Get treated ASAP if you want insurance to cover it

[newlywed4ever]

carollevin - thank you so much for your suggestions and sample letter! I just got off the phone with BC/BS. Regarding a check that was issued to the provider 4/9/11 (which provider does not want to accept because the payment is $5300 rather than $10,000), the rep called Empire BC/BS. The rep also told me that because the provider is an approved provider, they should never have required payment up front. By contract, the provider is required to reimburse me for payment. She will follow up and get back with me next week.

Also, I did not refer to the Medical Policy and the BCBS rep did not refer to it either. (good news?)

bluesky - thanks for reminding me I, too, had to fight to get reimbursed for the home births of my daughters - 30 & 33 years ago...I won that fight!!!

[WeWillBeatMS]

Blue Cross Blue Shield has stopped paying for CCSVI treatment.

Cece, can you please verify for all of us whether this is for all 39 independant Blue Cross Blue Shield companies?

So far, I have only seen proof that Empire BCBS, which is strictly in 28 eastern and southeastern counties in New York. There are 4 different BCBS insurance companies in New York alone.

Below is a link for all 39 independant BCBS companies.

http://www.bcbs.com/coverage/find/plan/


WeWillBeatMS

[HappyPoet]

edit

[Cece]

WeWillBeatMS, you raise a good point, I don't know yet either. I am under the impression that AAC is no longer taking any BCBS regardless of which one it is. But I heard that someone whose BCBS was turned down at AAC may still be able to get it accepted at another provider in another state.

[carollevin]

Newlywed,
That is great news!.... I had a feeling something was "amuck"....Your experience with the reimbursement just didn't make sense.....What I don't understand though is why BCBS only reimbursed $5200 instead of the whole $10K, unless you had a large deductible or large copay or AAS didn't do the coding correctly to cover all the procedures, etc? I think most likely AAS may have done the coding wrong--but this is just a guess....

I think you are going to continue to have to get BCBS reps involved to get your reimbursement. I have had to do that when I overpaid docs and they didn't send the overpay back, despite my repeated requests to the doctors' offices. I think sometimes it is the fault of the billing departments at the doctors' offices, not that the docs are trying to rip us off..... In my case in the past on two unrelated medical issues, as soon as BCBS called the docs offices at my request because I had overpaid the doctors, the docs sent me the overpays pretty quickly once they heard from the BCBS reps.....These doctors offices don't want to lose their affiliation with the top insurance companies, unless they are docs who don't take insurance.

I know that last year when I had surgery on an unrelated issue (unrelated to CCSVI or MS), BCBS reps repeatedly told me that an in-network provider who provides a procedure is not allowed to bill the patient--except for copays or deductibles. And they even told me if the claim is denied, it falls on the provider (doctor) to be responsible to eat the costs of the procedure, for the doctor/provider is the one who felt it was medically necessary and that this is contracted through the in-network provider status and that there is no way I could be held responsible for the bill, as long as the doc was in-network. I can't verify for sure this true, but this what I was told in regard to the unrelated surgery.

It seems that possibly is it only AAS that is not accepting BCBS right now because of Empire BCBS's statement on April 12. I have yet to see a statement from BCBS that they are no longer reimbursing for CCSVI. I have only seen the statment that BCBS feels it is not medically necessary--this could just be the preliminary steps they are taking to eventually decline it. The "May 3rd effective date thing" I head through an AAS doc, so that may not be correct.. I have not heard it from BCBS directly.

I am sorry you are having to go through this stress to get your reimbursement but I do think eventually you will get all the money back other than any copays or deductibles you may have in your particular plan. I think you should continue to work with the BCBS reps on this matter. I know that is what worked for me in the past when I have had other issues, as I detailed above.

I am still waiting to hear from the insurance rep at the doctor's office in my state whom I am considering going to -- to verify whether my state's BCBS coverage for CCSVI/MS is affected or not.

