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Insurance Q &As
by and for Acoustic Neuroma patients
Insurance Q &As
for alternative or non-local AN treatments
Q: I am really afraid my insurance company is not going to pay for me to go out of town.
(by Lynne) Got an interesting tip yesterday from a patient who has been to Staten Island. He said that a lot of insurance companies cover travel to receive treatment and recommended to check the fine print on our policies to see if they do. He had travelled to Staten Island and had not done the four or five day continuous treatment but the four weeks, one day a week original program that they used in the beginning. He flew in from Colorado to New York each week for the treatment and returned. Did this four times and says the air fare was covered. Just some information which may help defer costs for some of us who are considering out-of-state treatment.
Another thing, you can fight your HMO if your HMO does not have a surgeon or radiation oncologist of the caliber and experience of the one you are proposing to go to. A lot of state laws are covering this problem now. Do not accept their decision without a fight. It is well worth it to make a stand and appeal.
My HMO balked at my first treatment provider, too. I fought them, found that there was something called a "patient advocate" and eventually, the HMO approved it. Fight, fight, fight. It is your BRAIN, and no matter what treatment you choose, you need to have the best of the best doing it.
Q: My insurance company does not want to cover alternate treatments.
They will, once they understand the possible implications of having to pay for your post-surgical complications. After all, nothing is as correlated with the success of AN treatment's outcome as the choice of a doctor. Last summer's (1997) newsletter from the IRSA (http://www.irsa.org ) had a wonderful article from a woman who did this successfully. Your AN treatment provider, if they are used to seeing out-of-town patients (and the radiosurgeons, as well as the best of microsurgeons, are), should help you with it:
I have Blue Shield of California. The staff at SIUH took charge of making sure all of the insurance coverages were in place. They were authoritative, accommodating and understanding. They can sort out all those coverage issues for you. Ask for Cookie (the person, not the chocolate chip.)
Don't forget, you have multiple levels of appeal if the HMO initially denies your request. But be careful with going ahead with treatment until this is straightened out. These days, most insurance companies demand that you get precertified before treatment. For this, it is a good idea to enroll the support of your primary care physician (PCP). Their help can make all the difference, as in this story by Charles Gruber:
After an intense weekend of web research, I came to the inescapable conclusions that... making sure that my insurance would cover the $35,000 cost of the procedure was rather important... Although Johns Hopkins Hospital had contacted my insurance company and felt reasonably confident that the insurance company would cover the procedure, I was still on the hook if, for some unanticipated reason, the insurance company changed its mind. I got on the phone with my insurance company. After explaining the situation to a benefits manager, a claims manager and some medical people at the insurance company, I could only get a "please submit all the appropriate paperwork and we'll decide in 4-6 weeks whether we'll pre-certify payment for the procedure."
Then my Principal Care Physician happened to walk into my office. After I explained to him what the insurance problem was, he got on the phone with the aforementioned phalanx of "Sorry, can't help you" phenoms and spent the next 90 minutes being bumped up supervisory levels until we got the same message from someone REALLY high up. Dispirited, I took a call late the next day from a woman who said sheíd been assigned as case manager to be liason between the hospital and the insurance company and little old me. "What do you need?", she asked. "I need a written confirmation that your company will pre-certify the payment for the procedure I need to have performed. "No problem", she said. It seems that my physician had made SO much noise about immediate pre-certification that my case had been bumped up to someone who could say "No problem."
The pre-certification led to an immediate call to Johns Hopkins to set as early a date for the procedure as possible.
Some HMOs will cover out of network treatment if you can convince your PCP into submitting a request for a "Non-Par Referal". No guarantee that the HMO will honor the request, but worth a shot. For this, a well-written letter is very important:
I also would be happy to provide a copy of the "winning" letter I wrote to my primary care physician which got me her support. She reallized I was quite knowlegable - perhaps more so than she. If I were unable to gain her support, my case would be hopeless.
Another possible option, which is also known to have been done, is to switch insurance companies prior to any treatment, while in watch-and-wait mode.
Q: Our insurance company is refusing to pay a huge chunk of the FSR bill because the hospital billed us for multiple charges of "radiosurgery".
Go back to the facility that provided the radiosurgery and have them re-write and re-submit the bill as a SINGLE item including the total costs of all the sessions in one lump sum. To effect this change, it will be necessary to talk to a supervisor there. Also, get a detailed letter from them saying that there was ONE treatment involving several sessions of radiation, explaining the procedure and what it was. One letter is worth more than 10 phone calls.
Until this is done, the insurance company will continue to reject it as duplicate billing or duplicate services. That will be the way the computer reads it and until it is changed NOTHING will make the computer stop rejecting the bill(s). Computers are, unfortunately, dumb in pretty fundamental ways and cannot be reasoned with and reject claims with i's not dotted, t's not crossed and incorrect codes assigned to procedures/providers etc.
