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I have been reading some of the posts for a few months now and was

hoping that maybe someone would have some help/suggestions for me.

My son, Tysen, was born on February 18, 2005. We didn't know until he

was born that his left foot is a club foot. Two weeks after he was

born we met with the pediatric orthopaedic recommended by our

pediatrician and his first cast was applied. We have done six weeks

of castings (the first actually was removed early due to unexplained

swelling in his toes), a tenotomy, and are 1 1/2 months into the full-

time bracing. His foot looks great and we are pleased with the

results.

We didn't have much time to research things, but were very fortunate

in that the doctor we were referred to is a Ponseti qualified doctor.

From what I have been able to find so far is that he is actually the

only doctor in the area that will treat children with club foot. The

unfortunate part for us is that both the doctor and the orthodist

(also the only one in the area that supplies the brace) are out-of-

network providers as far as our insurance is concerned. The

difference being that they are only paying 60% of their allowable

charges instead of 90% and we have to meet a higher deductible, which

for the medical bills we have so far is a big difference. I applied

for Medicaid, but lately my husband has been working just enough

overtime to not qualify. Financially we qualify for the next program,

CHIP, but they will not help children that are covered under

insurance. I also checked into another state program for children

with special needs and was told that they quit helping people with

insurance a year ago due to funding issues. I have submitted one

appeal to the insurance. I hate to say that it was no big surprise to

receive a letter in the mail today saying that the appeals (for the

doctor and the orthodist) were denied. I figured they would resist

paying and they just said that according to the policy with my

husband's company, they cannot cover out-of-network under anything

but the benefits as stated -- even if there is no provider in our

area.

I am just feeling very frustrated right now...the insurance is paying

low and we don't qualify for other help because of the

insurance. I was hoping that maybe someone would have some

suggestions to appeal or get the insurance to pay more. It kind of

angers me that they won't even pay 90% of their allowable charges for

out-of-network and leave me with the difference plus my 10%. They are

actually saving money by me going out of network. I am grateful they

are at least covering the 60%, but I guess I don't feel that is fair

where I didn't even have an in-network choice. I talked to an

insurance representative a week and a half ago and he said that he

has only seen once when the insurance did pay in-network benefits for

an out-of-network doctor so I guess I feel like there is possibly

some way to get it done, but I'm not sure what to do to get there. I

can submit another appeal, but not sure what I would submit.

I would really appreciate any suggestions/experiences/help with this.

Thanks for listening!

Lorinda

P.S. Don't know if it makes a difference, but we live in Idaho.

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Posted
Posted

I have been reading some of the posts for a few months now and was

hoping that maybe someone would have some help/suggestions for me.

My son, Tysen, was born on February 18, 2005. We didn't know until he

was born that his left foot is a club foot. Two weeks after he was

born we met with the pediatric orthopaedic recommended by our

pediatrician and his first cast was applied. We have done six weeks

of castings (the first actually was removed early due to unexplained

swelling in his toes), a tenotomy, and are 1 1/2 months into the full-

time bracing. His foot looks great and we are pleased with the

results.

We didn't have much time to research things, but were very fortunate

in that the doctor we were referred to is a Ponseti qualified doctor.

From what I have been able to find so far is that he is actually the

only doctor in the area that will treat children with club foot. The

unfortunate part for us is that both the doctor and the orthodist

(also the only one in the area that supplies the brace) are out-of-

network providers as far as our insurance is concerned. The

difference being that they are only paying 60% of their allowable

charges instead of 90% and we have to meet a higher deductible, which

for the medical bills we have so far is a big difference. I applied

for Medicaid, but lately my husband has been working just enough

overtime to not qualify. Financially we qualify for the next program,

CHIP, but they will not help children that are covered under

insurance. I also checked into another state program for children

with special needs and was told that they quit helping people with

insurance a year ago due to funding issues. I have submitted one

appeal to the insurance. I hate to say that it was no big surprise to

receive a letter in the mail today saying that the appeals (for the

doctor and the orthodist) were denied. I figured they would resist

paying and they just said that according to the policy with my

husband's company, they cannot cover out-of-network under anything

but the benefits as stated -- even if there is no provider in our

area.

I am just feeling very frustrated right now...the insurance is paying

low and we don't qualify for other help because of the

insurance. I was hoping that maybe someone would have some

suggestions to appeal or get the insurance to pay more. It kind of

angers me that they won't even pay 90% of their allowable charges for

out-of-network and leave me with the difference plus my 10%. They are

actually saving money by me going out of network. I am grateful they

are at least covering the 60%, but I guess I don't feel that is fair

where I didn't even have an in-network choice. I talked to an

insurance representative a week and a half ago and he said that he

has only seen once when the insurance did pay in-network benefits for

an out-of-network doctor so I guess I feel like there is possibly

some way to get it done, but I'm not sure what to do to get there. I

can submit another appeal, but not sure what I would submit.

I would really appreciate any suggestions/experiences/help with this.

Thanks for listening!

Lorinda

P.S. Don't know if it makes a difference, but we live in Idaho.

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Posted
Posted

Welcome, Lorinda & Tysen!

Glad to have you here! Are you seeing Dr. Showalter?

I'm not going to be much help with the insurance- my only suggestion

is if your insurance is through your husband's place of employment

to see if there is someone in the HR dept. who deals with the

insurance company regularly to help you appeal this.

I know that there are other families here who have appealed and won

for additional coverage, so hopefully they can help you with some

tips.

Welcome aboard- we hope to see you post more often!

Regards,

& (3-16-00, left clubfoot)

> I have been reading some of the posts for a few months now and was

> hoping that maybe someone would have some help/suggestions for me.

>

> My son, Tysen, was born on February 18, 2005. We didn't know until

he

> was born that his left foot is a club foot. Two weeks after he was

> born we met with the pediatric orthopaedic recommended by our

> pediatrician and his first cast was applied. We have done six

weeks

> of castings (the first actually was removed early due to

unexplained

> swelling in his toes), a tenotomy, and are 1 1/2 months into the

full-

> time bracing. His foot looks great and we are pleased with the

> results.

>

> We didn't have much time to research things, but were very

fortunate

> in that the doctor we were referred to is a Ponseti qualified

doctor.

> From what I have been able to find so far is that he is actually

the

> only doctor in the area that will treat children with club foot.

The

> unfortunate part for us is that both the doctor and the orthodist

> (also the only one in the area that supplies the brace) are out-of-

> network providers as far as our insurance is concerned. The

> difference being that they are only paying 60% of their allowable

> charges instead of 90% and we have to meet a higher deductible,

which

> for the medical bills we have so far is a big difference. I

applied

> for Medicaid, but lately my husband has been working just enough

> overtime to not qualify. Financially we qualify for the next

program,

> CHIP, but they will not help children that are covered under

> insurance. I also checked into another state program for children

> with special needs and was told that they quit helping people with

> insurance a year ago due to funding issues. I have submitted one

> appeal to the insurance. I hate to say that it was no big surprise

to

> receive a letter in the mail today saying that the appeals (for

the

> doctor and the orthodist) were denied. I figured they would resist

> paying and they just said that according to the policy with my

> husband's company, they cannot cover out-of-network under anything

> but the benefits as stated -- even if there is no provider in our

> area.

>

> I am just feeling very frustrated right now...the insurance is

paying

> low and we don't qualify for other help because of the

> insurance. I was hoping that maybe someone would have some

> suggestions to appeal or get the insurance to pay more. It kind of

> angers me that they won't even pay 90% of their allowable charges

for

> out-of-network and leave me with the difference plus my 10%. They

are

> actually saving money by me going out of network. I am grateful

they

> are at least covering the 60%, but I guess I don't feel that is

fair

> where I didn't even have an in-network choice. I talked to an

> insurance representative a week and a half ago and he said that he

> has only seen once when the insurance did pay in-network benefits

for

> an out-of-network doctor so I guess I feel like there is possibly

> some way to get it done, but I'm not sure what to do to get there.

I

> can submit another appeal, but not sure what I would submit.

>

> I would really appreciate any suggestions/experiences/help with

this.

>

> Thanks for listening!

> Lorinda

>

> P.S. Don't know if it makes a difference, but we live in Idaho.

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Posted
Posted

Welcome, Lorinda & Tysen!

Glad to have you here! Are you seeing Dr. Showalter?

I'm not going to be much help with the insurance- my only suggestion

is if your insurance is through your husband's place of employment

to see if there is someone in the HR dept. who deals with the

insurance company regularly to help you appeal this.

I know that there are other families here who have appealed and won

for additional coverage, so hopefully they can help you with some

tips.

