Re: Fw: House Hearing on: Raising Health Awareness Through E...

[Guest guest]

Angelika,

I personally hate to make these kinds of recommendations, as I am not a medical professional, nor a legal professional. However, any kind of plan is normally better than an HMO plan, unless it may be a National HMO Plan, which this one is Not! Who is the P3 plan with -- like, which insurance carrier, ie, Aetna, Blue Cross, Pacific Mutual, etc.?

Sincerely,

Martha Murdock

NSIF

MAM-NSIF@...

[Guest guest]

Do you think that I may have some leverage with getting insurance and McGhan to pay for the explant since I had the surgery in 1998 and the implants were not even approved by the FDA? Back then I didn't have access to the internet so I could not do all this research.

In a message dated 11/16/2001 9:17:49 PM Eastern Standard Time, fdp@... writes:

In May 2000, the FDA approved saline breast implants. The approval came

> in spite of Mr. Templer's recommendation, in spite of complications rates

> as high as 43% for cosmetic patients and complication rates of over 70%

for

> reconstruction patients (in the first 3 years), and in spite of an ongoing

> open criminal investigation into one of the manufacturers, which remains

> open even today.

Angelika

[Guest guest]

Through my husband, I have the option of the following insurance choices:

P3 (Preferred Provider Plan) provides coverage in-network through the United Healthcare (UHC)

An HMO with Trigon Healthkeepers

Do you know which one would be the best option?

Angelika

[Guest guest]

Thank you so much!!!! I really appreciate everyone's support. I don't think I could keep myself motivated without all of the help and suggestions that I have been getting. Thank you so much, again! I would probably have given up already, but I know that there are success cases and I want to be one of them. I hope I can make a difference and have something positive to offer the next person in my shoes to come along.

Love,

Angelika

[Guest guest]

Please review frequently asked questions at www.plastikos.com for a review of insurance issues. We frequently are able to obtain insurance coverage for saline explantation if certain clinical criteria are met. I am a reviewer for two major insurance companies so I do know how insurance approval works. Kolb M.D.

----- Original Message -----

From: amattoni@...

Sent: Friday, November 16, 2001 10:01 PM

Subject: Re: Fw: House Hearing on: Raising Health Awareness Through E...

Do you think that I may have some leverage with getting insurance and McGhan to pay for the explant since I had the surgery in 1998 and the implants were not even approved by the FDA? Back then I didn't have access to the internet so I could not do all this research.In a message dated 11/16/2001 9:17:49 PM Eastern Standard Time, fdp@... writes:

In May 2000, the FDA approved saline breast implants. The approval came> in spite of Mr. Templer's recommendation, in spite of complications rates> as high as 43% for cosmetic patients and complication rates of over 70%for> reconstruction patients (in the first 3 years), and in spite of an ongoing> open criminal investigation into one of the manufacturers, which remains> open even today.Angelika

[Guest guest]

There you go, Amattoni! Dr. Kolb may be able to come through for you with some insurance help. She is in Atlanta, Georgia.

Patty

----- Original Message -----

From: Dr. Kolb

Sent: Friday, November 16, 2001 6:55 PM

Subject: Re: Fw: House Hearing on: Raising Health Awareness Through E...

Please review frequently asked questions at www.plastikos.com for a review of insurance issues. We frequently are able to obtain insurance coverage for saline explantation if certain clinical criteria are met. I am a reviewer for two major insurance companies so I do know how insurance approval works. Kolb M.D.

----- Original Message -----

From: amattoni@...

Sent: Friday, November 16, 2001 10:01 PM

Subject: Re: Fw: House Hearing on: Raising Health Awareness Through E...

