strictly prohibited. If you received this message in error, or are not the named recipient(s), please notify the sender and delete this e-mail from your computer. ETMC has implemented secure messaging for certain types of messages. For more information about our secure messaging system, go to: http://www.etmc.org/mail/ Thank you. =========================================================== Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 27, 2006 Report Share Posted December 27, 2006 I had a patient last year who was covered under her husbands plan through a small group "self-funded" plan and after her liver transplant she got a letter stating they were dropping HER from the plan because it was costing the rest of the employees too much for their benefits since she had the transplant. The way they got around it was she had to find another plan and they would cover her premiums. She received the letter the day before Christmas last year and she had until 1/1/06 to find another plan. It was a nightmare trying to get her immunos in place etc. In response to the HR people not knowing what they are signing up for, I had another patient who's group had changed policies and when I went to authorize her transplant (she was at the top of the list), I was told there were no transplant benefits under this group. We had too inactivate her. I advised her to contact her HR people to straighten it out and she never got a response. I finally contacted the CEO of the company and through his secretary explained the situation. I got a call back within 10 minutes from the CEO telling me they had no idea transplant coverage was withheld from the package and assured me it would be fixed by the end of the day. Famous last words. But it was fixed and coverage and approval was done within 2 days. I always advice people to go back to their employer as sometimes these are overlooked because they are not every day events. Hogan Transplant Financial Coordinator Lahey Clinic 41 Mall Rd. Burlington, MA 01805 phone fax RE: 2007 Workshop.<http://geo.yahoo.com/serv?s=97359714/grpId=1988899/grpspId=1705061146/msgId=9973/stime=1166742496/nc1=3848474/nc2=3848570/nc3=3848644> =======================================================The information contained in this message may be privileged and/or confidentialand protected from disclosure. If the reader of this message is not the intended recipient or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received thiscommunication in error, please notify the sender immediately by replying to this message and deleting the material from any computer.======================================================= See our web page at http://www.lahey.org for a full directory of Lahey sites, staff, services and career opportunities.THIS MESSAGE IS INTENDED FOR THE USE OF THE PERSON TO WHOM IT IS ADDRESSED. IT MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW. If you are not the intended recipient, your use of this message for any purpose is strictly prohibited. If you have received this communication in error, please delete the message and notify the sender so that we may correct our records. Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.