Welcome aboard- we hope to see you post more often!

Regards,

& (3-16-00, left clubfoot)

> I have been reading some of the posts for a few months now and was

> hoping that maybe someone would have some help/suggestions for me.

>

> My son, Tysen, was born on February 18, 2005. We didn't know until

he

> was born that his left foot is a club foot. Two weeks after he was

> born we met with the pediatric orthopaedic recommended by our

> pediatrician and his first cast was applied. We have done six

weeks

> of castings (the first actually was removed early due to

unexplained

> swelling in his toes), a tenotomy, and are 1 1/2 months into the

full-

> time bracing. His foot looks great and we are pleased with the

> results.

>

> We didn't have much time to research things, but were very

fortunate

> in that the doctor we were referred to is a Ponseti qualified

doctor.

> From what I have been able to find so far is that he is actually

the

> only doctor in the area that will treat children with club foot.

The

> unfortunate part for us is that both the doctor and the orthodist

> (also the only one in the area that supplies the brace) are out-of-

> network providers as far as our insurance is concerned. The

> difference being that they are only paying 60% of their allowable

> charges instead of 90% and we have to meet a higher deductible,

which

> for the medical bills we have so far is a big difference. I

applied

> for Medicaid, but lately my husband has been working just enough

> overtime to not qualify. Financially we qualify for the next

program,

> CHIP, but they will not help children that are covered under

> insurance. I also checked into another state program for children

> with special needs and was told that they quit helping people with

> insurance a year ago due to funding issues. I have submitted one

> appeal to the insurance. I hate to say that it was no big surprise

to

> receive a letter in the mail today saying that the appeals (for

the

> doctor and the orthodist) were denied. I figured they would resist

> paying and they just said that according to the policy with my

> husband's company, they cannot cover out-of-network under anything

> but the benefits as stated -- even if there is no provider in our

> area.

>

> I am just feeling very frustrated right now...the insurance is

paying

> low and we don't qualify for other help because of the

> insurance. I was hoping that maybe someone would have some

> suggestions to appeal or get the insurance to pay more. It kind of

> angers me that they won't even pay 90% of their allowable charges

for

> out-of-network and leave me with the difference plus my 10%. They

are

> actually saving money by me going out of network. I am grateful

they

> are at least covering the 60%, but I guess I don't feel that is

fair

> where I didn't even have an in-network choice. I talked to an

> insurance representative a week and a half ago and he said that he

> has only seen once when the insurance did pay in-network benefits

for

> an out-of-network doctor so I guess I feel like there is possibly

> some way to get it done, but I'm not sure what to do to get there.

I

> can submit another appeal, but not sure what I would submit.

>

> I would really appreciate any suggestions/experiences/help with

this.

>

> Thanks for listening!

> Lorinda

>

> P.S. Don't know if it makes a difference, but we live in Idaho.

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Posted
Posted

Thanks for the welcome! Yep, we see Dr. Showalter....do you? He is

great and we've enjoyed working with him. We feel very lucky that he

is so close to us.

Thanks also for the suggestion about talking to HR at my husband's

work. The orthodist told me they just don't see alot of people with

this insurance. The provider list is growing, but is still limited.

I've always tried to make sure our providers are in-network, and

after this nightmare, I'll do my best to stay in-network. I called

half of the in-network doctors and most just said I would have to

seek treatment from Dr. Showalter. One said that he would meet with

Tysen, but would probably refer him to Dr. Showalter. There is

another guy that my husband works with whose son has an orthopaedic

issue that also goes to Dr. Showalter. They have been fighting the

insurance too, but I'm not sure if they've made any progress. My

husband doesn't see him that often.

Have a great day!

Lorinda

> > I have been reading some of the posts for a few months now and

was

> > hoping that maybe someone would have some help/suggestions for

me.

> >

> > My son, Tysen, was born on February 18, 2005. We didn't know

until

> he

> > was born that his left foot is a club foot. Two weeks after he

was

> > born we met with the pediatric orthopaedic recommended by our

> > pediatrician and his first cast was applied. We have done six

> weeks

> > of castings (the first actually was removed early due to

> unexplained

> > swelling in his toes), a tenotomy, and are 1 1/2 months into the

> full-

> > time bracing. His foot looks great and we are pleased with the

> > results.

> >

> > We didn't have much time to research things, but were very

> fortunate

> > in that the doctor we were referred to is a Ponseti qualified

> doctor.

> > From what I have been able to find so far is that he is actually

> the

> > only doctor in the area that will treat children with club foot.

> The

> > unfortunate part for us is that both the doctor and the orthodist

> > (also the only one in the area that supplies the brace) are out-

of-

> > network providers as far as our insurance is concerned. The

> > difference being that they are only paying 60% of their allowable

> > charges instead of 90% and we have to meet a higher deductible,

> which

> > for the medical bills we have so far is a big difference. I

> applied

> > for Medicaid, but lately my husband has been working just enough

> > overtime to not qualify. Financially we qualify for the next

> program,

> > CHIP, but they will not help children that are covered under

> > insurance. I also checked into another state program for children

> > with special needs and was told that they quit helping people

with

> > insurance a year ago due to funding issues. I have submitted one

> > appeal to the insurance. I hate to say that it was no big

surprise

> to

> > receive a letter in the mail today saying that the appeals (for

> the

> > doctor and the orthodist) were denied. I figured they would

resist

> > paying and they just said that according to the policy with my

> > husband's company, they cannot cover out-of-network under

anything

> > but the benefits as stated -- even if there is no provider in our

> > area.

> >

> > I am just feeling very frustrated right now...the insurance is

> paying

> > low and we don't qualify for other help because of the

> > insurance. I was hoping that maybe someone would have some

> > suggestions to appeal or get the insurance to pay more. It kind

of

> > angers me that they won't even pay 90% of their allowable charges

> for

> > out-of-network and leave me with the difference plus my 10%. They

> are

> > actually saving money by me going out of network. I am grateful

> they

> > are at least covering the 60%, but I guess I don't feel that is

> fair

> > where I didn't even have an in-network choice. I talked to an

> > insurance representative a week and a half ago and he said that

he

> > has only seen once when the insurance did pay in-network benefits

> for

> > an out-of-network doctor so I guess I feel like there is possibly

> > some way to get it done, but I'm not sure what to do to get

there.

> I

> > can submit another appeal, but not sure what I would submit.

> >

> > I would really appreciate any suggestions/experiences/help with

> this.

> >

> > Thanks for listening!

> > Lorinda

> >

> > P.S. Don't know if it makes a difference, but we live in Idaho.

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Posted
Posted

Thanks for the welcome! Yep, we see Dr. Showalter....do you? He is

great and we've enjoyed working with him. We feel very lucky that he

is so close to us.

Thanks also for the suggestion about talking to HR at my husband's

work. The orthodist told me they just don't see alot of people with

this insurance. The provider list is growing, but is still limited.

I've always tried to make sure our providers are in-network, and

after this nightmare, I'll do my best to stay in-network. I called

half of the in-network doctors and most just said I would have to

seek treatment from Dr. Showalter. One said that he would meet with

Tysen, but would probably refer him to Dr. Showalter. There is

another guy that my husband works with whose son has an orthopaedic

issue that also goes to Dr. Showalter. They have been fighting the

insurance too, but I'm not sure if they've made any progress. My

husband doesn't see him that often.

Have a great day!

Lorinda

> > I have been reading some of the posts for a few months now and

was

> > hoping that maybe someone would have some help/suggestions for

me.

> >

> > My son, Tysen, was born on February 18, 2005. We didn't know

until

> he

> > was born that his left foot is a club foot. Two weeks after he

was

> > born we met with the pediatric orthopaedic recommended by our

> > pediatrician and his first cast was applied. We have done six

> weeks

> > of castings (the first actually was removed early due to

> unexplained

> > swelling in his toes), a tenotomy, and are 1 1/2 months into the

> full-

> > time bracing. His foot looks great and we are pleased with the

> > results.

> >

> > We didn't have much time to research things, but were very

> fortunate

> > in that the doctor we were referred to is a Ponseti qualified

> doctor.

> > From what I have been able to find so far is that he is actually

> the

> > only doctor in the area that will treat children with club foot.

