More UHC.....

As I have noted in the past, UHC has denied payment for my last surgery. It has been resubmitted numerous times and still denied. After Maria's article was published, I contacted Cheryl Randolph, the PR exec from UHC quoted in the article via email, regarding my claim. I cc'd a few other PR people at UHC as well. I got no response. I sent another email to the same group of people this week, but signed it with my credentials (thanks Maria!). When I got home from work today I had a message from Linda @ UHC regarding my emails.

I called the number and got UHC corporate offices...ooh lala! Linda is a consumer advocate, she told me I would need to appeal the decision. What I explained was that I didn't see the need to do this since the procedure had already been paid for 3 previous times. She was stumped. Regardless, she said to write an appeal and send it to her, and she would expedite it and get it to the right people. And to make sure I stated that it had been previosuly paid for.

I don't know if in the end this will help me or not, but it pays to be the squeaky wheel...someone is going to listen...or get really annoyed!

FML

That pretty much describes the way I am feeling right now. I am having a lot of discomfort in my joint, and have felt my hip "shift" or "sublux" or "de-stabilize" or something multiple times. I am not a happy camper to say the least. I had PT today and my therapist is very concerned about this. He thinks that my femoral head is sitting anterior, which is why I don't have full hip flexion, and why I am so unstable. It is anterior because I have nothing restraining it, I ruptured the ligamentum teres on that 'fateful' June night, and he is pretty sure that my capsular shift was ineffective. He thinks that most likely my capsular tissue was no longer of good quality and just couldn't hold the repair.

That leaves me beyond upset, angry, sad, disappointed.....3 fucking surgeries later and I still have pain. He told me not to give up yet....he is not giving up yet. At this time I am really inflamed so I can't do much of anything. He was also palpating around my ASIS/AIIS and found swelling...he is not sure why but thinks that something there is also very inflamed and irritated. Fabulous.

I am to do one exercise for now. Lying on my back with my knees bent, push my hands into my knees and hold for about 10 seconds. This is to activate my abs...which have most definitely shut down. I iced with the gameready afterwards...it felt great. He wants me to rent one for now but I know I won't use it! It is bags of frozen vegetables for me!!!

He also thinks it may be helpful to get an active fluoroscopy of me bending forward to see exactly what is happening in the joint, and to get an idea of how 'fixable' I am!

Back To Work!

Well, the party had to end at some point I guess, and it was back to work for me yesterday! Work itself went well, it was extremely busy and I had a ton of paperwork, but I managed! Yesterday morning I had what I have come to call one of my "episodes", where I will be doing something and my hip feels like it is subluxing. It usually happens when I am bending down to get something from the floor. It really hurts and is really disconcerting, especially after having surgery to stabilize my hip. I had on and off pain throughout the day, at periods I had no pain at all and others I had excruciating pain. Today was the same, on and off pain throughout the day.I am extremely frustrated with this and was hoping that by 3 months I would be past this. Tomorrow I have PT so hopefully we can work on stabilizing me a little bit and avoid this.

Good News For One Reader

Whenever someone posts a comment on my blog, I get an email about it, even if it is an old post. I was thrilled to get this comment today from Tim on the post about UHC's new FAI ruling:

"I just had my 2nd level appeal hearing with UHC today. Great news! They called back within 15 minutes and have agreed to pay for the surgery I had last September"

Congratulations Tim!!! I hope to get more news like this very soon from many readers!!!

Overcoverage, Undercoverage...Why Can't I Just Get It Right!

I have been totally slacking on the blogging front and once again apologize. I just feel the need to be done with hip shit once and for all.
I am totally done with my original PT and now on to PT #2, who works closely with my OS.

I have been having some feelings of instability, especially when I bend down quickly. Also, I went sledding on Sunday and walking up the hill killed me the next day. I had a lot of groin pain and got really nervous.

