2 DOC bands- Denial overturned, but still out of network.... yada yada yada.....

[Guest guest]

Hi! I am new to the group, but not really. We are on band #2 for

Sawyer (now 9 months) and I have used the group's resources in the

past. I haven't posted before because I always had a clear path as

to what to do next. Today I feel overwhelmed and I coul duse some

help. Here is our story:

We moved from Indiana

to Savannah when my son was 2 weeks old. Unfortunately, the move

(w/ a 2 year-old and 2 week old) made us so busy that the

torticollis and

plagiocephaly were not diagnosed until about 4 months (we also had

some pediatrician challenges). In December we had Sawyer casted for

his 1st band and just went ahead and paid it. I had tried to get it

precertified, but the doctor's office was not helpful, and of course

BCBS would not allow me to talk to anyone in the department.

Surprise, surprise, they denied coverage.

My sister is a dear, and she wrote an awesome appeal letter (which

is posted) (I just did not have the energy or time). Blue Cross

overturned the denial while Sawyer was just getting band #2. (I may

have forgotten to mention that I had to drive him to

Atlanta/Charlotte which is almost 5 hours away weekly- thus the

fatigue.)

The last 2 months have been crazy with the insurance company saying

there was a problem with how it was being processed, but that it

would get worked out. I finally talked to someone today and she

said that all the other people were wrong. The insurance will only

consider 2/3 of the fee as reasonable and then they will apply our

less than generous out-of-network benefits. I have been looking for

appeals on the UCF (usual customary fee) and processing the helmets

as out-of-network, but I haven't seen much. Does anyone have any

experience or advice. I feel like I have just had it, been steam-

rolled, but I REFUSE TO LET THEM WIN!!!!! Even if only on principal!

I guess I am just glad that I didn't open the letter until after

Mother's Day! Hope you all had a nice day and got to enjoy some

family fun.

Thanks for your time.

-Skye

[Guest guest]

Since my daughter's graduation, I rarely check this anymore. I am

always shocked when I see how much trouble people have with Blue

Cross. I was really lucky with insurance, though I always

contribute some of that luck to the incredible lack of support for

treating plagio in Colorado. We flew out of state for our

treatment, after being told banding was " too much hassle " .

I got BCBS of Colorado to pay 100%, twice. According to them, they

provided " in-network benefits for an out-of-network provider " . I

was able to get a pre-authorization for each band - she wore 2. My

pediatrician wrote a prescription for " DOC Band, no substitutions " .

Since there was no in-network provider for the prescribed treatment,

I guess they were willing to recognize Cranial Technologies as the

only option.

Good luck!

Tammy

Teagan DOC Grad March '06

>

> Hi! I am new to the group, but not really. We are on band #2 for

> Sawyer (now 9 months) and I have used the group's resources in the

> past. I haven't posted before because I always had a clear path

as

> to what to do next. Today I feel overwhelmed and I coul duse some

> help. Here is our story:

>

> We moved from Indiana

> to Savannah when my son was 2 weeks old. Unfortunately, the move

> (w/ a 2 year-old and 2 week old) made us so busy that the

> torticollis and

> plagiocephaly were not diagnosed until about 4 months (we also had

> some pediatrician challenges). In December we had Sawyer casted

for

> his 1st band and just went ahead and paid it. I had tried to get

it

> precertified, but the doctor's office was not helpful, and of

course

> BCBS would not allow me to talk to anyone in the department.

> Surprise, surprise, they denied coverage.

>

> My sister is a dear, and she wrote an awesome appeal letter (which

> is posted) (I just did not have the energy or time). Blue Cross

> overturned the denial while Sawyer was just getting band #2. (I

may

> have forgotten to mention that I had to drive him to

> Atlanta/Charlotte which is almost 5 hours away weekly- thus the

> fatigue.)

>

> The last 2 months have been crazy with the insurance company

saying

> there was a problem with how it was being processed, but that it

> would get worked out. I finally talked to someone today and she

> said that all the other people were wrong. The insurance will

only

> consider 2/3 of the fee as reasonable and then they will apply our

> less than generous out-of-network benefits. I have been looking

for

> appeals on the UCF (usual customary fee) and processing the

helmets

> as out-of-network, but I haven't seen much. Does anyone have any

> experience or advice. I feel like I have just had it, been steam-

> rolled, but I REFUSE TO LET THEM WIN!!!!! Even if only on

principal!