> The

> > unfortunate part for us is that both the doctor and the orthodist

> > (also the only one in the area that supplies the brace) are out-

of-

> > network providers as far as our insurance is concerned. The

> > difference being that they are only paying 60% of their allowable

> > charges instead of 90% and we have to meet a higher deductible,

> which

> > for the medical bills we have so far is a big difference. I

> applied

> > for Medicaid, but lately my husband has been working just enough

> > overtime to not qualify. Financially we qualify for the next

> program,

> > CHIP, but they will not help children that are covered under

> > insurance. I also checked into another state program for children

> > with special needs and was told that they quit helping people

with

> > insurance a year ago due to funding issues. I have submitted one

> > appeal to the insurance. I hate to say that it was no big

surprise

> to

> > receive a letter in the mail today saying that the appeals (for

> the

> > doctor and the orthodist) were denied. I figured they would

resist

> > paying and they just said that according to the policy with my

> > husband's company, they cannot cover out-of-network under

anything

> > but the benefits as stated -- even if there is no provider in our

> > area.

> >

> > I am just feeling very frustrated right now...the insurance is

> paying

> > low and we don't qualify for other help because of the

> > insurance. I was hoping that maybe someone would have some

> > suggestions to appeal or get the insurance to pay more. It kind

of

> > angers me that they won't even pay 90% of their allowable charges

> for

> > out-of-network and leave me with the difference plus my 10%. They

> are

> > actually saving money by me going out of network. I am grateful

> they

> > are at least covering the 60%, but I guess I don't feel that is

> fair

> > where I didn't even have an in-network choice. I talked to an

> > insurance representative a week and a half ago and he said that

he

> > has only seen once when the insurance did pay in-network benefits

> for

> > an out-of-network doctor so I guess I feel like there is possibly

> > some way to get it done, but I'm not sure what to do to get

there.

> I

> > can submit another appeal, but not sure what I would submit.

> >

> > I would really appreciate any suggestions/experiences/help with

> this.

> >

> > Thanks for listening!

> > Lorinda

> >

> > P.S. Don't know if it makes a difference, but we live in Idaho.

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Posted
Posted

I don't know if it's feasible for you to drive to Salt Lake City, but the

Shriner's will pay 100% for orthotics and treatment... WE haven't gone there.

Gabe's cf are atypical and we go directly to Ponseti himself, but I understand

that there is one doc there who practices the Ponseti method although he isn't

on Ponseti's list.

lorinda_coombs wrote:

I have been reading some of the posts for a few months now and was

hoping that maybe someone would have some help/suggestions for me.

My son, Tysen, was born on February 18, 2005. We didn't know until he

was born that his left foot is a club foot. Two weeks after he was

born we met with the pediatric orthopaedic recommended by our

pediatrician and his first cast was applied. We have done six weeks

of castings (the first actually was removed early due to unexplained

swelling in his toes), a tenotomy, and are 1 1/2 months into the full-

time bracing. His foot looks great and we are pleased with the

results.

We didn't have much time to research things, but were very fortunate

in that the doctor we were referred to is a Ponseti qualified doctor.

From what I have been able to find so far is that he is actually the

only doctor in the area that will treat children with club foot. The

unfortunate part for us is that both the doctor and the orthodist

(also the only one in the area that supplies the brace) are out-of-

network providers as far as our insurance is concerned. The

difference being that they are only paying 60% of their allowable

charges instead of 90% and we have to meet a higher deductible, which

for the medical bills we have so far is a big difference. I applied

for Medicaid, but lately my husband has been working just enough

overtime to not qualify. Financially we qualify for the next program,

CHIP, but they will not help children that are covered under

insurance. I also checked into another state program for children

with special needs and was told that they quit helping people with

insurance a year ago due to funding issues. I have submitted one

appeal to the insurance. I hate to say that it was no big surprise to

receive a letter in the mail today saying that the appeals (for the

doctor and the orthodist) were denied. I figured they would resist

paying and they just said that according to the policy with my

husband's company, they cannot cover out-of-network under anything

but the benefits as stated -- even if there is no provider in our

area.

I am just feeling very frustrated right now...the insurance is paying

low and we don't qualify for other help because of the

insurance. I was hoping that maybe someone would have some

suggestions to appeal or get the insurance to pay more. It kind of

angers me that they won't even pay 90% of their allowable charges for

out-of-network and leave me with the difference plus my 10%. They are

actually saving money by me going out of network. I am grateful they

are at least covering the 60%, but I guess I don't feel that is fair

where I didn't even have an in-network choice. I talked to an

insurance representative a week and a half ago and he said that he

has only seen once when the insurance did pay in-network benefits for

an out-of-network doctor so I guess I feel like there is possibly

some way to get it done, but I'm not sure what to do to get there. I

can submit another appeal, but not sure what I would submit.

I would really appreciate any suggestions/experiences/help with this.

Thanks for listening!

Lorinda

P.S. Don't know if it makes a difference, but we live in Idaho.

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Posted
Posted

I don't know if it's feasible for you to drive to Salt Lake City, but the

Shriner's will pay 100% for orthotics and treatment... WE haven't gone there.

Gabe's cf are atypical and we go directly to Ponseti himself, but I understand

that there is one doc there who practices the Ponseti method although he isn't

on Ponseti's list.

lorinda_coombs wrote:

I have been reading some of the posts for a few months now and was

hoping that maybe someone would have some help/suggestions for me.

My son, Tysen, was born on February 18, 2005. We didn't know until he

was born that his left foot is a club foot. Two weeks after he was

born we met with the pediatric orthopaedic recommended by our

pediatrician and his first cast was applied. We have done six weeks

of castings (the first actually was removed early due to unexplained

swelling in his toes), a tenotomy, and are 1 1/2 months into the full-

time bracing. His foot looks great and we are pleased with the

results.

We didn't have much time to research things, but were very fortunate

in that the doctor we were referred to is a Ponseti qualified doctor.

From what I have been able to find so far is that he is actually the

only doctor in the area that will treat children with club foot. The

unfortunate part for us is that both the doctor and the orthodist

(also the only one in the area that supplies the brace) are out-of-

network providers as far as our insurance is concerned. The

difference being that they are only paying 60% of their allowable

charges instead of 90% and we have to meet a higher deductible, which

for the medical bills we have so far is a big difference. I applied

for Medicaid, but lately my husband has been working just enough

overtime to not qualify. Financially we qualify for the next program,

CHIP, but they will not help children that are covered under

insurance. I also checked into another state program for children

with special needs and was told that they quit helping people with

insurance a year ago due to funding issues. I have submitted one

appeal to the insurance. I hate to say that it was no big surprise to

receive a letter in the mail today saying that the appeals (for the

doctor and the orthodist) were denied. I figured they would resist

paying and they just said that according to the policy with my

husband's company, they cannot cover out-of-network under anything

but the benefits as stated -- even if there is no provider in our

area.

I am just feeling very frustrated right now...the insurance is paying

low and we don't qualify for other help because of the

insurance. I was hoping that maybe someone would have some

suggestions to appeal or get the insurance to pay more. It kind of

angers me that they won't even pay 90% of their allowable charges for

out-of-network and leave me with the difference plus my 10%. They are

actually saving money by me going out of network. I am grateful they

are at least covering the 60%, but I guess I don't feel that is fair

where I didn't even have an in-network choice. I talked to an

insurance representative a week and a half ago and he said that he

has only seen once when the insurance did pay in-network benefits for

an out-of-network doctor so I guess I feel like there is possibly

some way to get it done, but I'm not sure what to do to get there. I

can submit another appeal, but not sure what I would submit.

I would really appreciate any suggestions/experiences/help with this.

Thanks for listening!

Lorinda

P.S. Don't know if it makes a difference, but we live in Idaho.

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Posted
Posted

Good suggestion, Faith!

Lorinda,

You'd want to request Dr. Santora at the Inter-mountain

Shriners........

I always forget about recommending him because he's not on Dr. P's

list, but he has been using the method successfully for quite a few

years now.

> I have been reading some of the posts for a few months now and was

> hoping that maybe someone would have some help/suggestions for me.

>

> My son, Tysen, was born on February 18, 2005. We didn't know until

he

> was born that his left foot is a club foot. Two weeks after he was

> born we met with the pediatric orthopaedic recommended by our

> pediatrician and his first cast was applied. We have done six

weeks

> of castings (the first actually was removed early due to

unexplained

> swelling in his toes), a tenotomy, and are 1 1/2 months into the

full-

> time bracing. His foot looks great and we are pleased with the

> results.

>

> We didn't have much time to research things, but were very

fortunate

> in that the doctor we were referred to is a Ponseti qualified

doctor.

> From what I have been able to find so far is that he is actually

the

> only doctor in the area that will treat children with club foot.

