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!
10 comments:
Hi Susie -
I didn't realize that UHC had paid for it previously. Were the previous 3 surgeries basically the same (in terms of insurance code etc.?) In my case UHC sounds like they'll pay for everything EXCEPT the surgeon...which makes no sense any way you look at it!
I'm begining my investigation of all of this now, even tho' my surgery hasn't even happened yet! I'm watching your blog daily to see if there is new UHC info.
Wish you all the best with your continuing recovery!
Becky
Becky, yes, they were paid for the first 3 times, this time all but the surgeon was paid for, go figure!!
Becky,
You can contact me as well (Susie has my email info). We have a sample letter with a good literature review.
It's very interesting because BCBS and Cigna for the most part pay for this surgery. My external review through UHC (paid by UHC) came back in June indicating that UHC needed to pay my claim for the surgery and that UHC was being unethical and arbitrary in their decision making process. It was shortly after that when UHC made a formal policy that they will not pay for any surgery (open or scope) to treat FAI.
you should post her contact info for everyone to have that needs it - we need to shake up the bloody health co's
Hi Susie, glad to see you've finally got someone who will do something for you! Good luck with the appeal, I wouldn't think they have a leg to stand on!
Sorry to hear of your recent troubles too. I'm hoping you and your brilliant physios can get to the bottom of things, it must be a huge let down for you and I really feel for you.
xxxx
Re: Insurance Woes-Hang in There, Help is on the Way!
As patients may or may not know, one of the reasons that insurers have been able to set up policy's stating that FAI surgeries are "experimental and investigational" is because there are currently no Level 1 CPT codes for hip arthroscopy. In order for Level 1 codes to be created, there needs to be a process (approx 2 years) for multiple committees to review & determine the need for the creation of new codes as well as the value (reimbursement) for each code. The good news is that the process for the creation of several new, specific Level 1 CPT codes for FAI (ie. code for cam, code for pincer) has been going on throughout 2009. It looks like the completion should happen this year (if all goes well & the new codes are approved) so that the new Level1 CPT codes will be included in the 2011 manual!
There are 2 carriers that recently changed their policies regarding FAI & now cover the procedure, Cigna & BC/BS, and if you google either and include "FAI" you will be able to access each policy which includes a list of the scientific publications that support the change. BC/BS actually provides abstracts for each publication (most are from 2008/2009) that you can use in an appeal letter with companies such as UHC to support the fact that your procedure is not "experimental and investigational".
Its unfortunate that there are insurers who will continue to hang on to their policies until they are absolutely forced to give them up when the new codes are created, but as everyone knows, the insurers are about profit and aren't going to voluntarily lose money.
In the meantime, keep fighting, appeal the denials to the end--the insurers know that w/each denial they will have to pay one less claim because there are people that will simply get frustrated and give up. Don't be one of those people if you can help it!!
STAY STRONG, STAY DETERMINED, DON'T QUIT.
Here is the link to the Cigna policy. It provides a lengthy list of publications, including the abstracts, that PROVIDE THE SCIENTIFIC EVIDENCE & SUPPORT for Cigna's change in policy to COVER FAI surgeries:
http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0485_hip_arthroscopy_for_femoroacetabular_impingement_syndrome.pdf
wow! thanks so much!!! This just helps with my appeal!
Full link to cigna, take out dashes
http://www.cigna.com/-customer_care/healthcare_professional/-coverage_positions/-medical/mm_0485_hip_arthroscopy_for_femoroacetabular_impingement_syndrome.pdf
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