Re: Insurance hassle

[Guest guest]

Dave,

So many people get into difficulties with their insurance companies

because they try to do it themselves. Don't Do It Yourself! Have Dr.

Amstutz's office handle it. They've been thrugh this many times before and

know what to say etc. Besides, when I've had medical trearment out of my

BC/BS region, BC/BS in the state where the services were performed handled

the claim.

Good Luck,

[Guest guest]

That all sounds good about letting JRI handle the insurance claim,

but I found out, like Dave, its not the way it really works unless

the insurance company already has agreed to accept resurfacing as a

coverable operation. When I talked to Carol at JRI about having Dr S

do my resurfacing, she told me they would submit a " predermination "

to Tricare, my health plan. She then told me that Tricare had never

approved a JRI resurfacing and that when I received the denial, I

(that's 'I' as in ME) would have to make the appeal with Tricare. For

that reason, I think those group members who have been through this

would do the rest of us a real service if they could outline the

process/approach they took to getting it approved and also provide

the name of the company that approved it. We can then use the list

of approving companies as further ammunition in appealing the initial

denial...thanks. I should also say that Cate has been a real 'role

model' in fighting this battle. I hope the rest of us 'Wannabe-

Surfers' have her tenacity and endurance in our personal insurance

battles. (ridiculous that we should have to go through this isn't

it???)

[Guest guest]

At 06:07 AM 12/18/2001 -0000, you wrote:

>That all sounds good about letting JRI handle the insurance claim,

>but I found out, like Dave, its not the way it really works unless

>the insurance company already has agreed to accept resurfacing as a

>coverable operation. When I talked to Carol at JRI about having Dr S

>do my resurfacing, she told me they would submit a " predermination "

>to Tricare, my health plan. <snip> and that when I received the denial, I

>(that's 'I' as in ME) would have to make the appeal with Tricare.

I was told to let the Dr's staff make the first attempt at approval. They

know how to submit the claim so that it is most likely to be paid, if it is

to be paid at all. I was also told when mine was denied that I had to

appeal. I don't believe it is up to the Dr. to appeal. It does not affect

his life drastically if you gets the procedure or not, and the insurance

company would readily pay for him to do a THR, so he is not necessarily

losing money. It is up to us, the patients, to convince the insurance

companies that this is the best procedure for us and them. They are, of

course, most interested in the bottom line. We need to convince them that

this procedure will most likely save them money in the long run by not

having to pay for repeated revisions, complications such as dislocations, etc.

I am happy to share my appeal letter, but I don't agree that listing the

insurance companies that have agreed to pay is the best idea. The

contracts all specifically exclude investigational procedures and devices.

Each case needs to be appealed and decided on its own merits, not " You paid

for ny's hip so you should pay for mine " . The contract also

specifically says that approval of one case does not constitute precedence

being set that they will necessarily pay for others. I also have a hard

time with those that threaten to sue the insurance company. For what???

For sticking to their contract? I firmly believe that if someone were to

sue, that company would immediately cease paying for the procedure for

anyone else until it is FDA approved. Why should they have the headache?

Hopefully this will all come to an end relatively shortly. When the FDA

issues final approval of the devices, I pray these battles with insurance

will come to an end. Those of us that fought and won surely savor the

sweet victory though. I know I do!!!

Best,

Conserve Plus 5/25/01 and 6/28/01

[Guest guest]

> >That all sounds good about letting JRI handle the insurance claim,

> >but I found out, like Dave, its not the way it really works unless

> >the insurance company already has agreed to accept resurfacing as a

> >coverable operation. When I talked to Carol at JRI about having Dr

S

> >do my resurfacing, she told me they would submit a " predermination "

> >to Tricare, my health plan. <snip> and that when I received the

denial, I

> >(that's 'I' as in ME) would have to make the appeal with Tricare.

>

>

> I was told to let the Dr's staff make the first attempt at

approval. They

> know how to submit the claim so that it is most likely to be paid,

if it is

> to be paid at all. I was also told when mine was denied that I had

to

> appeal. I don't believe it is up to the Dr. to appeal. It does not

affect

> his life drastically if you gets the procedure or not, and the

insurance

> company would readily pay for him to do a THR, so he is not

necessarily

> losing money. It is up to us, the patients, to convince the

insurance

> companies that this is the best procedure for us and them.

I agree 100% with this. You have to show its the right thing for you

and them. Also you have to review your contract fine print for all

the appeal details. Oftentimes the patient is asking for an exception

to the investigational device clause in the contract. Exceptions can

be granted, but each contract varies from state-to-state and even

among employers in the same state. If the company paid for " ny's

surgery " maybe ny is 10 years younger than you, or his contract

was written differently, or he just plain had different reviewers look

at his case (its not a reproducible science).