The

> unfortunate part for us is that both the doctor and the orthodist

> (also the only one in the area that supplies the brace) are out-of-

> network providers as far as our insurance is concerned. The

> difference being that they are only paying 60% of their allowable

> charges instead of 90% and we have to meet a higher deductible,

which

> for the medical bills we have so far is a big difference. I

applied

> for Medicaid, but lately my husband has been working just enough

> overtime to not qualify. Financially we qualify for the next

program,

> CHIP, but they will not help children that are covered under

> insurance. I also checked into another state program for children

> with special needs and was told that they quit helping people with

> insurance a year ago due to funding issues. I have submitted one

> appeal to the insurance. I hate to say that it was no big surprise

to

> receive a letter in the mail today saying that the appeals (for

the

> doctor and the orthodist) were denied. I figured they would resist

> paying and they just said that according to the policy with my

> husband's company, they cannot cover out-of-network under anything

> but the benefits as stated -- even if there is no provider in our

> area.

>

> I am just feeling very frustrated right now...the insurance is

paying

> low and we don't qualify for other help because of the

> insurance. I was hoping that maybe someone would have some

> suggestions to appeal or get the insurance to pay more. It kind of

> angers me that they won't even pay 90% of their allowable charges

for

> out-of-network and leave me with the difference plus my 10%. They

are

> actually saving money by me going out of network. I am grateful

they

> are at least covering the 60%, but I guess I don't feel that is

fair

> where I didn't even have an in-network choice. I talked to an

> insurance representative a week and a half ago and he said that he

> has only seen once when the insurance did pay in-network benefits

for

> an out-of-network doctor so I guess I feel like there is possibly

> some way to get it done, but I'm not sure what to do to get there.

I

> can submit another appeal, but not sure what I would submit.

>

> I would really appreciate any suggestions/experiences/help with

this.

>

> Thanks for listening!

> Lorinda

>

> P.S. Don't know if it makes a difference, but we live in Idaho.

>

>

>

>

>

>

>

>

>

>

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Guest guest

Guest guest

Posted
Posted

Good suggestion, Faith!

Lorinda,

You'd want to request Dr. Santora at the Inter-mountain

Shriners........

I always forget about recommending him because he's not on Dr. P's

list, but he has been using the method successfully for quite a few

years now.

> I have been reading some of the posts for a few months now and was

> hoping that maybe someone would have some help/suggestions for me.

>

> My son, Tysen, was born on February 18, 2005. We didn't know until

he

> was born that his left foot is a club foot. Two weeks after he was

> born we met with the pediatric orthopaedic recommended by our

> pediatrician and his first cast was applied. We have done six

weeks

> of castings (the first actually was removed early due to

unexplained

> swelling in his toes), a tenotomy, and are 1 1/2 months into the

full-

> time bracing. His foot looks great and we are pleased with the

> results.

>

> We didn't have much time to research things, but were very

fortunate

> in that the doctor we were referred to is a Ponseti qualified

doctor.

> From what I have been able to find so far is that he is actually

the

> only doctor in the area that will treat children with club foot.

The

> unfortunate part for us is that both the doctor and the orthodist

> (also the only one in the area that supplies the brace) are out-of-

> network providers as far as our insurance is concerned. The

> difference being that they are only paying 60% of their allowable

> charges instead of 90% and we have to meet a higher deductible,

which

> for the medical bills we have so far is a big difference. I

applied

> for Medicaid, but lately my husband has been working just enough

> overtime to not qualify. Financially we qualify for the next

program,

> CHIP, but they will not help children that are covered under

> insurance. I also checked into another state program for children

> with special needs and was told that they quit helping people with

> insurance a year ago due to funding issues. I have submitted one

> appeal to the insurance. I hate to say that it was no big surprise

to

> receive a letter in the mail today saying that the appeals (for

the

> doctor and the orthodist) were denied. I figured they would resist

> paying and they just said that according to the policy with my

> husband's company, they cannot cover out-of-network under anything

> but the benefits as stated -- even if there is no provider in our

> area.

>

> I am just feeling very frustrated right now...the insurance is

paying

> low and we don't qualify for other help because of the

> insurance. I was hoping that maybe someone would have some

> suggestions to appeal or get the insurance to pay more. It kind of

> angers me that they won't even pay 90% of their allowable charges

for

> out-of-network and leave me with the difference plus my 10%. They

are

> actually saving money by me going out of network. I am grateful

they

> are at least covering the 60%, but I guess I don't feel that is

fair

> where I didn't even have an in-network choice. I talked to an

> insurance representative a week and a half ago and he said that he

> has only seen once when the insurance did pay in-network benefits

for

> an out-of-network doctor so I guess I feel like there is possibly

> some way to get it done, but I'm not sure what to do to get there.

I

> can submit another appeal, but not sure what I would submit.

>

> I would really appreciate any suggestions/experiences/help with

this.

>

> Thanks for listening!

> Lorinda

>

> P.S. Don't know if it makes a difference, but we live in Idaho.

>

>

>

>

>

>

>

>

>

>

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Guest guest

Posted
Posted

I wonder, if his foot is good and only needs checkups from now on maybe

your future appointments won't cost as much? Driving to Seattle wouldn't

save much money, unless you wish to vacate there a few times a year

anyway. I think there's docs at Spokane Shriners doing Ponseti now, but

that's just something I heard here once. I can't verify it, you'd have to

call them. In that case, your only costs would be travel. They provide

treatment for free.

I'd keep on with the insurance company. If someone has done it, you can

too. Especially if this doc is the only one who will even treat CF in your

area. It may be a lot of work, but I bet it can be done if you don't let

up. I'm pretty sure the squeaky wheel gets oiled with insurance

companies. I think they like to deny a few times and then finally let up,

if only to get rid of you.

Good luck!

Kori

At 01:02 PM 6/4/2005, you wrote:

>I have been reading some of the posts for a few months now and was

>hoping that maybe someone would have some help/suggestions for me.

>

>My son, Tysen, was born on February 18, 2005. We didn't know until he

>was born that his left foot is a club foot. Two weeks after he was

>born we met with the pediatric orthopaedic recommended by our

>pediatrician and his first cast was applied. We have done six weeks

>of castings (the first actually was removed early due to unexplained

>swelling in his toes), a tenotomy, and are 1 1/2 months into the full-

>time bracing. His foot looks great and we are pleased with the

>results.

>

>We didn't have much time to research things, but were very fortunate

>in that the doctor we were referred to is a Ponseti qualified doctor.

> From what I have been able to find so far is that he is actually the

>only doctor in the area that will treat children with club foot. The

>unfortunate part for us is that both the doctor and the orthodist

>(also the only one in the area that supplies the brace) are out-of-

>network providers as far as our insurance is concerned. The

>difference being that they are only paying 60% of their allowable

>charges instead of 90% and we have to meet a higher deductible, which

>for the medical bills we have so far is a big difference. I applied

>for Medicaid, but lately my husband has been working just enough

>overtime to not qualify. Financially we qualify for the next program,

>CHIP, but they will not help children that are covered under

>insurance. I also checked into another state program for children

>with special needs and was told that they quit helping people with

>insurance a year ago due to funding issues. I have submitted one

>appeal to the insurance. I hate to say that it was no big surprise to

>receive a letter in the mail today saying that the appeals (for the

>doctor and the orthodist) were denied. I figured they would resist

>paying and they just said that according to the policy with my

>husband's company, they cannot cover out-of-network under anything

>but the benefits as stated -- even if there is no provider in our

>area.

>

>I am just feeling very frustrated right now...the insurance is paying

>low and we don't qualify for other help because of the

>insurance. I was hoping that maybe someone would have some

>suggestions to appeal or get the insurance to pay more. It kind of

>angers me that they won't even pay 90% of their allowable charges for

>out-of-network and leave me with the difference plus my 10%. They are

>actually saving money by me going out of network. I am grateful they

>are at least covering the 60%, but I guess I don't feel that is fair

>where I didn't even have an in-network choice. I talked to an

>insurance representative a week and a half ago and he said that he

>has only seen once when the insurance did pay in-network benefits for

>an out-of-network doctor so I guess I feel like there is possibly

>some way to get it done, but I'm not sure what to do to get there. I

>can submit another appeal, but not sure what I would submit.

>

>I would really appreciate any suggestions/experiences/help with this.

>

>Thanks for listening!

>Lorinda

>

>P.S. Don't know if it makes a difference, but we live in Idaho.

>

>

>

>

>

>

>

>

>

>

>

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Share on other sites
Guest guest

Guest guest

Posted
Posted

I wonder, if his foot is good and only needs checkups from now on maybe

your future appointments won't cost as much? Driving to Seattle wouldn't

save much money, unless you wish to vacate there a few times a year

anyway. I think there's docs at Spokane Shriners doing Ponseti now, but

that's just something I heard here once. I can't verify it, you'd have to

call them. In that case, your only costs would be travel. They provide

treatment for free.