Do you think that I may have some leverage with getting insurance and McGhan to pay for the explant since I had the surgery in 1998 and the implants were not even approved by the FDA? Back then I didn't have access to the internet so I could not do all this research.In a message dated 11/16/2001 9:17:49 PM Eastern Standard Time, fdp@... writes:

In May 2000, the FDA approved saline breast implants. The approval came> in spite of Mr. Templer's recommendation, in spite of complications rates> as high as 43% for cosmetic patients and complication rates of over 70%for> reconstruction patients (in the first 3 years), and in spite of an ongoing> open criminal investigation into one of the manufacturers, which remains> open even today.Angelika

[Guest guest]

I have worked with United Healthcare quite a bit, and

have found them to be very responsive to requests for

auth for explant. They got a bad rap back in the mid

90's for being so rigid and never approving any surgical

procedures and not allowing members to see specialists.

Well, the bad rap finally did them in. They were one of

the first managed care companies to allow members to see

specialists without an auth, and started approving more

and more procedures as long as a doc could document

medical necessity.

I have not heard of the other company.

e

> Through my husband, I have the option of the following insurance choices:

>

> P3 (Preferred Provider Plan) provides coverage in-network through the United

> Healthcare (UHC)

>

> An HMO with Trigon Healthkeepers

> Do you know which one would be the best option?

>

> Angelika

[Guest guest]

Angelika,

Martha is right. Local HMO's are much more difficult to

work with; however, the nat'l HMO's are much easier and

willing to consider things. Nat'l HMO's that I have

worked with in my nursing career and had to obtain auth

for various services include United, Aetna, Sloan's

Lake, Pacificare, and Cigna. Nat'l PPO's are not as

easy to work with as people like to think. Usually

there is a large deductible, and the review process is

sometimes very lengthy, not to mention grueling for the

nurse who is trying to get something approved. If you

have insurance issued in one state, and go to another

for services, that makes it that much more complicated,

for whatever reason. I have found this out first hand

as well since doing travel nursing. The companies offer

nat'l PPO's, which are supposed to be " just wonderful

and accepted nationwide. " That is not the case. Since

moving across the country with the same insurance (BC/BS

who by the way usually denies explantations) it has been

hell to see doctors. I'm not supposed to need any type

of auth to see a specialist, yet they are denying all my

requests to see specialists. They are denying a badly

needed CT and xray series of my entire spine. I am now

in the process of going 'round and 'round with them.

When I had my HMO's, everything went so much smoother,

and even though they are cost conscious, I honestly

don't know that they are any worse than PPO's. In

today's society where more lawsuits are being brought

against insurance companies, you would think that if a

doctor writes something up as medically necessary, they

would approve it, esp if you have documentation of other

health problems related to it. In the case managment

that I do, I am actually seeing more problems getting

auths with PPO's than with HMO's. Yes, I have to submit

more documentation initially for HMO's than with PPO's,

but in the end, it amts to the same if not more with the

PPO's (I am currently doing some insurance auth work for

Cigna--I'm known as a pt care coordinator). I think you

mentioned United as an option. They are a nat'l HMO

that is very well respected since they changed their

policies in the late 90's (I think it was 1998). The

other plan you mentioned I have never heard of, so I'm

not sure what to tell you on that. If there are

different tiers, then it is your usual HMO, and going

outside the tier you have chosen results in less benefit

coverage, although they will usually pay for at least

50%. But that is something that is common across the

board, and is very policy specific.

I would check which doc(s) you want to see or may need

to see at some point down the road, find out if they're

in the tier you may choose, and find out if the

facilities they practice out of are in that tier. Do

the same with United. Then compare prices. And then

make your decision. Another thing that I personally do,

is call docs around your area that you've never seen and

see if they accept the insurances you may get. Request

a EOB and a CURRENT listing of participating

physicians. Look over the EOB very carefully. This

tells you a lot.

Good luck and don't hesitate to ask more questions!

e

> Angelika,

>

> I personally hate to make these kinds of recommendations, as I am not a

medical

> professional, nor a legal professional. However, any kind of plan is normally

> better than an HMO plan, unless it may be a National HMO Plan, which this one

is

> Not! Who is the P3 plan with -- like, which insurance carrier, ie, Aetna,

Blue

> Cross, Pacific Mutual, etc.?

