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My friend needs back surgery for a ruptured disk and other serious issues with her back.  She has had (2) recommendations for surgery from two surgeons.  However, the BCBS policy she has through the federal health exchange has denied covering her surgery.  She has had the back problems for a long time, but I didn't think they could deny her for pre-existing conditions anymore.  Or, is this just SOP for insurance companies to deny surgery so you have to appeal? She is really upset because she was waiting for ACA to get her back fixed.  Does anyone know where she can go to get help?

What was really disturbing is that her doctor told her she would be denied because her insurance was through the exchange.  He also told her that he only gets 5% of his fee paid from insurance through the exchange.  So the question is why would he accept her insurance at all?  Or, why would he do surgery on her if he knew he wasn't get 95% of his fee?  I don't know, it just sounded fishy to me that he knew she'd be denied.

Any guidance on where she can go to get help for an appeal would be appreciated.

Thanks.

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Comment Preferences

  •  What was the reason given for denial. They have to (4+ / 0-)
    Recommended by:
    VClib, worldlotus, denise b, Lujane

    give some explanation.

    It’s the Supreme Court, stupid! Followed by: It's always the Supreme Court! Progressives will win only when we convince a majority that they, too, are Progressive.

    by auapplemac on Fri May 16, 2014 at 05:59:44 PM PDT

  •  Where did this happen and... (4+ / 0-)
    Recommended by:
    ZenTrainer, AJayne, Lujane, Pluto

    ...what plan (bronze, silver, gold, platinum) did she pick.

    Here in California I have many doctor friends who may help.

    For profit insurance companies have an instinctive reflex to deny everything they think they can get away with.

    As time goes by it will become clear that Single Payer must be our final destination.

    Daily Kos an oasis of truth. Truth that leads to action.

    by Shockwave on Fri May 16, 2014 at 06:05:33 PM PDT

  •  call a navigator (6+ / 0-)

    One of the jobs of the healthcare navigators is to call hospitals, doctors, and insurance companies on this kind of BS. Give them a ring and see if they can clear it up.

  •  There is typically a therapy progression (7+ / 0-)

    The insurance company might have rules that require all therapies short of surgery be attempted and analyzed before surgery is approved. She should find out the most aggressive way to treat her back that is covered under her plan, and try that next.

    "let's talk about that" uid 92953

    by VClib on Fri May 16, 2014 at 06:17:45 PM PDT

    •  Yeah, and that isn't good medicine all the time (4+ / 0-)
      Recommended by:
      VClib, AJayne, Lujane, ybruti

      My partner hurt her knee.  The doc sent her for an xray (not that useful for knee injuries).  Didn't find anything so they sent her to Physical Therapy.  Kinda made everything way worse.  Finally sent her for an MRI, which found that she had 2 fractures, a shredded meniscus, and various other injuries.  The required PT made the damage worse.  

      All of these steps were required by the insurance (which is platinum level from Healthcare.gov), but if they had been more aggressive from the start, she would be way better off right now.  She is eventually going to have to have her knee replaced because of the damage.  And she had REALLY healthy knees before the injury, although severe osteoporosis probably contributed to the problem.  Of course they didn't consider that when they made her go through their progression of treatment.

      "The next time I tell you someone from Texas should not be president of the United States, please, pay attention." Molly Ivins

      by janmtairy on Fri May 16, 2014 at 06:33:49 PM PDT

      [ Parent ]

  •  Sounds more like reluctant/biased doctor (6+ / 0-)

    The thing with BSBC affiliates is that they usually requires really complicated coding for stuff.  It's possible that the doctor used the wrong coding (though quite impossible unless the nurse in charge of billing never dealt with BSBC) and is too lazy to try to sort it out.

    BSBC rarely denies common and necessary treatments.  They "might" deny common but necessary procedures (like the time when my mother requested to have her IUD removed through a simple procedure, her group plan denied it the first time, but paid for it after appeal).  However, I'd think a ruptured disk surgery is a pretty necessary treatment.