I told PT #2 that I really want my full hip flexion, on top of the other things that are going on. He said that one of the issues is that my capsular shift is not doing what its supposed to do, and my hip feels "sloppy", when he externally rotates it there is almost no end feel, it just flops. He also felt that my femoral head was too anterior causing it to jam up into the joint, so he wants to try some things to reposition it. He ended up taping me into a little pelvic anterior rotation to try to get more coverage of the femoral head. After a few hours I had a lot of back pain so had to remove it. We are going to work on some exercises from now on to get that back into place.

He also worked on some muscles trying to get my hip flexion increased. There is a spot on the inside of my leg where the adductor meet the VMO that is incredibly tender, he worked it so hard but it increased my ROM...not without leaving behind some nasty marks though!

I go back to work on Monday...I am nervous about it...I will keep you posted!

Take That UHC

Many many thanks to fellow hipster Maria, who is paving the way for the rest of us to have our claims paid. Below is an article she was interviewed for in the New York Times. As you can see, the article quotes Cheryl Radolph, VP of PR at UHC, who says "the company is now rethinking things once again because of "the changing landscape of medical literature" about the procedure"

Funny, because my surgery was not covered, and the reason UHC gave me is that "This Service Is Unproven And Is Not Covered. Therefore, No Benefits Are Payable For This Expense. In Order For This Service To Be Considered For Coverage, Scientific Evidence Must Be Submitted, That Meets The Standards Described In Your Benefit Plan Language, That Demonstrates The Safety And Effectiveness Of This Service For Your Particular Condition".


Fighting Denied Claims Requires Perseverance

MARIA CARR, a 43-year-old school administrator from Tulare, Calif., could not believe it when her insurer, UnitedHealth, denied coverage for arthroscopic surgery she underwent last year to treat a bone spur on her hip.

Her doctor told Ms. Carr he had successfully performed this procedure for eight other UnitedHealth patients suffering from the same ailment in the same year. To Ms. Carr’s mind, arthroscopy seemed a much less invasive and cheaper way to treat the problem than open hip surgery, the traditional treatment for bone spurs.

“When the denial came I was shocked,” Ms. Carr said, “but I figured I’d just have to find a way to pay.” The total bill for the hospital and surgeon fee was $21,225.

Ms. Carr’s form of shock is all too common. The Department of Labor estimates that each year about 1.4 billion claims are filed with the employer-based health plans the department oversees.

Of those, according to data collected from health insurance industry sources, 100 million are initially denied. In simpler numbers, that is one of every 14 claims.

But Ms. Carr, whose hip pain ceased after the arthroscopic surgery, did not give up on the reimbursement. And neither should you. When Ms. Carr, a special education administrator at a local charter school, read her explanation of benefits statement more carefully, she spotted some instructions on how patients can appeal denied claims.

“I decided I would fight,” she said. “After all, what did I have to lose?”

Ms. Carr researched medical journals and other publications to find proof that her procedure was a bona fide and safe treatment. She then wrote a formal letter to her insurer making her case and including copies of the research she had found. Her doctor backed her up with a thorough letter of his own.

The appeal was initially denied, but Ms. Carr kept fighting. She took her case to her insurer’s external review board, where an impartial medical expert weighed the evidence.

The expert agreed with Ms. Carr, saying UnitedHealth had to pay the claim. “The expert felt UnitedHealth couldn’t call the procedure experimental if it paid for other patients to have it,” Ms. Carr said.

UnitedHealth ended up paying $12,282 for Ms. Carr’s claim — at a rate the insurer negotiated with the doctor and hospital. Ms. Carr’s share was about $500.

“That’s what the appeals process is there for,” said Cheryl Randolph, a spokeswoman for the insurer. “We’re glad it worked for her, and we encourage members to exercise their right to appeal whenever they need to.”

Not that UnitedHealth now happily pays all such claims. Soon after Ms. Carr’s successful appeal, the insurer revised its policy to stipulate that it did not cover that type of hip procedure — although Ms. Randolph says the company is now rethinking things once again because of "the changing landscape of medical literature" about the procedure.

Whatever the treatment or procedure a patient receives or is contemplating, a variety of things can prompt a claims denial. It might be a simple clerical error, like an incorrect address, or a doctor’s use of the wrong diagnostic or treatment code for your treatment.