Anyway, I am glad I could be of help to a couple of people here. It makes me feel really happy that I could give some suggestions that could possibly help others.

[carollevin]

I meant AAC, not AAS above. I am still trying to understand all these terms and acronyms.

[Cece]

In a google search of key words from the Empire BCBS medical policy document, the same document turned up in Anthem of California and Anthem of the Central Region medical policies. (The latter says their policy goes into effect July 3rd. Links posted in other threads.) I also found it on a page that seemed to be a national Anthem page.

I searched under UnitedHealthCare, which is my own, and there's nothing yet. Here is the link for UnitedHealthCare's medical policy update page. It is updated every month on the 1st. I will be watching UHC closely.

http://www.unitedhealthcareonline.com/b ... 007740dc0a____

[carollevin]

Great detective work CeCe!

It sounds like BCBS is moving in the direction of denying this, but as to which if any BCBS plans have actually put the denial into effect is still in question. I am not even convinced it is in effect in New York yet. I haven't seen an official "effective date" for NY, I only heard about it from one of the AAC offices.

In my state there are seriously at least 20 or more BCBS plans, although I imagine once it goes though here in my state, if it hasn't already, it will be throughout the state. And probably eventually national at least for BCBS.

As others have mentioend, we now have to make the decision whether to "rush" into treatment to get covered in time, or not rush because in years to come we may not be covered for restenosis or to a lesser extent the minority who have complicaitons could have trouble with coverage.

[1eye]

This is an example of how a promise to "do no harm" can assume an immense irony. The ones who are doing the most harm here?

Every dollar counts! Don't let any get away! We'll soon see just how fast those limping wheeling 'patients' can get to the operating table now! Bwa hah hah hah!!!

Oh, did someone rush things a little? Tsk. Tsk. Never hurry when you are disabled. You might fall, and then look at all the paperwork!

No pressure. Hakuna matata.

[carollevin]

Dear 1Eye,
I am not sure I understand your post. Do you mean that you think we should rush in before insurance cuts us off -- In this case ,my concern is that if I have multiple restenoses and the insurance is cut off at that point, my family could end up in serious financial hardship, affecting not only me but my whole family. I suppose if the success rate was 100% for CCSVI treatment, it would be worth it, but as we know, at least 1/3 do not get results and as many as 50% restenose.

As an aside, I was thinking that if we do go through our insurance and coverage is denied there is usually an option to ask the doctor or hospital for a "write-off" or a low monthly payment like $50 per month to prevent being sent to a collection agency-- especially if a family can show that they do not have a huge annual household income......

I hope this doesn't become a treatment for the wealthy only.

[1eye]

Hi. I was never a fan of rushing. I think it unconscionable that pwCCSVI are being issued this kind of bureaucratic fatwa to save money by refusing to treat people who have been diagnosed with the pre-existing condition 'MS'. I am sympathetic with you who have not yet been treated, as I am with the people in my country who have been marginalized and refused treatment that would be given by default to a stray animal, merely because they have had the temerity to go outside country and the neurological money-net. And also because they have been diagnosed with the invisible arm-tatoo 'MS'.

There have always been a wealthier few who could afford the more expensive versions of this treatment. Not I, I'm afraid. I have been lucky so far: 7 1/2 months without a restenosis I know of, and bill paid in full.

If it were available in Canada, our feds and provinces would not be paying no $20K for it either. Dr. Sandy MacDonald has told us that. There are still new frontiers being crossed, by people like Dr. Sclafani who is getting his hands dirty with real plumbing. The scary thing to me is that all the commerce and economics, politics and law going on, may actually prevent a key discovery from being made, and we will be left where some people might prefer us to be: in the 1960s.

Whether it's worth it, the potential is there, but the decision is yours. I think it beats Las Vegas odds, but it depends on your own circumstances. Breathe deep while you decide...

[anamishguy]

I am having issues with my private insurance after they pre-certified the procedure.

