For Anybody who has Blue Cross, Blue Shield

[Kathyj08]

I got a call earlier today from American Access Care (where I am due to have my second procedure this fall) and they wanted to notify me that Blue Cross Blue Shield has pulled out from covering the procedure because it is experimental. Hopefully this doesn't involve too many of us.

[newlywed4ever]

Here's what AAC has done to me...

First, please note that I think the world of Dr Sclafani and do not wish to hurt him and what he is doing. However, I am very frustrated with AAC billing. I had my 2nd procedure 1/28/11 by Dr Sclafani (my 1st procedure was with Dr Siskin and BC/BS covered 100%). Prior to my appt., Deb Helmer of AAC billing told me that she tried to get pre-auth from BC/BS - which BC/BS denies ever getting a call from AAC and indicated the pre-auth was unnecessary. I did get the procedure & diagnosis codes from Ms Helmer and called BC/BS myself. I was told that all the codes were covered and Dr Sclafani is an approved provider. When I told Deb Helmer this, she indicated verbally that she had "a bad feeling" about my insurance covering this and I would be required to self-pay. I kept my appt. with AAC feeling that I had covered all bases. At AAC, I again indicated to Nancy (office manager) that I was told by BC/BS that the procedure was covered and that it was probably in AAC's best interest financially to bill the insurance company. I also indicated to Nancy that I would guarantee payment if the procedure was denied. Nancy told me that it came from billing that I would have to self-pay the discounted price which I then put on my credit card (yikes). I still felt confident that I would be reimbursed in a timely manner. I rec'd an itemized statement from AAC to submit to BC/BS. The itemized statement showed the procedure billed at $10,000. I submitted this and BC/BS processed a check on 4/5/11 - however, since they only cover a percentage of the cost, the reimbursement was only a little over $5300. BC/BS sent this check to AAC (by contract, they must do this and then the provider reimburses me). Numerous phone calls were made to AAC with different excuses as to why they hadn't reimbursed me. As of 5/2/11, AAC told me they had to send the check back to BC/BS due to a new Medical Policy from Empire BC/BS that CCSVI was not covered. The AAC contract manager at AAC claims that this is retroactive and all $$ rec'd prior to 4/12/11 will have to be paid back to BC/BS (I find this hard to believe). I have a copy of the Medical Policy and it states: "Venous angioplasty is considered investigational and not medically necessary for the treatment of multiple sclerosis." Dr Sclafani has always indicated that he is NOT treating MS, he is treating CCSVI.

This whole mess has been financially and emotionally taxing. Anyone else with similar problems from AAC billing? My belief is that Ms Helmer made a very costly mistake and I am the one who ultimately loses.

[zinamaria]

Oh man, this is not good news if it is true....that would mean I would not be covered. I have written to Karen Moran to see what's going on.
Boy do I hope there is some mix-up.
Kathy, thank you for the heads-up, and Newlywed, thank you for posting too; it's important we know everything we can know about all of this.

[drsclafani]

Here's what AAC has done to me...

First, please note that I think the world of Dr Sclafani and do not wish to hurt him and what he is doing. However, I am very frustrated with AAC billing. I had my 2nd procedure 1/28/11 by Dr Sclafani (my 1st procedure was with Dr Siskin and BC/BS covered 100%). Prior to my appt., Deb Helmer of AAC billing told me that she tried to get pre-auth from BC/BS - which BC/BS denies ever getting a call from AAC and indicated the pre-auth was unnecessary. I did get the procedure & diagnosis codes from Ms Helmer and called BC/BS myself. I was told that all the codes were covered and Dr Sclafani is an approved provider. When I told Deb Helmer this, she indicated verbally that she had "a bad feeling" about my insurance covering this and I would be required to self-pay. I kept my appt. with AAC feeling that I had covered all bases. At AAC, I again indicated to Nancy (office manager) that I was told by BC/BS that the procedure was covered and that it was probably in AAC's best interest financially to bill the insurance company. I also indicated to Nancy that I would guarantee payment if the procedure was denied. Nancy told me that it came from billing that I would have to self-pay the discounted price which I then put on my credit card (yikes). I still felt confident that I would be reimbursed in a timely manner. I rec'd an itemized statement from AAC to submit to BC/BS. The itemized statement showed the procedure billed at $10,000. I submitted this and BC/BS processed a check on 4/5/11 - however, since they only cover a percentage of the cost, the reimbursement was only a little over $5300. BC/BS sent this check to AAC (by contract, they must do this and then the provider reimburses me). Numerous phone calls were made to AAC with different excuses as to why they hadn't reimbursed me. As of 5/2/11, AAC told me they had to send the check back to BC/BS due to a new Medical Policy from Empire BC/BS that CCSVI was not covered. The AAC contract manager at AAC claims that this is retroactive and all $$ rec'd prior to 4/12/11 will have to be paid back to BC/BS (I find this hard to believe). I have a copy of the Medical Policy and it states: "Venous angioplasty is considered investigational and not medically necessary for the treatment of multiple sclerosis." Dr Sclafani has always indicated that he is NOT treating MS, he is treating CCSVI.

