MIS Quad Sparing Insurance Problem!!!

[hollie9]

Just got a letter from California Blue Cross that they are not covering "Computer Assisted surg navigational procedures" because these are considered "investigational".

Has anyone else run into this, and were you able to turn it over on appeal?

Hollie

 

[JudyS]

Hollie,
What I do not understand is if surgery must be pre-approved, how can they claim this after the fact?

I did have a claim come in recently denied saying it was investigational, however I did not have the procedure they mentioned. I believe the dr's office must have appealed or sent in the proper code to get it covered.

I know my hyalgan injections had to be pre-approved, so like I said I really do not get it.

Good Luck with it , I hope it is simple to figure out. I would call my docs office if I were you.
Judy

 

[Josephine]

'Investigational'??? I think some clerk must be confusing this with a scan or something! No way can it be considered investigational! I suggest you ring your OS office and ask them to help. Don't they often have admins who's job it is to deal with these problems?

 

[hollie9]

I called the OS and they are "eating" the disallowed cost because they are in Blue Cross' network.

But this is outrageous, so many hips and knees are done with computers to assist in alignment, this is common now. And Judy you are right, I don't think they have a leg to stand on when they already "approved" the procedure. Who ever heard of a "retrospective" review of a surgery by the insurance company.

Blue Cross sucks, this never happened when I was with Blue Shield (they aren't together in California).

Hollie

 

[JudyS]

Hollie
i agree that Blue Cross "sucks". I always look at the amount they actually pay out. I am always shocked and upset.
I did call once and ask to speak to Mr. Blue Cross!!!

Glad it did not fall on you to fight.
Judy

 

[Simon]

Hollie

I had the same problem with BLue Cross/Blue Shield of Alabama. The OS office filed the appeal explaining with 9 previous surgeries to correct malalignment problems it would be next to impossible to get a good alignment without the use of the computer. They also said the surgery would be more difficult with possible future problems which of course would cost them more money but that does not compute with them.

Most insurance companies pre approve the surgery but not the specifics so if the OS does not state the computer navigation up front the insurance company would have no way of knowing they are using it.

My OS also is "eating" it. Many years when I was between jobs, I took out a catastrophic insurance policy that had a $15,000 deductible which is now up to $35.000 (that deductible really means they won't consider a claim until the total charges are over $35,000). So I submitted the claim to them, along with all the deductibles I had paid (including the walker and drugs) and they paid all of it. This was nice as the out of pocket for PT was $1,000 and the hospital deductible was $800 plus all those office visit deductibles and the OS got paid as well. It did come to alot less then I have paid in
premiums though.

I am sure in a few years when more of the research is in, they will start paying for it.

Simon

 

[hollie9]

Simon, after those appeals did Blue Cross/Blue Shield ever pay for the computer nav part of surgery?

And Judy, I agree with you. When I see those statements of how little they actually pay the surgeons in network, it's surprising any of them will join a network. What a scam this all is.

Hollie

 

[Simon]

Hollie

Blue Cross never paid for the computer part of the surgery. I was able to get him paid through a second insurance that I carry.

Blue Cross also reject the last 4 days of my inpatient rehab stay (they approved 7 days and I was there 11). The hospital appealed and they rejected that. Then I was getting ready to write an appeal but for some reason before that happened they did pay it.

Outside of the navigational part Blue Cross has been very good and paid everything else and they have not put any limits on physical therapy, they are even now paying all of it as I hit the $1,000 out of pocket. I consider that I have been really luck in the insurance department compared to most.

Simon

 

[hollie9]

I've paid a lot more than $1,000 out of pocket, it must be approaching $3,000 by now.

Also, I keep getting Blue Cross letters saying the rest of the cost isn't covered yet because the doc's office hasn't sent them information. The competent insurance person at doc's office says she keeps sending everything over and over and they are acting like they are not receiving it. She was going to call them next, says she's used to it.

Blue Cross (here) sucks!

Hollie

 

[Simon]

Hollie

The didn't receive stuff is typical insurance company. I hope the doctor's office sends the next package addressed to a specific person and sends it UPS or Fed Ex or return receipt by the post office as all these will give proof of delivery.

The $1000 was just PT. I paid $800 for the hospital deductible and the typical office visit deductibles.

Insurance in general just is an exercise in frustration

Good luck

Simon

 

[hollie9]

I haven't heard anything from the insurance people or the doc's staff, so hopefully the insurance problem is resolved.

Hollie

 

[Josephine]

I hope it is too, hollie.

 

[Jamie]

Boy, I really feel for you guys! We have Blue Cross/Blue Shield of Kansas City and we LOVE it. There are never any problems and all the good doctors in town are in the network. I look at what they are paid and it seems reasonable to me. Does that mean different Blue Cross/Blue Shield networks make different contracts with the local doctors and hospitals? If that's the case, I'm thankful we live here in Kansas City.

 

[Simon]

Jamie

Yes Blue Cross does differ my area. The other difference is your company as each company negotiates with BLue Cross on what they will cover and cost issues. I have Blue Cross of Alabama and overall they have been very good, just a few problems as I mentioned. Our company self insures as use Blue Cross as the processing agent and I think that is one reason the coverage has been good.

Simon