>

> I guess I am just glad that I didn't open the letter until after

> Mother's Day! Hope you all had a nice day and got to enjoy

some

> family fun.

>

> Thanks for your time.

> -Skye

>

[Guest guest]

Skye,Hi! Where do you live? Is there an in-network provider within 70 miles? If so do they have the level of training and experience as the CT clinic (I'm assuming it's a DOC band because of the locations mentioned). If there is no comparable in-network alternative then they may have a clause for how to cover. My Bluechoice (BCBS - SC) I think has a 50-70 mile radius then you can go out of network for in-network coverage. Where are they getting their reasonable fee from. If this is the only provider then how can they say it is not reasonable.

1) Out of Network:

a) Determine if there were in-network options within 50 miles. Some insurance companies have a 50-70 miles radius rule. Once you prove you meet the requirements, you get in-network coverage.

Determine if the in-network options are qualified and offer the service needed.

i) Very few orthotic companies offer cranial remolding.

ii) Some offer cranial remolding but see very few patients each month, have no formal/extensive training, or are new to the process.

(1) For comparison the Charlotte, NC Cranial Tech office casts 50-60 new patients each month (per conversation with clinician in Oct 2004).

(2) Cranial Tech requires extensive in house training prior to treating infants. They also do refresher courses each year. They will provide you with the details or check their website, www.cranialtech.com

(3) Does the in-network band have documented research (DOC band I believe is the only one that does)?

c) Have your dr write the RX for the specific band/helmet you want. Have the dr indicate in the letter of medical necessity why this particular band is required.

i) A very severe case

ii) An after surgery case, currently only DOC band is FDA approved, even though others are used.

iii) A specific headshape that requires special treatment. For example, the scaphocephaly shape is rare and would be best treated by someone with that specific experience.

iv) Have the insurance company check to see if they have any facilities in network that do (wording is important) DYNAMIC ORTHOTIC CRANIOPLASTY.

v) continuation of treatment may be an argument

Feel free to email me offline for specific help. filyaw @ bellwouth.net (get rid of the spaces)

na, DOC Grad Feb 04Kiersten, DOC Grad April 06www.thefilyaws.com/plagio/plagio.html>> Hi! I am new to the group, but not really. We are on band #2 for > Sawyer (now 9 months) and I have used the group's resources in the > past. I haven't posted before because I always had a clear path as > to what to do next. Today I feel overwhelmed and I coul duse some > help. Here is our story:> > We moved from Indiana > to Savannah when my son was 2 weeks old. Unfortunately, the move > (w/ a 2 year-old and 2 week old) made us so busy that the > torticollis and > plagiocephaly were not diagnosed until about 4 months (we also had > some pediatrician challenges). In December we had Sawyer casted for > his 1st band and just went ahead and paid it. I had tried to get it > precertified, but the doctor's office was not helpful, and of course > BCBS would not allow me to talk to anyone in the department. > Surprise, surprise, they denied coverage.> > My sister is a dear, and she wrote an awesome appeal letter (which > is posted) (I just did not have the energy or time). Blue Cross > overturned the denial while Sawyer was just getting band #2. (I may > have forgotten to mention that I had to drive him to > Atlanta/Charlotte which is almost 5 hours away weekly- thus the > fatigue.)> > The last 2 months have been crazy with the insurance company saying > there was a problem with how it was being processed, but that it > would get worked out. I finally talked to someone today and she > said that all the other people were wrong. The insurance will only > consider 2/3 of the fee as reasonable and then they will apply our > less than generous out-of-network benefits. I have been looking for > appeals on the UCF (usual customary fee) and processing the helmets > as out-of-network, but I haven't seen much. Does anyone have any > experience or advice. I feel like I have just had it, been steam-> rolled, but I REFUSE TO LET THEM WIN!!!!! Even if only on principal!> > I guess I am just glad that I didn't open the letter until after > Mother's Day! Hope you all had a nice day and got to enjoy some > family fun.> > Thanks for your time.> -Skye>