This whole mess has been financially and emotionally taxing. Anyone else with similar problems from AAC billing? My belief is that Ms Helmer made a very costly mistake and I am the one who ultimately loses.

We did not bill with the diagnosis of MS, but with stenosis of the jugular veins. BC/BS of Brooklyn and many other areas of the country. BC/BS posted their statement above on april 12 and thus are stating that that was sufficient notice. Ms Helmer actually was giving reasonable warning .

This is really discouraging to me as well. I am willing to treat as many patients as possible. As soon as possible is a good idea.

Canada may be arriving

[hope410]

Canada may be arriving

I'm not understanding this. What do you mean?

[newlywed4ever]

As I sat wondering about the wisdom of my public post and opinion and whether to figure out how to delete a post, Dr Sclafani posted after me. It is more important than my post.

I think we are warned here, folks. God help us.

My problems are merely a grain of sand when it comes to the bigger picture of the potential negative impact that insurers and neuros have on all of us.

[orion98665]

Canada may be arriving

I'm not understanding this. What do you mean?

i think what Dr. Sclafani is saying is its just a matter of time before all
insurance companies refuse to cover this procedure. Will all end up in the same shoes as Canada. No coverage and a procedure deemed experimental that is not recognized.

I'm just curious of all those who had the procedure covered in the past if
insurance companies will go back look at all their records and demand
reimbursement for the procedure. God i hope not!


I just thought of a great idea. Tell your insurance company that your willing to stop taking your lousy DMD's for 4 months if they are willing to cover the procedure for CCSVI. Insurance companies would actually save money.

Bob

[CureIous]

I recall warning specifically of this last year, more than once. It's only a matter of time. Back then, the "word on the street" was, just plug in correct code, in correct manner, and your verifiable pathology is covered. True, then, for the most part, but then ominous signs began to appear, in dribs and drabs, and the writing was plainly on the wall, "if you are going to go for it, do it now". If not, just wait and pay cash, your choice. This is big BIG money we are talking about here, and all the comparisons to expensive MS drugs makes for good philosophical arguments, but does nothing to cure the sticker shock insurance companies are facing.

So yeah, some of us were warning, more than once, and it was dismissed as conspiracy theory, or just not getting it or not understanding the ICD codes.

Here's one after another one of Trevor's inflammatory blog postings:
http://www.thisisms.com/ftopicp-133243- ... age#133243

.....And of course, since getting anything treatment-wise now through an IRB is like pulling eye teeth blindfolded, patients could conceivably in the future, be faced with much fewer options, to wit:
1. Fly overseas, mortgage the house, do what you have to do, roll the dice.
2. Hope your insurance doesn't begin to get ahead of this, and force you to choose as nick stated above, or makes a specific exclusion for any type of CCSVI treatment as experimental, IF you are already dx'd with MS. And once one of them does it, finds a way to get those exclusions in there, the rest won't be far behind.
3. Wait on the studies to not only be completed, but accepted in academia, 5-10 years. Not "A" study, but the study(ies), confirming the studies, making CCSVI not just accepted, but embraced and pursued as a viable alternative to MS treatment, either concomitant with the DMD's, or instead of for the earliest dx'd cases.
4. Suggestions?

This is not to fearmong, focus on the negative, roll things up and call it a day, because something somewhere on the internet is amiss.

But, it is something to keep in mind for future reference. I have a sense we may be referencing this more very soon.

Mark.

Or this one: http://www.thisisms.com/ftopicp-133497- ... age#133497
Posted: Sun Sep 12, 2010 12:47 pm Post subject: Re: Time To Stand Up And Fight

--------------------------------------------------------------------------------

Blight wrote:
Hello,
Eventually my surgeon was barred from treating MS patients by his insurance company.



A slightly different angle than what I was alluding to last night in my post about the possibility (despite the accepted treatment of venous occlusions as a known pathology with it's own code) of insurance companies in the future "tightening the belt" so to speak, until as such time that CCSVI gets it's OWN code, or is accepted to be treated industry-wide under the codes already in existence for IJV's.

One person answered that they were given what amounts to an ultimatum by their insurer, drugs, or procedure, but not both.

Now if I gather what you are saying, it was the Dr's own insurance (i.e. malpractice insurance, which is a huge factor in any office) put the kibbosh on him doing any more procedures?

That's yet another angle I had not considered.

Insurance companies are corporations. They aren't there for your health, my health, or any other health besides the bottom line. Think we all get that.

Insurance companies always work off what is best for the bottom line, and I offer for any given quarter.