I'd keep on with the insurance company. If someone has done it, you can

too. Especially if this doc is the only one who will even treat CF in your

area. It may be a lot of work, but I bet it can be done if you don't let

up. I'm pretty sure the squeaky wheel gets oiled with insurance

companies. I think they like to deny a few times and then finally let up,

if only to get rid of you.

Good luck!

Kori

At 01:02 PM 6/4/2005, you wrote:

>I have been reading some of the posts for a few months now and was

>hoping that maybe someone would have some help/suggestions for me.

>

>My son, Tysen, was born on February 18, 2005. We didn't know until he

>was born that his left foot is a club foot. Two weeks after he was

>born we met with the pediatric orthopaedic recommended by our

>pediatrician and his first cast was applied. We have done six weeks

>of castings (the first actually was removed early due to unexplained

>swelling in his toes), a tenotomy, and are 1 1/2 months into the full-

>time bracing. His foot looks great and we are pleased with the

>results.

>

>We didn't have much time to research things, but were very fortunate

>in that the doctor we were referred to is a Ponseti qualified doctor.

> From what I have been able to find so far is that he is actually the

>only doctor in the area that will treat children with club foot. The

>unfortunate part for us is that both the doctor and the orthodist

>(also the only one in the area that supplies the brace) are out-of-

>network providers as far as our insurance is concerned. The

>difference being that they are only paying 60% of their allowable

>charges instead of 90% and we have to meet a higher deductible, which

>for the medical bills we have so far is a big difference. I applied

>for Medicaid, but lately my husband has been working just enough

>overtime to not qualify. Financially we qualify for the next program,

>CHIP, but they will not help children that are covered under

>insurance. I also checked into another state program for children

>with special needs and was told that they quit helping people with

>insurance a year ago due to funding issues. I have submitted one

>appeal to the insurance. I hate to say that it was no big surprise to

>receive a letter in the mail today saying that the appeals (for the

>doctor and the orthodist) were denied. I figured they would resist

>paying and they just said that according to the policy with my

>husband's company, they cannot cover out-of-network under anything

>but the benefits as stated -- even if there is no provider in our

>area.

>

>I am just feeling very frustrated right now...the insurance is paying

>low and we don't qualify for other help because of the

>insurance. I was hoping that maybe someone would have some

>suggestions to appeal or get the insurance to pay more. It kind of

>angers me that they won't even pay 90% of their allowable charges for

>out-of-network and leave me with the difference plus my 10%. They are

>actually saving money by me going out of network. I am grateful they

>are at least covering the 60%, but I guess I don't feel that is fair

>where I didn't even have an in-network choice. I talked to an

>insurance representative a week and a half ago and he said that he

>has only seen once when the insurance did pay in-network benefits for

>an out-of-network doctor so I guess I feel like there is possibly

>some way to get it done, but I'm not sure what to do to get there. I

>can submit another appeal, but not sure what I would submit.

>

>I would really appreciate any suggestions/experiences/help with this.

>

>Thanks for listening!

>Lorinda

>

>P.S. Don't know if it makes a difference, but we live in Idaho.

>

>

>

>

>

>

>

>

>

>

>

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Posted
Posted

Lorinda,

I thought of that very thing last night after I sent you that e-mail. Your

visits will be less after the first three months- if there are no other

problems. We are just a few months in front of you as far as the treatment

time line. We don't go back to Dr. Showalter till November. We go to see Tom

next month for new shoes and then when ever we need new shoes. Tenny's shoes

have lasted four months-fit wise-but he is kind of a runt.

Re: Any ideas with insurance??

I wonder, if his foot is good and only needs checkups from now on maybe

your future appointments won't cost as much? Driving to Seattle wouldn't

save much money, unless you wish to vacate there a few times a year

anyway. I think there's docs at Spokane Shriners doing Ponseti now, but

that's just something I heard here once. I can't verify it, you'd have to

call them. In that case, your only costs would be travel. They provide

treatment for free.

I'd keep on with the insurance company. If someone has done it, you can

too. Especially if this doc is the only one who will even treat CF in your

area. It may be a lot of work, but I bet it can be done if you don't let

up. I'm pretty sure the squeaky wheel gets oiled with insurance

companies. I think they like to deny a few times and then finally let up,

if only to get rid of you.

Good luck!

Kori

At 01:02 PM 6/4/2005, you wrote:

>I have been reading some of the posts for a few months now and was

>hoping that maybe someone would have some help/suggestions for me.

>

>My son, Tysen, was born on February 18, 2005. We didn't know until he

>was born that his left foot is a club foot. Two weeks after he was

>born we met with the pediatric orthopaedic recommended by our

>pediatrician and his first cast was applied. We have done six weeks

>of castings (the first actually was removed early due to unexplained

>swelling in his toes), a tenotomy, and are 1 1/2 months into the full-

>time bracing. His foot looks great and we are pleased with the

>results.

>

>We didn't have much time to research things, but were very fortunate

>in that the doctor we were referred to is a Ponseti qualified doctor.

> From what I have been able to find so far is that he is actually the

>only doctor in the area that will treat children with club foot. The

>unfortunate part for us is that both the doctor and the orthodist

>(also the only one in the area that supplies the brace) are out-of-

>network providers as far as our insurance is concerned. The

>difference being that they are only paying 60% of their allowable

>charges instead of 90% and we have to meet a higher deductible, which

>for the medical bills we have so far is a big difference. I applied

>for Medicaid, but lately my husband has been working just enough

>overtime to not qualify. Financially we qualify for the next program,

>CHIP, but they will not help children that are covered under

>insurance. I also checked into another state program for children

>with special needs and was told that they quit helping people with

>insurance a year ago due to funding issues. I have submitted one

>appeal to the insurance. I hate to say that it was no big surprise to

>receive a letter in the mail today saying that the appeals (for the

>doctor and the orthodist) were denied. I figured they would resist

>paying and they just said that according to the policy with my

>husband's company, they cannot cover out-of-network under anything

>but the benefits as stated -- even if there is no provider in our

>area.

>

>I am just feeling very frustrated right now...the insurance is paying

>low and we don't qualify for other help because of the

>insurance. I was hoping that maybe someone would have some

>suggestions to appeal or get the insurance to pay more. It kind of

>angers me that they won't even pay 90% of their allowable charges for

>out-of-network and leave me with the difference plus my 10%. They are

>actually saving money by me going out of network. I am grateful they

>are at least covering the 60%, but I guess I don't feel that is fair

>where I didn't even have an in-network choice. I talked to an

>insurance representative a week and a half ago and he said that he

>has only seen once when the insurance did pay in-network benefits for

>an out-of-network doctor so I guess I feel like there is possibly

>some way to get it done, but I'm not sure what to do to get there. I

>can submit another appeal, but not sure what I would submit.

>

>I would really appreciate any suggestions/experiences/help with this.

>

>Thanks for listening!

>Lorinda

>

>P.S. Don't know if it makes a difference, but we live in Idaho.

>

>

>

>

>

>

>

>

>

>

>

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Share on other sites
Guest guest

Guest guest

Posted
Posted

Lorinda,

I thought of that very thing last night after I sent you that e-mail. Your

visits will be less after the first three months- if there are no other

problems. We are just a few months in front of you as far as the treatment

time line. We don't go back to Dr. Showalter till November. We go to see Tom

next month for new shoes and then when ever we need new shoes. Tenny's shoes

have lasted four months-fit wise-but he is kind of a runt.

Re: Any ideas with insurance??

I wonder, if his foot is good and only needs checkups from now on maybe

your future appointments won't cost as much? Driving to Seattle wouldn't

save much money, unless you wish to vacate there a few times a year

anyway. I think there's docs at Spokane Shriners doing Ponseti now, but

that's just something I heard here once. I can't verify it, you'd have to

call them. In that case, your only costs would be travel. They provide

treatment for free.

I'd keep on with the insurance company. If someone has done it, you can

too. Especially if this doc is the only one who will even treat CF in your

area. It may be a lot of work, but I bet it can be done if you don't let

up. I'm pretty sure the squeaky wheel gets oiled with insurance

companies. I think they like to deny a few times and then finally let up,

if only to get rid of you.

Good luck!

Kori

At 01:02 PM 6/4/2005, you wrote:

>I have been reading some of the posts for a few months now and was

>hoping that maybe someone would have some help/suggestions for me.