That said, I think the surgeons should assist you in getting you the

latest published research for your appeal. I'm pretty sure JRI will

do that for you, and from what I've heard also Dr. Mont and Dr Gross

will too. You could also ask the manufacturers for supporting

documentation.

After Christmas and an early Jan deadline at work, I will try to post

an insurance FAQ on the site.

[Guest guest]

When dealing with insurance company remember (it may be difficult) that you

need to have that person on your side. Ranting will not help. Give them

everything they need to help you. My contract said investigational /

experimental procedures were not covered. I lost two internal appeals before I

knew what was happening. Next step was external review. Wanted someone to know

my case. Wrote the president/ceo. My letter was forwarded to the president of

the insurance division. Then forwarded to the medical director. This letter was

about 4 pages long (pros / cons of THR vs BHR) with about 20 more pages of

supporting documents. I then called the medical director. He agreed the

procedure / device was not the issue, the contract wording was. He was bound by

the contract. The external review would not challange the procedure BUT the

contract wording. I reviewed the contract in detail for anything that would

allow him to help me. I found my saving clause buried in the glossary which

defined investigative / experimental procedures. The last paragraph stated that

the medical director could deem a procedure non-investigative. Another 2 page

letter went out to him (be civil ... you need him/her) showing what was found.

He agreed to deem the procedure non-investigational. There are so many

versions of contracts, they lose track. You have to dig. Admittedly I was

lucky. Lucky to have and find the clause but also for making the medical

director my allie.

kbrews wrote:

> >That all sounds good about letting JRI handle the insurance claim,

> >but I found out, like Dave, its not the way it really works unless

> >the insurance company already has agreed to accept resurfacing as a

> >coverable operation. When I talked to Carol at JRI about having Dr

S

> >do my resurfacing, she told me they would submit a " predermination "

> >to Tricare, my health plan. <snip> and that when I received the

denial, I

> >(that's 'I' as in ME) would have to make the appeal with Tricare.

>

>

> I was told to let the Dr's staff make the first attempt at

approval. They

> know how to submit the claim so that it is most likely to be paid,

if it is

> to be paid at all. I was also told when mine was denied that I had

to

> appeal. I don't believe it is up to the Dr. to appeal. It does not

affect

> his life drastically if you gets the procedure or not, and the

insurance

> company would readily pay for him to do a THR, so he is not

necessarily

> losing money. It is up to us, the patients, to convince the

insurance

> companies that this is the best procedure for us and them.

I agree 100% with this. You have to show its the right thing for you

and them. Also you have to review your contract fine print for all

the appeal details. Oftentimes the patient is asking for an exception

to the investigational device clause in the contract. Exceptions can

be granted, but each contract varies from state-to-state and even

among employers in the same state. If the company paid for " ny's

surgery " maybe ny is 10 years younger than you, or his contract

was written differently, or he just plain had different reviewers look

at his case (its not a reproducible science).

That said, I think the surgeons should assist you in getting you the

latest published research for your appeal. I'm pretty sure JRI will

do that for you, and from what I've heard also Dr. Mont and Dr Gross

will too. You could also ask the manufacturers for supporting

documentation.

After Christmas and an early Jan deadline at work, I will try to post

an insurance FAQ on the site.

[Guest guest]

If you don't mind shareing your info, who was the insur. co. that declined

your offer.? Have you considered Eng.? they are much less expensive and more

experienced.

[Guest guest]

I congratulate Trudy on her success.

Unfortunately, my level 2 appeal was denied yesterday. Once again the

reason for denial was that the procedure was considered

" Investigational " . The information that I sent in for this appeal was

prepared by the staff of Dr. Amstutz and was very specific as to why

this would be the best procedure in my case. My benefit booklet calls

out what is considered " Experimental or Investigative " quite clearly and

I see no obvious way around this exception.

Initially my attitude was that I would just go ahead and pay myself but

then I noted the exclusion " Complications of Noncovered Services " and

this made me think twice. Since the M/M resurface would fall under this

exclusion I would not have any coverage if anything were to go wrong.

This just isn't an acceptable risk.

Just got off the phone with the medical director at BC/BS New Mexico, he

basically said that if the device isn't FDA approved they simply will

not cover the procedure, end of story. Said that they had reviewed this

procedure a few months back and decided that there was not enough

research available to approve it.