To have an onslaught of 50-100k operations for (estimated) 2-500,000 patients (assuming a certain % want to get treated, can find treatment, have insurance, and identifiable and treatable conditions), would put a serious cramp on the bottom line, and I understand the logic is, "well DMD's cost x dollars over lifetime". Yes, they do.

Spread out over a lifetime. Palatable. Plus insurance rarely if ever pays the going rate. Bigger the company, better their negotiating power to drive costs down via volume. (This is how Costco strongarms it's suppliers to get the best price).

So let's just go 50k, testing to treatment to follow up, for say half the MS'ers in America only. 250,000 x 50,000= 12.5 BILLION dollars of outlay in a very short period of time. And that's just a thumbnail with round numbers.

Let's say every person in the US with MS, and the count of 500,000 I think to be very outdated and low, but lets just bump the example above up to 75% of the 500,000 = 375,000x50k a pop= 18 billion, 750 million dollars.

That is a substantial, humongous outlay of money in a short period of time, with the presumption that say only 20-40% of those treated will discontinue their meds.

Now this may appear to be mere moaning and groaning and negativity, but for the rest of us in the real world, life is lived by the numbers game. Insurance doesn't lower my rates on my auto because they like me, think I'm cool, or in need, or anything else. I played the numbers game well, didn't have any accidents, or tickets, for x years, and the actuarials are pretty heartless and cruel if one has the opposite.


So, now my question is, besides the insurance company angle, which many will say, including me, "well my insurance covered it, no problem", at what point in the future will they do the simple math I did above and balance out their inclusion/exclusion criteria to effect the best condition for their corporation, OR, attempt to spread out those big numbers over the longest period possible, so the CEO doesn't get canned when the quarterlies (which most corps live and die for) show a substantial drop?

And at what point will insurers for malpractice step in and say, "no vein treatments for any MS patients or you lose coverage?".

Things to keep in mind in the times ahead, just because all seems cut and dried with the 50%+ stenosis treatment paradigm under established codes, doesn't predict the future, it's just a good guess.

Mark


I hope so, but if the bean counters I've ever known get their hands on it, there won't be any interviews when the calculators start whirring... This is working off a presumption of where CCSVI research may end up in the future, a seriously big "if". Then furthering that presumption to assume that people would be inclined to discontinue their DMD's, sans any recommendations from the PTB, which we can safely assume is not going to come any time soon.

So what I see happening, is a continuance of the DMD machine, it's not going away any time soon, thereby it's costs will continue unabated, but now we've tacked on an expensive surgery atop that cost. I doubt the insurance companies are going to sit idly by while all that occurs and just keep plunking down big bucks for MS patients who just *happen* to collectively, at the same time, require expensive surgery on the same collection of veins....

I mean I hope it don't go down like that, but that's where I see it is heading very quickly....

Really, I mean I REALLY hope none of that happens. I'd be happy to be wrong about it, but we are seeing little snippets of it here and there, keep a watchful ear...

Mark



They are doing pretty much what I expected, and we will continue to get reports like these from across the country, and once that train looks like it's leaving the station, expect an onslaught of other providers to get on board.

Best bet, is for CIS people to NOT get an MS diagnosis until after they are treated, after all, it does nothing to improve your circumstance anyways. (having the dx).

Beyond that, I would expect that the insurers will say, "be more than happy to treat CCSVI, after it's been thoroughly studied". Expect to wait more than a few years for that one, if ever, this is how treating will be delayed, we've already been "actuarial'd" in with our pricey drugs and care, tossing in another experimental, unproven, untested procedure to treat MS patients is something the insurers won't allow. If you think Canada had a "bum rush" on IR's and MRI tubes and ultrasound machines, wait until the media stops kissing pharaceutical big $$ butt and goes nationwide with this on a real news report and not sporadic obscure markets where it has a miniscule impact in comparison. Wait until Montel (if and when of course) get's his limelight on this.

As I've stated before, the above will basically (as happened in Canada), compel insurers, government and private alike, to take a stance on the issue, and fall on one side or the other, more action will likely cement that into place even more, but perhaps not on the side we would prefer.

And once again, the MS patient comes a distant last place in all of this.

That's not negative talk, it's not conspiracy talk, it's real life and it's the truth.

It's not insurmountable, but I think just telling people that "oh, just get the ICD's and boom, you're in" is, and has been, the WRONG THING TO SAY. I'd go so far as to say it's been very bad advice, as it leaves out the above warnings which I copied from my other postings, call this a time sensitive situation.

I'd max out every credit card I have ever had to get what I've got the past 2 years, and would be thankful for only having to do that.

[Cece]

This is very upsetting news. (And newlywed4ever, I am so sorry you are caught up in this, I do not understand it being retroactive. I had heard before that if Medicare stopped covering CCSVI, the providers would have to return Medicare funds and then might come after the patients for the money. I didn't think it was true but now I do. Can you appeal?)