Then there are the more serious causes — as when a treatment is specifically excluded from your policy, for example, or, as in Ms. Carr’s case, when the insurer deems a procedure experimental and therefore ineligible for reimbursement. Other frequently denied claims involve emergency room visits, especially those at out-of-network hospitals and clinics.

Another big category involves chronically ill patients, who often must try several medicines and treatments to find the one that works best for them. Such patients can become all too familiar with insurance denials, says Jennifer C. Jaff, founder of Advocacy for Patients with Chronic Illness.

But as Ms. Carr discovered, if you are denied coverage you have a right to appeal. And in most cases, experts advise you to do just that. Approximately half of all appeals are successful, according to anecdotal evidence from patient advocacy groups and data from individual states.

“About 53 percent of appeals work in our state,” said the Kansas insurance commissioner, Sandy Praeger. “That demonstrates that the process works.”

Use the following advice to increase your chances of success in appealing a health insurance denial. As you’ll see below, expert help may be available. And if you feel in over your head, and a significant amount of money at stake, it may even be worth hiring a type of specialist known as a billing advocate.

READ YOUR POLICY Always check your policy carefully before you undergo treatment.

Many denials are made because the policy specifically excludes coverage of a certain treatment, procedure or medicine, Ms. Praeger said. When it is spelled out that something specific is not covered, an appeal will not work.

TAKE YOUR TIME When you decide to appeal, do not act in haste, advises Ms. Jaff, of the patient advocacy group.

Most insurers allow a certain amount of time to file for an appeal, usually 60, 90 or 180 days. If you call and say I want to appeal, an insurer may consider that the appeal itself. So you want to take advantage of the time you have (without missing the deadline) to build your case.

Before you file, make sure you have all the information you need from your insurer to start your appeal in earnest. Your explanation of benefits should provide a code for the reason for the denial, and that code should be translated somewhere on the statement. If it is not or if you still have questions, contact your insurer.

Make it clear in your phone call or letter that you are not officially starting the appeal process. You simply have questions. If it is not already clear, you should also ask exactly to whom the appeal should be sent. (You do not want precious time wasted because your appeal was shuffled from desk to desk. )

Whenever you call your insurer, be sure to make a note of the time and date and the person you talked to. If you send a letter, send it registered mail with return receipt, and keep your own copy.

DO RESEARCH Once you learn why your claim was denied, customize your appeal to argue specifically against that reason. A clerical or coding error is fairly straightforward, but just to be sure, enlist the help of your doctor’s or hospital’s billing specialist to back you up with a letter explaining how the mistake was made.

Something more complicated, like an out-of-network emergency claim, will require proof that the situation was indeed a medical emergency and that no in-network provider was available. Obtaining your medical records can help support your argument, so can letters from the doctors who treated you.

Fighting a denial for something your insurer deems experimental can be the trickiest appeal. In addition to support from your doctor, you will need to find articles from established medical journals for evidence that the treatment is not only effective but safe.

You can find abstracts of many articles free on pubmed.gov, the library of the National Institutes of Health. Often the abstracts are enough to make your point. If you need the full article, which can be expensive, ask your doctor’s office for help or check with a local medical school library.

Any proof you can show that other insurers in your area cover the treatments in question can be valuable. Most big insurers list medical policies concerning treatments on their Web sites. Your doctor’s office can probably help with this, too.

You also must prove the medical necessity of a treatment, especially if it is considered experimental.

Ms. Jaff, for instance, learned this when she was denied coverage for a certain drug her doctor prescribed for Crohn’s disease. Her insurer argued that other, more established drugs could treat the problem. True enough, but Ms. Jaff had already tried those drugs without success.

For her appeal, Ms. Jaff collected her medical records that showed when she had tried each drug and how each had failed. The strategy worked, and her claim was ultimately paid.

Be sure to stick to the facts in any argument you make. Emotional or angry arguments, as much as they may feel warranted, will not help your case, said Erin Moaratty, who heads special projects for a group called the Patient Advocate Foundation.