Hard to think I would make any progress appealing again. I most likely

will go to the State Insurance Commission and file a complaint.

Re: Insurance hassle

> >That all sounds good about letting JRI handle the insurance claim,

> >but I found out, like Dave, its not the way it really works unless

> >the insurance company already has agreed to accept resurfacing as a

> >coverable operation. When I talked to Carol at JRI about having Dr

S

> >do my resurfacing, she told me they would submit a " predermination "

> >to Tricare, my health plan. <snip> and that when I received the

denial, I

> >(that's 'I' as in ME) would have to make the appeal with Tricare.

>

>

> I was told to let the Dr's staff make the first attempt at

approval. They

> know how to submit the claim so that it is most likely to be paid,

if it is

> to be paid at all. I was also told when mine was denied that I had

to

> appeal. I don't believe it is up to the Dr. to appeal. It does not

affect

> his life drastically if you gets the procedure or not, and the

insurance

> company would readily pay for him to do a THR, so he is not

necessarily

> losing money. It is up to us, the patients, to convince the

insurance

> companies that this is the best procedure for us and them.

I agree 100% with this. You have to show its the right thing for you

and them. Also you have to review your contract fine print for all

the appeal details. Oftentimes the patient is asking for an exception

to the investigational device clause in the contract. Exceptions can

be granted, but each contract varies from state-to-state and even

among employers in the same state. If the company paid for " ny's

surgery " maybe ny is 10 years younger than you, or his contract

was written differently, or he just plain had different reviewers look

at his case (its not a reproducible science).

That said, I think the surgeons should assist you in getting you the

latest published research for your appeal. I'm pretty sure JRI will

do that for you, and from what I've heard also Dr. Mont and Dr Gross

will too. You could also ask the manufacturers for supporting

documentation.

After Christmas and an early Jan deadline at work, I will try to post

an insurance FAQ on the site.

[Guest guest]

Give 'em hell, Dave!

Re: Insurance hassle

> >That all sounds good about letting JRI handle the insurance claim,

> >but I found out, like Dave, its not the way it really works unless

> >the insurance company already has agreed to accept resurfacing as a

> >coverable operation. When I talked to Carol at JRI about having Dr

S

> >do my resurfacing, she told me they would submit a " predermination "

> >to Tricare, my health plan. <snip> and that when I received the

denial, I

> >(that's 'I' as in ME) would have to make the appeal with Tricare.

>

>

> I was told to let the Dr's staff make the first attempt at

approval. They

> know how to submit the claim so that it is most likely to be paid,

if it is

> to be paid at all. I was also told when mine was denied that I had

to

> appeal. I don't believe it is up to the Dr. to appeal. It does not

affect

> his life drastically if you gets the procedure or not, and the

insurance

> company would readily pay for him to do a THR, so he is not

necessarily

> losing money. It is up to us, the patients, to convince the

insurance

> companies that this is the best procedure for us and them.

I agree 100% with this. You have to show its the right thing for you

and them. Also you have to review your contract fine print for all

the appeal details. Oftentimes the patient is asking for an exception

to the investigational device clause in the contract. Exceptions can

be granted, but each contract varies from state-to-state and even

among employers in the same state. If the company paid for " ny's

surgery " maybe ny is 10 years younger than you, or his contract

was written differently, or he just plain had different reviewers look

at his case (its not a reproducible science).

That said, I think the surgeons should assist you in getting you the

latest published research for your appeal. I'm pretty sure JRI will

do that for you, and from what I've heard also Dr. Mont and Dr Gross

will too. You could also ask the manufacturers for supporting

documentation.

After Christmas and an early Jan deadline at work, I will try to post

an insurance FAQ on the site.

[Guest guest]

-

It's bizarre that BC/BS seems to decide if resurfacing is a viable procedure on

a state by state basis. I guess they can do this because they are all

" independent licensees " of the Blue Cross and Blue Shield Association. BC/BS in

some states will pay for the procedure (for example Oregon and Washington) and

then in other states (like yours) they are firmly against it. Maybe you could

use this information when talking to the insurance commissioner?

I bet if that BC/BS director was facing having his hip replaced he'd suddenly

change his mind about the viability resurfacing!

I understand your frustration...

Good luck-

Ann

surfacehippy wrote:

>

I congratulate Trudy on her success.

>

>

Unfortunately, my level 2 appeal was denied yesterday. Once again the

>

reason for denial was that the procedure was considered

>

" Investigational " . The information that I sent in for this appeal was

>

prepared by the staff of Dr. Amstutz and was very specific as to why

>

this would be the best procedure  in my case. My benefit booklet calls

>

out what is considered " Experimental or Investigative " quite clearly and

>

I see no obvious way around this exception.