How likely is it that other insurance companies will follow suit?

If I restenose and my insurance won't cover it....

And what about people with BCBS who had had the procedure but have complications?

If a patient does not have the label of MS, will BCBS pay for their jugular venoplasty?

This is genuinely very scary.

[Brightspot]

I wish to make a couple of comments.

One is about the medical system in Canada, and the other is about the cost of angioplasty.

In Canada private medical care is basically illegal. There are not supposed to be any private clinics here.

Instead, we have publicly funded health care and the Canada Health act.
The Canada Health Act stipulates that all Canadians are entitled to medically necessary treatment without cost to the individual.

We also have Human Rights Legislation which stipulates that a service cannot be denied to someone on the basis that they are disabled.

Both of these peices of legislation are being broken when it comes to CCSVI.
Canadians who are disabled with MS are being denied access to the services of vascular medical treatment.

The MS Society and the Neurological sections of our provincial medical associations have advised our government to deny persons with MS access to the services of vascular specialists for assessment, and for treatment of CCSVI.

This is a big problem, and I have read comments from Canadians saying they wish they lived in the USA, where they could obtain treatment. They do not seem to be aware that most folks living in the USA pay huge monthly bills for medical insurance, and often have to make co payments when they require medical care.

When (notice I do not say if) the MS Society and Neorologists are no longer allowed to act as gatekeepers, denying persons with MS access to vascular medical care, then Canadians who require angioplasty will have access to it without cost.

I have had testing and treatment out of country, but I am doing everything I can to ensure that all Canadians with MS will be tested and treated in Canada, at no cost to themselves.

This brings me to my second point. The cost of angiplasty to the medical system in Canada ,(that is to the system and not the patient), is less than 2000 dollars. This is exclusive of ultrasound and MRI, and stents.

This point was made by Dr. Sandy MacDonald when he testified ,at the request of Kirsty Duncan, to the parliamentary sub committee on neurological health). You can verify this by going to your provincial medical services plan and doing a search.

I must say I am a bit startled that the procedure has been billed to insurance companies in the USA at a rate of 50 to 100,000 dollars.

Even with the addition of MRIs, I am wondering how the price can be as much as 100,000 dollars.

[Kathyj08]

I actually happen to be one of the few that does not have the ms label. I have had the procedure and have re-stenosed and looking forward to Dr. Sclafani doing my next procedure. The Drs. can't seem to find what my problem is. I think I will try and fight this one. Like I have been told though, even if they agree to pay, in the end they may refuse.
I heard (I don't remember who called me yesterday) that they were billing EXCLUDING ms in their codes but BS/BS was maybe putting things together on their end, which doesn't seem right.
Wow, newlywed, I am so sorry for what you are going through.

[newlywed4ever]

I am reluctant to copy the entire policy here as there is some clause at the bottom prohibiting electronic copying.... but here's the link:

http://www.empireblue.com/medicalpolici ... 136297.htm

[newlywed4ever]

I actually happen to be one of the few that does not have the ms label. I have had the procedure and have re-stenosed and looking forward to Dr. Sclafani doing my next procedure. The Drs. can't seem to find what my problem is. I think I will try and fight this one. Like I have been told though, even if they agree to pay, in the end they may refuse.
I heard (I don't remember who called me yesterday) that they were billing EXCLUDING ms in their codes but BS/BS was maybe putting things together on their end, which doesn't seem right.
Wow, newlywed, I am so sorry for what you are going through.

Kathyj - I would fight, too! My advice to you is to always document who you talk to, the date, and the jist of the conversation. For example, if BC/BS tells you something is covered, document it. I appealed a denial of covering my Walkaide because someone at Bc/BS told me twice that it would be covered and I could provide documentation of who and when this was told to me. They really do record those calls even though they usually state "your call may be monitored...". A letter from my attorney also helped. I wish you only the best.

[Cece]

I must say I am a bit startled that the procedure has been billed to insurance companies in the USA at a rate of 50 to 100,000 dollars.

I think the negotiated rate with insurance companies is around $9000. That'll vary between insurance companies and how it is billed.

Newlywed4ever, thanks for the posting that link.

This is as upsetting today as it was yesterday. There would not be this controversy if CCSVI weren't associated with MS (but still with the symptoms such as fatigue and cogfog and diminished colors that I certainly suffered and that were alleviated post-procedure).

If CCSVI and MS are separate conditions, treat them both. People with cardiovascular malformations elsewhere in the body are not expected to simply live with them.

[BooBear]

I posted my question on BCBS before I found this thread. Now I am just pissed.

So if the dx is not MS, are these still treatable conditions? Because I would hope that is the case.

I love that BCBS will pay for a drug that hurts my heart, but not for a procedure to fix my veins.