>

>My son, Tysen, was born on February 18, 2005. We didn't know until he

>was born that his left foot is a club foot. Two weeks after he was

>born we met with the pediatric orthopaedic recommended by our

>pediatrician and his first cast was applied. We have done six weeks

>of castings (the first actually was removed early due to unexplained

>swelling in his toes), a tenotomy, and are 1 1/2 months into the full-

>time bracing. His foot looks great and we are pleased with the

>results.

>

>We didn't have much time to research things, but were very fortunate

>in that the doctor we were referred to is a Ponseti qualified doctor.

> From what I have been able to find so far is that he is actually the

>only doctor in the area that will treat children with club foot. The

>unfortunate part for us is that both the doctor and the orthodist

>(also the only one in the area that supplies the brace) are out-of-

>network providers as far as our insurance is concerned. The

>difference being that they are only paying 60% of their allowable

>charges instead of 90% and we have to meet a higher deductible, which

>for the medical bills we have so far is a big difference. I applied

>for Medicaid, but lately my husband has been working just enough

>overtime to not qualify. Financially we qualify for the next program,

>CHIP, but they will not help children that are covered under

>insurance. I also checked into another state program for children

>with special needs and was told that they quit helping people with

>insurance a year ago due to funding issues. I have submitted one

>appeal to the insurance. I hate to say that it was no big surprise to

>receive a letter in the mail today saying that the appeals (for the

>doctor and the orthodist) were denied. I figured they would resist

>paying and they just said that according to the policy with my

>husband's company, they cannot cover out-of-network under anything

>but the benefits as stated -- even if there is no provider in our

>area.

>

>I am just feeling very frustrated right now...the insurance is paying

>low and we don't qualify for other help because of the

>insurance. I was hoping that maybe someone would have some

>suggestions to appeal or get the insurance to pay more. It kind of

>angers me that they won't even pay 90% of their allowable charges for

>out-of-network and leave me with the difference plus my 10%. They are

>actually saving money by me going out of network. I am grateful they

>are at least covering the 60%, but I guess I don't feel that is fair

>where I didn't even have an in-network choice. I talked to an

>insurance representative a week and a half ago and he said that he

>has only seen once when the insurance did pay in-network benefits for

>an out-of-network doctor so I guess I feel like there is possibly

>some way to get it done, but I'm not sure what to do to get there. I

>can submit another appeal, but not sure what I would submit.

>

>I would really appreciate any suggestions/experiences/help with this.

>

>Thanks for listening!

>Lorinda

>

>P.S. Don't know if it makes a difference, but we live in Idaho.

>

>

>

>

>

>

>

>

>

>

>

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Guest guest

Guest guest

Posted
Posted

Squeeky wheel does get the grease. Do not give up your battle with

the insurance company with out putting up a good fight. I would call

and send letters daily. Make sure you get your husband's company

involved (if insurance is through his work). Have his company's

human resources call and write letters on your behalf. Whoever pays

the insurance premiums needs to squeek, squeek, squeek.

Keep copies of all your letters. Document days, times, and names of

everyone you talk to and ask for personal extensions so that you can

call people back directly. Hell, call them at home if you can get

their last name.You can look up their phone numbers and call their

grandparents, aunts and uncles and cousins. I would be spoutin' off

to anyone I could get a hold of! The point is to be a thorn in their

side. You know you are right and what they are doing is wrong.

Insurance co's are great at using stall tactics and will eventually

pay if pressured. They are great at collecting premiums, but not at

paying. The longer they hold on to money the more intrest they make.

I would crawl so far up their ass until they did the right thing.

GOOD LUCK in your battle!! I have been in your shoes and won. Do not

let them wear you down. SQUEEK ON!

Jen mom of

Ava 1-18-02

Addie 8-2-04 (Dobbs Brace 23/7)

> >I have been reading some of the posts for a few months now and

was

> >hoping that maybe someone would have some help/suggestions for

me.

> >

> >My son, Tysen, was born on February 18, 2005. We didn't know

until he

> >was born that his left foot is a club foot. Two weeks after he

was

> >born we met with the pediatric orthopaedic recommended by our

> >pediatrician and his first cast was applied. We have done six

weeks

> >of castings (the first actually was removed early due to

unexplained

> >swelling in his toes), a tenotomy, and are 1 1/2 months into

the full-

> >time bracing. His foot looks great and we are pleased with the

> >results.

> >

> >We didn't have much time to research things, but were very

fortunate

> >in that the doctor we were referred to is a Ponseti qualified

doctor.

> > From what I have been able to find so far is that he is

actually the

> >only doctor in the area that will treat children with club

foot. The

> >unfortunate part for us is that both the doctor and the

orthodist

> >(also the only one in the area that supplies the brace) are out-

of-

> >network providers as far as our insurance is concerned. The

> >difference being that they are only paying 60% of their

allowable

> >charges instead of 90% and we have to meet a higher deductible,

which

> >for the medical bills we have so far is a big difference. I

applied

> >for Medicaid, but lately my husband has been working just enough

> >overtime to not qualify. Financially we qualify for the next

program,

> >CHIP, but they will not help children that are covered under

> >insurance. I also checked into another state program for

children

> >with special needs and was told that they quit helping people

with

> >insurance a year ago due to funding issues. I have submitted one

> >appeal to the insurance. I hate to say that it was no big

surprise to

> >receive a letter in the mail today saying that the appeals (for

the

> >doctor and the orthodist) were denied. I figured they would

resist

> >paying and they just said that according to the policy with my

> >husband's company, they cannot cover out-of-network under

anything

> >but the benefits as stated -- even if there is no provider in

our

> >area.

> >

> >I am just feeling very frustrated right now...the insurance is

paying

> >low and we don't qualify for other help because of the

> >insurance. I was hoping that maybe someone would have some

> >suggestions to appeal or get the insurance to pay more. It kind

of

> >angers me that they won't even pay 90% of their allowable

charges for

> >out-of-network and leave me with the difference plus my 10%.

They are

> >actually saving money by me going out of network. I am grateful

they

> >are at least covering the 60%, but I guess I don't feel that is

fair

> >where I didn't even have an in-network choice. I talked to an

> >insurance representative a week and a half ago and he said that

he

> >has only seen once when the insurance did pay in-network

benefits for

> >an out-of-network doctor so I guess I feel like there is

possibly

> >some way to get it done, but I'm not sure what to do to get

there. I

> >can submit another appeal, but not sure what I would submit.

> >

> >I would really appreciate any suggestions/experiences/help with

this.

> >

> >Thanks for listening!

> >Lorinda

> >

> >P.S. Don't know if it makes a difference, but we live in Idaho.

> >

> >

> >

> >

> >

> >

> >

> >

> >

> >

> >

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Posted
Posted

Squeeky wheel does get the grease. Do not give up your battle with

the insurance company with out putting up a good fight. I would call

and send letters daily. Make sure you get your husband's company

involved (if insurance is through his work). Have his company's

human resources call and write letters on your behalf. Whoever pays

the insurance premiums needs to squeek, squeek, squeek.

Keep copies of all your letters. Document days, times, and names of

everyone you talk to and ask for personal extensions so that you can

call people back directly. Hell, call them at home if you can get

their last name.You can look up their phone numbers and call their

grandparents, aunts and uncles and cousins. I would be spoutin' off

to anyone I could get a hold of! The point is to be a thorn in their

side. You know you are right and what they are doing is wrong.

Insurance co's are great at using stall tactics and will eventually

pay if pressured. They are great at collecting premiums, but not at

paying. The longer they hold on to money the more intrest they make.

I would crawl so far up their ass until they did the right thing.

GOOD LUCK in your battle!! I have been in your shoes and won. Do not

let them wear you down. SQUEEK ON!

Jen mom of

Ava 1-18-02

Addie 8-2-04 (Dobbs Brace 23/7)

> >I have been reading some of the posts for a few months now and

was

> >hoping that maybe someone would have some help/suggestions for

me.

> >

> >My son, Tysen, was born on February 18, 2005. We didn't know

until he

> >was born that his left foot is a club foot. Two weeks after he

was

> >born we met with the pediatric orthopaedic recommended by our

> >pediatrician and his first cast was applied. We have done six

weeks

> >of castings (the first actually was removed early due to

unexplained

> >swelling in his toes), a tenotomy, and are 1 1/2 months into

the full-

> >time bracing. His foot looks great and we are pleased with the

> >results.

> >

> >We didn't have much time to research things, but were very

fortunate

> >in that the doctor we were referred to is a Ponseti qualified

doctor.