>

> Sincerely,

> Martha Murdock

> NSIF

> MAM-NSIF@...

>

>

[Guest guest]

I understand, I just would like any feedback. The other which I currently have is Trigon, which I was denied already once.

Angelika

[Guest guest]

We recently changed to USAble . . . So far it looks

very good!

Rogene

__________________________________________________

[Guest guest]

e,

I was approved for explant by United Healthcare last year. I had scheduled

my surgery with Dr. Huang and had just a week to get insurance approval.

They got me approved quickly by telling United Healthcare about the pain I

was in (true) and that it was an emergency (also true). I will never forget

the relief and gratitude I felt when I heard I had been approved. They did

not cover the mastopexy however.

Also e, I also had a constant rash and acne on my chest and legs for

years which disappeared the day of explant.

Groovy-cool huh?

Dana in Longmont CO

> [Original Message]

> From: <eRene@...>

> < >

> Date: 11/16/01 9:48:17 PM

> Subject: Re: Fw: House Hearing on: Raising Health

Awareness Through E...

>

> I have worked with United Healthcare quite a bit, and

> have found them to be very responsive to requests for

> auth for explant. They got a bad rap back in the mid

> 90's for being so rigid and never approving any surgical

> procedures and not allowing members to see specialists.

> Well, the bad rap finally did them in. They were one of

> the first managed care companies to allow members to see

> specialists without an auth, and started approving more

> and more procedures as long as a doc could document

> medical necessity.

>

> I have not heard of the other company.

>

> e

> > Through my husband, I have the option of the following insurance

choices:

> >

> > P3 (Preferred Provider Plan) provides coverage in-network through the

United

> > Healthcare (UHC)

> >

> > An HMO with Trigon Healthkeepers

> > Do you know which one would be the best option?

> >

> > Angelika

>

>

[Guest guest]

One possible way to get coverage is to phrase it as a

procedure which will save them money in the long run.

Leaving implants in, especially once symptoms start,

can be very expensive for the insurance companies.

This is a website that has a great deal of information

about getting your insurance company to pay for

explant. http://www.plastic-surgery.net/explant.html .

Don't be put off . . . .it appears a plastic surgeon

is sponsoring the site ... Barbara Stock is an implant

survivor too.

Rogene

__________________________________________________

[Guest guest]

Rogene,

Thank you for this website. I was wondering what the heck happened to

Barbara Stock. She was my mentor when I first got sick and put me in touch

with Ilena Rose--I owe her much, but she " disappeared " on me and never

answered my emails, and now I know why--a new email address. I'm going to

contact her again, so thank you!

Patty

----- Original Message -----

From: " Rogene S " <saxony01@...>

< >

Sent: Monday, November 19, 2001 6:30 AM

Subject: Re: Fw: House Hearing on: Raising Health Awareness

Through E...

> One possible way to get coverage is to phrase it as a

> procedure which will save them money in the long run.

> Leaving implants in, especially once symptoms start,

> can be very expensive for the insurance companies.

>

> This is a website that has a great deal of information

> about getting your insurance company to pay for

> explant. http://www.plastic-surgery.net/explant.html .

> Don't be put off . . . .it appears a plastic surgeon

> is sponsoring the site ... Barbara Stock is an implant

> survivor too.

>

> Rogene

[Guest guest]

Thanks Angelika, that is why we are here! I am sure you will be a success case, too. I think most of the saline women who act quickly to get their implants out and follow a dedicated healing path can get better. It still takes time, so patience is the key, but I am glad to hear that you want to be there to help others. That is what compassion is all about.

Patty

----- Original Message -----

From: amattoni@...

Sent: Friday, November 16, 2001 10:25 PM

Subject: Re: Fw: House Hearing on: Raising Health Awareness Through E...