It will be necessary to talk to a supervisor at the insurance company. If the insurance is through employment, get the official at employment involved because they usually have connections with the insurance company. Make it clear that this has been submitted before incorrectly with dates, invoice numbers etc, if possible. Think like you are reasoning with a dinosaur. It takes ten minutes for it to realize its tail is on fire -- e.g computers. In the end, this problem may have to be processed by hand (by a live human being) if proceedure codes don't fit the computer's pre-set program for the codes and fees for the provider in question.
Q: I've been talking to everyone, but things are not getting straightened out.
Don't just talk, but get it documented!
My sister-in-law, who happens to be a benefit manager herself,
If the insurance company denies the claim repeatedly, there is probably a government organization overseeing the insurance company that you can complain to, such as the State Insurance Commissioner. For example, in California, it is the Department of Corporations. You should see the insurance company jump when you "cc" the Dept of Corporations with your complaint mail!
Once I realized that the insurance companies refer to policy holders and benefit claimants as " loss units" I became a lot more agressive in my dealings with them...
Also, you can get a lawyer involved, one who deals with this kind of thing...
I feel we won this fight because... we sought legal action and our lawyer was filing a state insurance complaint, and my husband told them so, so they took notice just how serious he was.
In a recent (fall'98) Wall Street Journal feature section on using the internet for better health care, it was noted that Susan Stewart, the founder of the Blood and Marrow Transplant Newsletter (http://www.bmtnews.org) provides an attorney-referral service via phone, e-mail, or fax for patients fighting insurance companies over payment for transplants. Perhaps she can refer you as well?
Q: I am concerned about pre-existing conditions related to switching health insurances. Has anyone else experienced job changes during the wait and see process?
I am a benefits administrator for health insurance at my company. Before you change employment you need to provide a letter from your existing insurance carrier confirming your coverage under their plan. If you were covered for treatment by them and had no lapse in coverage, I believe the new plan must cover you as well. Check with your insurance carrier. It's called the HIPPA law.
Nevertheless, it probably would be wise to ask about prior conditions being covered before accepting employment with a particular firm, or selecting a new insurer from among the choices.
Q: What is the cost of these procedures as I will have to pay 20-40% of the bill.
Quotes for surgery costs can range from $9500 at NYU to $55,000 at the House Clinic, and that is just the surgeon's fee! To complicate matters, fees vary not only place to place, but within one place. One rate, which we might call 'retail', is what you would pay if you had no insurance. Second rate, called 'usual and customary', is what the insurance company will pay for a procedure in A PARTICULAR PLACE. So, your insurance company may pay X$ for a proceedure in Boston and Y$ for it in St. Louis. That sounds crazy, I know, but that is the way their contracts are written with particular providers.
Your goal, regardless of where you have your procedure done is to get the provider to accept the 'usual and customary' fee paid by your insurer as the full payment for the procedure. You want to avoid any additional costs beyond 'usual and customary' which you would have to pay in addition. Don't be afraid to bargain about this!
Some indemnity plans have an annual out of pocket ceiling that takes the sting out of the 20-40% copay. Also, it is possible to negotiate w/hospital and doctors for further reduced rates, and to avoid paying anything out of pocket.
(by Lynne) I am in an open insurance plan and locally can get 100% coverage as long as the neurotologists or radiation oncologists are network providers. However I can get 70% from any doctor or oncologist anywhere in the country (including local who are not in the huge network I am connected to). Various of the out-of-state providers (surgeons and radiation oncologists) told me they would do the procedures for the cost of my coverage, i.e. 70%. You may want to check with anyone you are considering either surgery or radiosurgery, to see if they are willing to do this. Dr. Lederman at Staten Island has mentioned also that he will take70% so it is worth a try if you find you have to go somewhere that will not be covered 100%.
Personally, I also feel that I would be willing to go to the best doctor/oncologist even if I could only get 70% coverage and the doctor was not willing to waive the balance (perhaps paying in installments over years). I feel the benefit of receiving treatment from the best and most experienced provider (who may be out of state) is worth the extra money I may have to pay. I am not wealthy, just an average working person, so even if it might be a struggle I decided that I am worth it.
Insurance Q & As
for follow-up treatments and procedures
Q: My insurance company has rejected my doctor's request that physical therapy for my facial paralysis be covered. They are saying that neuromuscular rehab. is not viewed as customary or appropriate for facial parylasis associated with Acoustic Neuroma surgery.
A lot of insurance companies assume that the patient/consumer will accept the denial and not go any further. Always file an immediate appeal, and if possible follow up with reasons why, etc. etc. Be persistent, get doctors and documentation to support you and work the appeals process for all it is worth!
There is absolutely no reason why this kind of therapy should not be covered... Most health insurance companies routinely deny requests for therapy (or any procedure) that may be a little unusual; literally half the time those making the denial don't have a clue what is involved and they make a blanket denial rather than investigate whether it is a valid claim or not.
My sister works as office manager in a physical therapy office dealing with a lot of insurance companies. She says that when claims are rejected hardly anyone thinks to use the appeals process. The few times she's recommended patients to try this, they have all won their cases.
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Last Edited: Wednesday, October 30, 2002