> > From what I have been able to find so far is that he is

actually the

> >only doctor in the area that will treat children with club

foot. The

> >unfortunate part for us is that both the doctor and the

orthodist

> >(also the only one in the area that supplies the brace) are out-

of-

> >network providers as far as our insurance is concerned. The

> >difference being that they are only paying 60% of their

allowable

> >charges instead of 90% and we have to meet a higher deductible,

which

> >for the medical bills we have so far is a big difference. I

applied

> >for Medicaid, but lately my husband has been working just enough

> >overtime to not qualify. Financially we qualify for the next

program,

> >CHIP, but they will not help children that are covered under

> >insurance. I also checked into another state program for

children

> >with special needs and was told that they quit helping people

with

> >insurance a year ago due to funding issues. I have submitted one

> >appeal to the insurance. I hate to say that it was no big

surprise to

> >receive a letter in the mail today saying that the appeals (for

the

> >doctor and the orthodist) were denied. I figured they would

resist

> >paying and they just said that according to the policy with my

> >husband's company, they cannot cover out-of-network under

anything

> >but the benefits as stated -- even if there is no provider in

our

> >area.

> >

> >I am just feeling very frustrated right now...the insurance is

paying

> >low and we don't qualify for other help because of the

> >insurance. I was hoping that maybe someone would have some

> >suggestions to appeal or get the insurance to pay more. It kind

of

> >angers me that they won't even pay 90% of their allowable

charges for

> >out-of-network and leave me with the difference plus my 10%.

They are

> >actually saving money by me going out of network. I am grateful

they

> >are at least covering the 60%, but I guess I don't feel that is

fair

> >where I didn't even have an in-network choice. I talked to an

> >insurance representative a week and a half ago and he said that

he

> >has only seen once when the insurance did pay in-network

benefits for

> >an out-of-network doctor so I guess I feel like there is

possibly

> >some way to get it done, but I'm not sure what to do to get

there. I

> >can submit another appeal, but not sure what I would submit.

> >

> >I would really appreciate any suggestions/experiences/help with

this.

> >

> >Thanks for listening!

> >Lorinda

> >

> >P.S. Don't know if it makes a difference, but we live in Idaho.

> >

> >

> >

> >

> >

> >

> >

> >

> >

> >

> >

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Posted
Posted

,

If we do decide to seek treatment at Shriners in Salt Lake, I'll

definately use your suggestion. I was wondering if they had any

doctors that used the Ponseti method. We need to decide what would be

best. Hopefully now we will only have the doctor visits and new shoes

as his feet grow, but the orthodist isn't in-network either, so it is

something to consider.

Thanks!

Lorinda

> > I don't know if it's feasible for you to drive to Salt Lake City,

> but the Shriner's will pay 100% for orthotics and treatment... WE

> haven't gone there. Gabe's cf are atypical and we go directly to

> Ponseti himself, but I understand that there is one doc there who

> practices the Ponseti method although he isn't on Ponseti's list.

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Posted
Posted

,

If we do decide to seek treatment at Shriners in Salt Lake, I'll

definately use your suggestion. I was wondering if they had any

doctors that used the Ponseti method. We need to decide what would be

best. Hopefully now we will only have the doctor visits and new shoes

as his feet grow, but the orthodist isn't in-network either, so it is

something to consider.

Thanks!

Lorinda

> > I don't know if it's feasible for you to drive to Salt Lake City,

> but the Shriner's will pay 100% for orthotics and treatment... WE

> haven't gone there. Gabe's cf are atypical and we go directly to

> Ponseti himself, but I understand that there is one doc there who

> practices the Ponseti method although he isn't on Ponseti's list.

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Posted
Posted

Faith,

Thank you so much for the suggestion. Everything happened so fast

when he was born and then going into his first cast that we didn't

get much time to explore all options. My parents live 2 hours from

Spokane, so we thought of going to the Shriners there, but hated to

have the family separated for 6 weeks for the castings (it's 8 1/2

hours to my parents so felt it would be better to stay there vs.

traveling each week). I also have a sister-in-law that lives in Salt

Lake that I could have stayed with each week but she was supposed to

be adopting a baby at the time so I didn't want to stress her more by

having house guests as she was making that new adjustment. At the

time we discussed it very briefly and didn't know if it would work

for us since we also have 2 other children. Now I need to get an idea

of what else lies in store for us as far as visits and things and

still possibly go to Shriners since the orthodist isn't in-network

either.

Wow, I would love to meet Dr. Ponseti! I am just amazed at what a

difference the method has made in Tysen's foot! That's great that he

is able to care for your son.

Thanks again!

Lorinda

> I don't know if it's feasible for you to drive to Salt Lake City,

but the Shriner's will pay 100% for orthotics and treatment... WE

haven't gone there. Gabe's cf are atypical and we go directly to

Ponseti himself, but I understand that there is one doc there who

practices the Ponseti method although he isn't on Ponseti's list.

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Posted
Posted

Faith,

Thank you so much for the suggestion. Everything happened so fast

when he was born and then going into his first cast that we didn't

get much time to explore all options. My parents live 2 hours from

Spokane, so we thought of going to the Shriners there, but hated to

have the family separated for 6 weeks for the castings (it's 8 1/2

hours to my parents so felt it would be better to stay there vs.

traveling each week). I also have a sister-in-law that lives in Salt

Lake that I could have stayed with each week but she was supposed to

be adopting a baby at the time so I didn't want to stress her more by

having house guests as she was making that new adjustment. At the

time we discussed it very briefly and didn't know if it would work

for us since we also have 2 other children. Now I need to get an idea

of what else lies in store for us as far as visits and things and

still possibly go to Shriners since the orthodist isn't in-network

either.

Wow, I would love to meet Dr. Ponseti! I am just amazed at what a

difference the method has made in Tysen's foot! That's great that he

is able to care for your son.

Thanks again!

Lorinda

> I don't know if it's feasible for you to drive to Salt Lake City,

but the Shriner's will pay 100% for orthotics and treatment... WE

haven't gone there. Gabe's cf are atypical and we go directly to

Ponseti himself, but I understand that there is one doc there who

practices the Ponseti method although he isn't on Ponseti's list.

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Posted
Posted

Hi Kori,

Ya, I hoping that we won't be facing any replapses or anything. Then

the costs should be more manageable. While we'd love to go on

vacation to Seattle, I think we'd only be able to make one trip a

year. I had considered Spokane (my parents live 2 hours from Spokane)

and staying with my parents during the casting period, but noticed

they didn't have a Ponseti doc listed plus it didn't really work for

our family at the time.

I definately plan to keep up with the insurance. I really feel they

should pay more where we had no other options in the area for

treatment...I really feel it was either leave him a cripple (not an

option) or go out of network as far as my insurance is concerned.

I've had a few people say that eventually they will pay just to get

rid of people, so I'm keeping my fingers crossed hoping that will

work. Just wondering what else I can use to appeal or if I can just

stress what I've already used...mainly that he is the only doc in the

area that will even treat children with club foot. Thanks for

responding, there are a lot of great people on here!

Lorinda

> I wonder, if his foot is good and only needs checkups from now on

maybe

> your future appointments won't cost as much? Driving to Seattle

wouldn't

> save much money, unless you wish to vacate there a few times a year

> anyway. I think there's docs at Spokane Shriners doing Ponseti

now, but

> that's just something I heard here once. I can't verify it, you'd

have to

> call them. In that case, your only costs would be travel. They

provide

> treatment for free.

>

> I'd keep on with the insurance company. If someone has done it,

you can

> too. Especially if this doc is the only one who will even treat CF

in your

> area. It may be a lot of work, but I bet it can be done if you

don't let

> up. I'm pretty sure the squeaky wheel gets oiled with insurance

> companies. I think they like to deny a few times and then finally

let up,

> if only to get rid of you.

>

> Good luck!

>

> Kori

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Posted
Posted

Hi Kori,

Ya, I hoping that we won't be facing any replapses or anything. Then

the costs should be more manageable. While we'd love to go on

vacation to Seattle, I think we'd only be able to make one trip a

year. I had considered Spokane (my parents live 2 hours from Spokane)

and staying with my parents during the casting period, but noticed

they didn't have a Ponseti doc listed plus it didn't really work for

our family at the time.

I definately plan to keep up with the insurance. I really feel they

should pay more where we had no other options in the area for

treatment...I really feel it was either leave him a cripple (not an

option) or go out of network as far as my insurance is concerned.