    As for the doctor getting only 5%... I'm just going to call BS on the doctor.  Looking through all my claims with BSBC of Alabama, the reimbursement is almost always more than 60% of what the doctor submitted, with some going as high as 80% (my colonoscopy had a $600 submitted charge from the doctor, and a $500 reimbursement total from my BSBC-Federal Exchange plan).  Tell your friend to look at the claims and reimbursement (or "Eligible Charges") for the doctor visits and services that was processed.

  •  Your friend needs to see another (7+ / 0-)

    doctor with a better attitude.  Seriously.  I am not joking.  I would not want a doctor operating on me with the attitude that she isn't quite worthy because he won't make any money off of her.  I'm not shocked.  There are a lot of really negative attitudes from medical "professionals" regarding the ACA.  Find one who can at least show a little compassion.  Greed, unfortunately, has infiltrated the medical profession too.  Doctors with that attitude shouldn't be practicing.  

    My brother was diagnosed with cancer in November, got coverage through the ACA for $19 a month, which covered his treatments.  His tumors (with fingers crossed) are gone, and his doctor and the staff were angels in human form.  I know they're out there.

    The GOP will destroy anything they can't own.

    by AnnieR on Fri May 16, 2014 at 06:49:22 PM PDT

    •  I want to know who told the friend her surgery (3+ / 0-)
      Recommended by:
      mumtaznepal, Pluto, AnnieR

      wouldn't be covered.  It sounds like it was the doctor rather than insurance company.  And it sounds like he's trying to discourage her from having the surgery because his contractual fee is lower than he would like so he won't make as much money as he would like on the procedure.

      Insurance companies negotiate the amount they will reimburse for various procedures.  One of the ways they held down premiums for in-network plans was to negotiate lower reimbursements, or fees-for-service with their in-network doctors.  ll insurance companies have these agreements with all their in-network doctors - they have for years.  That's why my explanation-of-benefits statement says my doctor charged $110 for my visit but the insurance only paid her $37.  That (plus my $10 co-pay) is the amount she agreed to accept in exchange for being in their network.  

      It sounds like your friend's doctor is having buyer's remorse over the reimbursement schedule he agreed to with this company.  So if the standard fee for this operation is, say, $8,000 (which nobody with insurance pays; they all have a negotiated fee structure), he will get 5% or $400.  He may be used to getting 7% or $560 per procedure.  Now he's blaming the ACA rather than the fee structure he's been a part of for decades.

      She should find another in-network doctor and as someone else said, she should call a Navigator.

      The past 50 years we: -Ended Jim Crow. -Enacted the Voting Rights Act. -Attained reproductive rights (contraceptive & abortion). -Moved toward pay equity. Republicans want to take our country back. I WON'T GO BACK!

      by petesmom on Fri May 16, 2014 at 10:49:01 PM PDT

      [ Parent ]

      •  It's not my friend, but I certainly (0+ / 0-)

        agree with what you have said.  And I certainly do agree that she needs to find another doctor.  I can't imagine a professional treating a patient like this.  

        The GOP will destroy anything they can't own.

        by AnnieR on Sat May 17, 2014 at 05:45:29 PM PDT

        [ Parent ]

  •  Oh, and just a commentary on the whole (4+ / 0-)
    Recommended by:
    worldlotus, tardis10, Lujane, mumtaznepal

    damn mess.  We've reached a point in this country where insurance companies and politicians are making our medical decisions for us.  We need to figure a way to return these decisions back to us and our doctors.

    The GOP will destroy anything they can't own.

    by AnnieR on Fri May 16, 2014 at 06:53:11 PM PDT

  •  Back surgery (10+ / 0-)

    is notoriously not successful, depending on the condition being treated and the specific type of surgery. The insurance company is not denying her due to it being a pre-existing condition but they are probably using a "proprietary medical criteria." Which is BS but most insurance companies use some form or another of this type of criteria. Her best bet is to pick up the phone and call them. Most bc/bs licensees have patient adovcates that will explain it in laymens terms and advise on what hoops they will make her jump through to get it approved.