>

>

Initially my attitude was that I would just go ahead and pay myself but

>

then I noted the exclusion " Complications of Noncovered Services " and

>

this made me think twice. Since the M/M resurface would fall under this

>

exclusion I would not have any coverage if anything were to go wrong.

>

This just isn't an acceptable risk.

>

>

Just got off the phone with the medical director at BC/BS New Mexico, he

>

basically said that if the device isn't FDA approved they simply will

>

not cover the procedure, end of story. Said that they had reviewed this

>

procedure a few months back and decided that there was not enough

>

research available to  approve it.

>

>

Hard to think I would make any progress appealing again. I most likely

>

will go to the State Insurance  Commission and file a complaint.

>

>

>

Re: Insurance hassle

>

>

>

>

> >That all sounds good about letting JRI handle the insurance claim,

>

> >but I found out, like Dave, its not the way it really works unless

>

> >the insurance company already has agreed to accept resurfacing as a

>

> >coverable operation.  When I talked to Carol at JRI about having Dr

>

S

>

> >do my resurfacing, she told me they would submit a " predermination "

>

> >to Tricare, my health plan. <snip> and that when I received the

>

denial, I

>

> >(that's 'I' as in ME) would have to make the appeal with Tricare.

>

>

>

>

>

> I was told to let the Dr's staff make the first attempt at

>

approval.  They

>

> know how to submit the claim so that it is most likely to be paid,

>

if it is

>

> to be paid at all.  I was also told when mine was denied that I had

>

to

>

> appeal.  I don't believe it is up to the Dr. to appeal.  It does not

>

affect

>

> his life drastically if you gets the procedure or not, and the

>

insurance

>

> company would readily pay for him to do a THR, so he is not

>

necessarily

>

> losing money.  It is up to us, the patients, to convince the

>

insurance

>

> companies that this is the best procedure for us and them.

>

>

>

I agree 100% with this.  You have to show its the right thing for you

>

and them.  Also you have to review your contract fine print for all

>

the appeal details.  Oftentimes the patient is asking for an exception

>

to the investigational device clause in the contract.  Exceptions can

>

be granted, but each contract varies from state-to-state and even

>

among employers in the same state.  If the company paid for " ny's

>

surgery " maybe ny is 10 years younger than you, or his contract

>

was written differently, or he just plain had different reviewers look

>

at his case (its not a reproducible science).

>

>

That said, I think the surgeons should assist you in getting you the

>

latest published research for your appeal.  I'm pretty sure JRI will

>

do that for you, and from what I've heard also Dr. Mont and Dr Gross

>

will too.  You could also ask the manufacturers for supporting

>

documentation.

>

>

After Christmas and an early Jan deadline at work, I will try to post

>

an insurance FAQ on the site.

>

>

>

[Guest guest]

> I congratulate Trudy on her success.

>

> Unfortunately, my level 2 appeal was denied yesterday. Once again

the

> reason for denial was that the procedure was considered

> " Investigational " . The information that I sent in for this appeal

was

> prepared by the staff of Dr. Amstutz

Dave,

You have no idea how many posts I've read over the months from people

who were having trouble getting approved finally being successful. I

was " always the bridesmaid never the bride " in my thinking. Even

last night as I lay awake trying to imagine what they could possibly

come back with at me I really couldn't let myself believe it would go

through. Every person who has been successful has started from the

same place and been successful for different reasons. It's an

unbelievably exciting, painful journey. Every story is different.

In my case it took 5 months from the time I was turned down the first

time till now. Yesterday marked my 4th turndown. Your family has to

be behind you 100% because of the stress. As far as I am concerned

this stress tops divorce, death or major moving. The whole time I

have been essentially worthless as a wife and mother though I did

try, but I was and am consumed by wanting what I believe will be

commonplace in the not too distant future. The fact that I can't

wait for that future angered and spurred me on. I promised my

youngest daughter that she would be sick to death of gormet meals

once I am healed, she will be begging for more frozen dinners! I

truly didn't know until yesterday how I could possibly win this

thing. But I had all the help of those who have been there, done

that. I couldn't have done any of this without the help and support

of the super, caring people who post to this board and to TH. So you

are on a downer right now. You will see in the next few days some

kind of revelation for you that will tell you your next move. It's a

one day at a time kind of thing. Good luck what ever way you decide

to go. With heartfelt understanding of where you are..

Trudy