I've had a few people say that eventually they will pay just to get

rid of people, so I'm keeping my fingers crossed hoping that will

work. Just wondering what else I can use to appeal or if I can just

stress what I've already used...mainly that he is the only doc in the

area that will even treat children with club foot. Thanks for

responding, there are a lot of great people on here!

Lorinda

> I wonder, if his foot is good and only needs checkups from now on

maybe

> your future appointments won't cost as much? Driving to Seattle

wouldn't

> save much money, unless you wish to vacate there a few times a year

> anyway. I think there's docs at Spokane Shriners doing Ponseti

now, but

> that's just something I heard here once. I can't verify it, you'd

have to

> call them. In that case, your only costs would be travel. They

provide

> treatment for free.

>

> I'd keep on with the insurance company. If someone has done it,

you can

> too. Especially if this doc is the only one who will even treat CF

in your

> area. It may be a lot of work, but I bet it can be done if you

don't let

> up. I'm pretty sure the squeaky wheel gets oiled with insurance

> companies. I think they like to deny a few times and then finally

let up,

> if only to get rid of you.

>

> Good luck!

>

> Kori

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Posted
Posted

Lorinda,

What a headache!!! I hate those darn insurance companies - it seems

like it's so hard just to get them to cover the most obviously

necessary things some times. I agree with all the previous posters -

keep harassing them.

There is a Shriner's hospital over in Spokane - have you looked in to

going there for treatment?

The only other thing I can think of is are you seeing your current

doc at a hospital or is he a private practice? Most hospitals have

their own financial aid program, separate from medicaid. We get aid

through Children's Hospital here, even though we also have other

insurance.

Good luck - I'm sure it will all work out for you some how!

Darby

Livi 3.15.04 bi cf

> >

> >

> > At 01:02 PM 6/4/2005, you wrote:

> > >I have been reading some of the posts for a few months now and

> was

> > >hoping that maybe someone would have some help/suggestions for

> me.

> > >

> > >My son, Tysen, was born on February 18, 2005. We didn't know

> until he

> > >was born that his left foot is a club foot. Two weeks after he

> was

> > >born we met with the pediatric orthopaedic recommended by our

> > >pediatrician and his first cast was applied. We have done six

> weeks

> > >of castings (the first actually was removed early due to

> unexplained

> > >swelling in his toes), a tenotomy, and are 1 1/2 months into

> the full-

> > >time bracing. His foot looks great and we are pleased with the

> > >results.

> > >

> > >We didn't have much time to research things, but were very

> fortunate

> > >in that the doctor we were referred to is a Ponseti qualified

> doctor.

> > > From what I have been able to find so far is that he is

> actually the

> > >only doctor in the area that will treat children with club

> foot. The

> > >unfortunate part for us is that both the doctor and the

> orthodist

> > >(also the only one in the area that supplies the brace) are

out-

> of-

> > >network providers as far as our insurance is concerned. The

> > >difference being that they are only paying 60% of their

> allowable

> > >charges instead of 90% and we have to meet a higher

deductible,

> which

> > >for the medical bills we have so far is a big difference. I

> applied

> > >for Medicaid, but lately my husband has been working just

enough

> > >overtime to not qualify. Financially we qualify for the next

> program,

> > >CHIP, but they will not help children that are covered under

> > >insurance. I also checked into another state program for

> children

> > >with special needs and was told that they quit helping people

> with

> > >insurance a year ago due to funding issues. I have submitted

one

> > >appeal to the insurance. I hate to say that it was no big

> surprise to

> > >receive a letter in the mail today saying that the appeals

(for

> the

> > >doctor and the orthodist) were denied. I figured they would

> resist

> > >paying and they just said that according to the policy with my

> > >husband's company, they cannot cover out-of-network under

> anything

> > >but the benefits as stated -- even if there is no provider in

> our

> > >area.

> > >

> > >I am just feeling very frustrated right now...the insurance is

> paying

> > >low and we don't qualify for other help because of the

> > >insurance. I was hoping that maybe someone would have some

> > >suggestions to appeal or get the insurance to pay more. It

kind

> of

> > >angers me that they won't even pay 90% of their allowable

> charges for

> > >out-of-network and leave me with the difference plus my 10%.

> They are

> > >actually saving money by me going out of network. I am

grateful

> they

> > >are at least covering the 60%, but I guess I don't feel that

is

> fair

> > >where I didn't even have an in-network choice. I talked to an

> > >insurance representative a week and a half ago and he said

that

> he

> > >has only seen once when the insurance did pay in-network

> benefits for

> > >an out-of-network doctor so I guess I feel like there is

> possibly

> > >some way to get it done, but I'm not sure what to do to get

> there. I

> > >can submit another appeal, but not sure what I would submit.

> > >

> > >I would really appreciate any suggestions/experiences/help

with

> this.

> > >

> > >Thanks for listening!

> > >Lorinda

> > >

> > >P.S. Don't know if it makes a difference, but we live in Idaho.

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

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Posted
Posted

Lorinda,

What a headache!!! I hate those darn insurance companies - it seems

like it's so hard just to get them to cover the most obviously

necessary things some times. I agree with all the previous posters -

keep harassing them.

There is a Shriner's hospital over in Spokane - have you looked in to

going there for treatment?

The only other thing I can think of is are you seeing your current

doc at a hospital or is he a private practice? Most hospitals have

their own financial aid program, separate from medicaid. We get aid

through Children's Hospital here, even though we also have other

insurance.

Good luck - I'm sure it will all work out for you some how!

Darby

Livi 3.15.04 bi cf

> >

> >

> > At 01:02 PM 6/4/2005, you wrote:

> > >I have been reading some of the posts for a few months now and

> was

> > >hoping that maybe someone would have some help/suggestions for

> me.

> > >

> > >My son, Tysen, was born on February 18, 2005. We didn't know

> until he

> > >was born that his left foot is a club foot. Two weeks after he

> was

> > >born we met with the pediatric orthopaedic recommended by our

> > >pediatrician and his first cast was applied. We have done six

> weeks

> > >of castings (the first actually was removed early due to

> unexplained

> > >swelling in his toes), a tenotomy, and are 1 1/2 months into

> the full-

> > >time bracing. His foot looks great and we are pleased with the

> > >results.

> > >

> > >We didn't have much time to research things, but were very

> fortunate

> > >in that the doctor we were referred to is a Ponseti qualified

> doctor.

> > > From what I have been able to find so far is that he is

> actually the

> > >only doctor in the area that will treat children with club

> foot. The

> > >unfortunate part for us is that both the doctor and the

> orthodist

> > >(also the only one in the area that supplies the brace) are

out-

> of-

> > >network providers as far as our insurance is concerned. The

> > >difference being that they are only paying 60% of their

> allowable

> > >charges instead of 90% and we have to meet a higher

deductible,

> which

> > >for the medical bills we have so far is a big difference. I

> applied

> > >for Medicaid, but lately my husband has been working just

enough

> > >overtime to not qualify. Financially we qualify for the next

> program,

> > >CHIP, but they will not help children that are covered under

> > >insurance. I also checked into another state program for

> children

> > >with special needs and was told that they quit helping people

> with

> > >insurance a year ago due to funding issues. I have submitted

one

> > >appeal to the insurance. I hate to say that it was no big

> surprise to

> > >receive a letter in the mail today saying that the appeals

(for

> the

> > >doctor and the orthodist) were denied. I figured they would

> resist

> > >paying and they just said that according to the policy with my

> > >husband's company, they cannot cover out-of-network under

> anything

> > >but the benefits as stated -- even if there is no provider in

> our

> > >area.

> > >

> > >I am just feeling very frustrated right now...the insurance is

> paying

> > >low and we don't qualify for other help because of the

> > >insurance. I was hoping that maybe someone would have some

> > >suggestions to appeal or get the insurance to pay more. It

kind

> of

> > >angers me that they won't even pay 90% of their allowable

> charges for

> > >out-of-network and leave me with the difference plus my 10%.

> They are

> > >actually saving money by me going out of network. I am

grateful

> they

> > >are at least covering the 60%, but I guess I don't feel that

is

> fair

> > >where I didn't even have an in-network choice. I talked to an

> > >insurance representative a week and a half ago and he said

that

> he

> > >has only seen once when the insurance did pay in-network

> benefits for

> > >an out-of-network doctor so I guess I feel like there is

> possibly

> > >some way to get it done, but I'm not sure what to do to get

> there. I

> > >can submit another appeal, but not sure what I would submit.

> > >

> > >I would really appreciate any suggestions/experiences/help

with

> this.

> > >

> > >Thanks for listening!

> > >Lorinda

> > >

> > >P.S. Don't know if it makes a difference, but we live in Idaho.

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

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