    The aca does require that the insurer offer an outside review of the denial, so if the surgery is the best medical option she should be able to get it approved.

    As far the doctor saying he/she only gets 5% that is complete and utter bullshit. To be "in network" with a payer she/he would have had to agree to a contract specifically delineating rates for procedures. Surely this doctor wouldn't have to agree to such a low rate. It may be lower for a bc/bs on exchange policy than the doctor agreed to for off exchange policies, as each "line" or "plan" from the payer often requires a separate contract with varying rates but nonetheless, the doctor agreed to it and is grossly breaching her contract by discussing her negotiated rate with a patient in way that disparages the insurer and attempts to influence the patients desire to have the procedure performed.

    I work in contracting and revenue cycle administration for a large health system so I am pretty well versed in these types of issues.

    Also your friend should inquire with the hospital about charity care. If it is a non profit, they are required to offer it and it's regulations require them to publicly post their freecare policy.

  •  This may actually be a simple and easily solved (4+ / 0-)
    Recommended by:
    AJayne, Lujane, mumtaznepal, bluenick

    problem if it involves a recently acquired health insurance policy that requires coordination by your primary care physician.

    If you have previously been a patient of a specialist and you have a pre-existing problem and relationship with that specialist, you may think that you can simply go to the specialist again and get treatment.  

    However, most health insurance that requires managed care by a primary health care provider, like a family physician, requires that the primary care physician (PCP) coordinate all specialist care you receive.

    This means, if a person newly acquired insurance coverage, that you must get your PCP to re-issue all of your referrals to specialist care before seeing those specialists....even if you have previously been seen before by the specialists during a time when you were not under your present health insurance.

    To fix this, have your newly designated primary care physician re-issue all of your referrals to all of the specialists and surgeons you previously saw.   This will not take long and it ensures that the specialist care will be reinbursed by your health insurance provider.

    If you don't do this, then there is no way for your new insurance to known that you were previously seen by these specialists.    Care by specialists that you arrange apart from what your PCP referred will probably not be reimbursed by your health insurance until you run through the PCP referral-to-specialist procedure.   Insurance companies will generally not pay anything on specialist care you arrange yourself with no PCP involvement.

    •  Very good point (3+ / 0-)
      Recommended by:
      LakeSuperior, Lujane, mumtaznepal

      about the PCP involvement. Especially if your friend has an HMO plan. They aren't as common anymore but I know several are offered on the exchange here.

      Tell your friend to remember that she pays premiums and the insurer works for her. Pick up the phone and ask. Most bc/bs licensees are non profit and slightly less greedy than most for profit insurers.

      I have negotiated many contracts with bc/bs licensees and they have always been very ethical and patient centered. Some people won't believe this, and I can only speak from my personal experience but I have never seen the games and tricks out of bc/bs that I have seen from some other big players, like UHC and Aetna.

  •  The only other problem that may be occurring (4+ / 0-)
    Recommended by:
    worldlotus, AJayne, Lujane, mumtaznepal

    is that if you are on Medicaid, then certain doctors may not be participating providers....and you and your primary care physician will have to find a different surgeon to do the work that participates with Medicaid.

  •  There are some great comments in this diary (4+ / 0-)
    Recommended by:
    trillian, AJayne, Lujane, mumtaznepal

    I can't add much other than to underscore the importance of having your friend contact the company directly to get further direction. My own back surgery required a certain number of physical therapy sessions before the company would approve it.

    Also, the doctor is full of crap. Maybe after some exorbitant overhead is paid for he's getting 5% in his pocket, but this would be so far out of line with the contracts I've seen as to be almost certainly a fabrication. If not, he's the worst businessman in medicine, as he's getting about a tenth of the amount his colleagues are making.

    No, you can't fix stupid. You OUTNUMBER stupid. -Wildthumb, 1/10/2013

    by newinfluence on Fri May 16, 2014 at 08:09:11 PM PDT

  •  If you go see a surgeon, (3+ / 0-)
    Recommended by:
    Lujane, denise b, mumtaznepal

    don't be surprised if he recommends surgery. The denial may actually be valid.  What less invasive options has she tried?