What a scarey thread title Cece! Since it sounds like it is confined to BCBS, why scare the b-gee-sus out of everyone?
People should not be encouraged to rush for treatment, under any circumstance.

[newlywed4ever]

WeWillBeatMS - the way I understand how BCBS works is if you are from out of state and go to Dr Sclafani (for example), your BCBS claim is handled by Empire. I say this because I have BCBS/State of Mich and the paperwork had to go through Empire BCBS of NY. If you have a little suitcase on your BCBS card, you can receive treatment anywhere in the USA but different offices/agencies handle it.

carollevin - you are a jewel and I thank you from the bottom of my heart for your kind & caring insights. I had no copay or deductible that had to be met. What I believe happened is that:
1) AAC made the wrong call when they insisted I self-pay
2) Because I had to pay up front, they charged me the discounted $10,000 price - even though I pointed out to them that they would benefit financially if they billed BCBS and I would guarantee payment if BCBS refused to pay
3) When I asked for an itemized bill to submit to BCBS, AAC showed the figures to add up to $10,000
4) BCBS never pays the full amount; therefore, they cut a check to AAC for $5300.
5) Under contract, providers have to accept the reduced amount from BCBS as payment in full
6) My suspicion is that AAC did not want to reimburse me the whole $10,000 so they kept giving me different excuses as to why they had not reimbursed me.
7) When the "horrid medical policy" came out, AAC then decided that would be the reason they would not reimburse me and told me "to fight it out with BCBS" (again, my opinion).
My last contact from AAC was an email telling me that I had to self-pay because I was unwilling to wait for pre-authorization. WRONG! I had been dealing with AAC and billing for 3 months prior to procedure. I believe this was a CYA (cover your ass) tactic.
9) BCBS gave me hope when the rep was quite outraged that they did not reimburse me as they are under contract to do so as an in-network provider (like you mentioned, carollevin).

My perception is that AAC screwed up royally. The very sad result is that I practically hero-worship Dr Sclafani and would not intentionally hurt him. Unfortunately, AAC billing made the mistake that I am not willing to pay for (literally).

And the most devastating thing of all is that the medical policy hurts hundreds of thousands of us.

[carollevin]

CeCe,
I'm glad I could be of some help to you.

Your theory about what happens sounds very logical and it certainly seems AAC screwed up. This is not to fault the IRs, as it is usually the case that an office manager or billing department handles these things. What nerve for them to tell you that you had declined to wait for the pre-authorization. I have over the years (because I have several medical conditions) have had to deal with similar things -- albeit smaller amounts of money -- where it got to the point that the doctors' offices tried to put lies or blames on me for their billing screw-ups. Some of it is also just simple incompetence, as well.

Anyway, I hope you are able to get the whole $10K back and not just the $5300. It sounds like maybe AAC is going to have to rebill BCBS the standard billing way and get their negotiated rate from BCBS and that AAC will have to reimburse you the $10K. As I've been saying I think you're actually going to have to use BCBS as your advocate on this -- as much as that sounds like an oxymoron.

I have a state plan that has no suitcase on it and doesn't say Empire. I think I'm just going to go ahead and use an IR in my state who is in my network and I don't expect to have problems, especially if I get in soon. But I will investigate beforehand.

By the way, to my understanding, the insurance policy should go by the "date of service" and not be the date the claim was submitted. So don't let anyone try to give you the runaround on that issue either.

Let us know when you get your money back and without stepping on toes here, I hope AAC will step up and do th right thing.

[carollevin]

I mistakenly wrote:

"CeCe,
I'm glad I could be of some help to you.

Your theory about what happens sounds very logical and it certainly seems AAC screwed up. This is not to fault the IRs, as it is usually the case that an office manager ..."

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

Oh boy my brain fog must be very bad today. I meant to write to "Newlywed," not to "CeCe" -- and I meant to say your theory about what "happened" with the AAC billing sounds very logical