GO THE DISTANCE Even if your well-researched and thorough appeal is denied, do not give up. You still have options, depending on the type of insurance you have.

If you receive coverage directly from an insurance company, say through a private policy or from your small or midsize employer, your insurer is regulated by your state’s insurance department. All but five states, Alabama, Mississippi, Nebraska, South Dakota and Wyoming, allow patients to have their appeals considered by an independent external review board, usually after all internal appeals have been exhausted.

In most cases the board consists of doctors and other professionals with an expertise in your condition. For more information on your state’s rules contact its department of insurance. To find yours, go to the National Insurance Commission’s Web site and click on your state.

Large employers that self-insure — meaning that they pay medical claims themselves, not through an insurance company — are not subject to state insurance laws. But most have provisions for external appeal reviews. Check your plan summary, the large booklet you received when you signed up for health care, for details.

GET HELP Your state insurance department can help answer questions and start an appeal. In addition, groups such as Advocacy for Patients with Chronic Illness and the Patient Advocate Foundation help seriously ill patients file appeals free.

Be sure to check the advocacy organizations for the illness you have. Many offer free advice on dealing with health insurance disputes with specific information related to your condition.

You may also want to seek help from a medical billing advocate (see our earlier column “A Guide through the Medical Wilderness”). Depending on the case, these professionals charge an hourly fee or a percentage of any recovered claim.

My PT Dilema

I told a little white lie today at PT! I told my PT that I went with my friend to her PT and he gave me some exercises to try and some manual techniques to try.

At this point, I am 9 weeks out, the back pain is a lot better just since I have been doing the exercises I got yesterday at "secret PT" and since the "secret PT" worked on my hip.

My complete exercise routine is as follows: Upright Bike, Leg press, single leg press, squats on 2 dynadiscs, sidestepping squats with a theraband, standing hip 4 way with theraband (both legs), squats on a foam roller, seated isometric hip abduction and extension, seated knee flexion with theraband, seated knee extension with 2# weight, seated hip IR with ball and theraband, sidelying hip abduction and end range hip abduction, clam shells, bridges, quadruped hip extension.

My 3 new exercises are: 1)supine, operated leg straight, other leg bent with foot flat, theraband around both knees, operated leg doesn't move, other leg abducts/ER (fall outs) 2) double leg bridge, hold, pick up non-op leg, hold 2-3 seconds, bring it down, raise it again for 2-3 seconds, bring it down, repeat 10 times, then slowly lower bridge maintaining pelvis level. 3) standing on op leg only, bend forward by hinging at hips until torso parallel with ground, keep standing leg straight, arms out to side, slowly bring one arm down to your center and return to start position, repeat 10 times, alternating sides.

My PT is only stretching me and not doing a lot of manual work anymore, there are days when I really need it. the "secret PT" did such a great job on me yesterday, I am considering going back to him. Once I go back to work things will be complicated, but I would rather be complicated for a bit than not well healed. If only P, my original PT were still at my practice I wouldn't have these issues!!!

Secret PT Visit: Part 2

Today was my follow up with my "secret" PT. I most likely will not be seeing him again, but he has been able to give me some great advice. It seems that my back pain is coming from muscle imbalances, mostly my glutes are super weak. He gave me 3 exercises to do for the next 10 days to activate the glutes and hopefully get me stronger and out of pain.

What's great is that immediately when I exercise, my back starts to feel better, so I know that by "waking up" my glutes, I start to move and function better.

In general my back has been better, I have increased my exercises in PT and added a few more challenging ones, and I had my back worked on 3 times last week. I still "spasmy" but definitely getting better.

I have to say that I know I post a lot less than I did for my previous surgeries, but life with 3 kids just wears me out, and by the time they are in bed, I am usually ready for bed too! I am still not back at work yet, but do find myself busy all the time. I plan on returning in 3 weeks. I will be working my regular, part time hours. I agreed to cover someones maternity leave in another office. It would be managing the office and working three 12 hour days....I hope I don't regret it!!