Thank you so much!!!! I really appreciate everyone's support. I don't think I could keep myself motivated without all of the help and suggestions that I have been getting. Thank you so much, again! I would probably have given up already, but I know that there are success cases and I want to be one of them. I hope I can make a difference and have something positive to offer the next person in my shoes to come along. Love,Angelika

[Guest guest]

Definitely groovy-cool Dana!

So glad to hear that you also had gotten insurance coverage for explant. I

think it can happen more often than we think. It just takes the right

doctor to say the right words I guess!

Patty

----- Original Message -----

From: " Currence " <bdcurrence@...>

< >; <eRene@...>

Sent: Sunday, November 18, 2001 5:16 PM

Subject: Re: Fw: House Hearing on: Raising Health Awareness

Through E...

> e,

> I was approved for explant by United Healthcare last year. I had

scheduled

> my surgery with Dr. Huang and had just a week to get insurance approval.

> They got me approved quickly by telling United Healthcare about the pain I

> was in (true) and that it was an emergency (also true). I will never

forget

> the relief and gratitude I felt when I heard I had been approved. They

did

> not cover the mastopexy however.

> Also e, I also had a constant rash and acne on my chest and legs for

> years which disappeared the day of explant.

> Groovy-cool huh?

> Dana in Longmont CO

>

>

> > [Original Message]

> > From: <eRene@...>

> > < >

> > Date: 11/16/01 9:48:17 PM

> > Subject: Re: Fw: House Hearing on: Raising Health

> Awareness Through E...

> >

> > I have worked with United Healthcare quite a bit, and

>

> > have found them to be very responsive to requests for

>

> > auth for explant. They got a bad rap back in the mid

>

> > 90's for being so rigid and never approving any surgical

>

> > procedures and not allowing members to see specialists.

>

> > Well, the bad rap finally did them in. They were one of

>

> > the first managed care companies to allow members to see

>

> > specialists without an auth, and started approving more

>

> > and more procedures as long as a doc could document

>

> > medical necessity.

>

> >

>

> > I have not heard of the other company.

>

> >

>

> > e

>

> > > Through my husband, I have the option of the following insurance

> choices:

>

> > >

>

> > > P3 (Preferred Provider Plan) provides coverage in-network through the

> United

>

> > > Healthcare (UHC)

>

> > >

>

> > > An HMO with Trigon Healthkeepers

>

> > > Do you know which one would be the best option?

>

> > >

>

> > > Angelika

>

> >

>

> >

[Guest guest]

Rogene,

I added Barbara's site to our bookmarks listing.

Thanks!

Patty

----- Original Message -----

From: " Rogene S " <saxony01@...>

< >

Sent: Monday, November 19, 2001 6:30 AM

Subject: Re: Fw: House Hearing on: Raising Health Awareness

Through E...

> One possible way to get coverage is to phrase it as a

> procedure which will save them money in the long run.

> Leaving implants in, especially once symptoms start,

> can be very expensive for the insurance companies.

>

> This is a website that has a great deal of information

> about getting your insurance company to pay for

> explant. http://www.plastic-surgery.net/explant.html .

> Don't be put off . . . .it appears a plastic surgeon

> is sponsoring the site ... Barbara Stock is an implant

> survivor too.

>

> Rogene

>

>

> __________________________________________________

>

[Guest guest]

Rogene,

Excellent advice, and one I forgot to mention. But that

is exactly what I did in my appeal letter to my

insurance company. It was a 3 page letter, and part of

it explained that they would end up paying more in the

long run for specialist visits, labs, special tests,

medications, and where was the cost savings in that?

Especially if I got sick enough where I ended up in the

hospital and/or needing surgery (which had already

happened several times). I was able to explain that my

stroke, my open heart surgery, my lupus and other

automimmune problems, my cervical spinal fusion and then

rejection of my sternal wires and the resultant removal

were all related to my implants. I reviewed with them

in my letter the money they had paid out already was far

in excess of paying a measly $3500. I carefully

explained that for them to pay $3500 now was a lot

better and made much more sense than paying another

$70,000+. It worked and they never questioned me after

that!

e