    If you want something other than the obvious to happen; you've got to do something other than the obvious. Douglas Adams

    by trillian on Fri May 16, 2014 at 08:37:59 PM PDT

  •  Diarist has decided our help is of no use. (3+ / 0-)
    Recommended by:
    Villanova Rhodes, mumtaznepal, TopCat

    I suggest diarist never wanted our help to begin with.

    We are all in this together.

    by htowngenie on Fri May 16, 2014 at 09:44:18 PM PDT

  •  If it's new insurance (1+ / 0-)
    Recommended by:
    bluenick

    she may need to document what conservative measures she's already taken. Ruptured disks usually get treated with physical therapy, anti-inflammatory drugs and time before resorting to surgery. I think it might be routine to deny surgery until the need is clearly established. If she's already done these things, her doctor should be able to make the case for her. If she hasn't, perhaps she should. And if she hasn't had a second opinion she should do that.

    I had surgery for two ruptured disks, but only after months of PT. They wouldn't even do an MRI until I'd continued to get worse with rest and anti-inflammatories.

    Back surgery isn't something you want to do unless all the alternatives have been explored. Although my surgery was successful, I've always wondered if I rushed into it; I have limited range of motion now and the fused disks cause problems in the ones above and below them. Surgeons are generally eager to operate, and didn't want to wait for a second opinion because I was in so much pain.

    I don't believe this has anything to do with the ACA and I'm certain it's not because it's a pre-existing condition. She needs to talk to BCBS and find out what's going on. And yeah, the doctor sounds fishy.

  •   The "policy she has through the exchange" (0+ / 0-)

    Well, the exchange has nothing to do with the policy.  It's the insurance company and the doctor.  A private insurance company.  The exchange is only the marketplace. The government doesn't get involved.

    I don't see how a doctor can identify which policies were purchased directly from a company by going to their website, vs going through the exchange which simply forwards you to the company website.

    Medicare-Medicaid - different issue.

    I suspect this diary is bogus.

    "Privatize to Profitize" explains every single Republican economic, social and governing philosophy. Take every taxpayer dollar from defense, education, health care, public lands, retirement - privatize it, and profit from it.

    by mumtaznepal on Fri May 16, 2014 at 11:53:03 PM PDT

  •  Sounds Very Familiar ... (0+ / 0-)

    I signed up with BCBS through Covered California in November back when no one could say for sure what doctors would be preferred providers. But I had to have insurance by January 1st, so I went with BCBS because I figured EVERY doctor signed on with them, right?

    Oh, so wrong. I had no doctor appointments until March of this year. What was my complete shock when I went to see my cardiologist ... and discovered that he was not a preferred provider. Quickly I did some research ... and found out that half of my doctors AND my local hospital all refused to take the Covered California BCBS policy! Fortunately, I had 3 days left before the end of the open enrollment period. So I did some very intense research, found a non-exchange policy that was accepted by all of my doctors, applied and was accepted. Thank god.

    I have a theory here ... pure speculation on my part. So many doctors appear to be refusing to sign contracts with BCBS on the exchange ... I wonder if their reimbursements are so low and the hassle of dealing with them is so great that many doctors just said "to hell with them"?

    I have to admit, the paperwork I saw in the short time I was with BCBS was truly awful. I'd get 2-page memos ... sent in TRIPLICATE. And a visit to one doctor generated an 8-page document full of crap (for lack of a better word!). No, I am well and truly relieved to be done with BCBS. I will NEVER use them again.

    "Long term: first the rich get mean, then the poor get mean, and the rest is history." My brother Rob.

    by Pat K California on Sat May 17, 2014 at 05:07:55 AM PDT

    •  In Minnesota BCBS had more than one plan (1+ / 0-)
      Recommended by:
      Pat K California

      offered and the cheapest silver plan has a very narrow network and the more expensive silver plan with a $3K deductible has their full network covering 90% of physicians and all hospitals.  They may be trying different things in different states.  

  •  What kind of surgery? (0+ / 0-)

    Does the surgeon want to perform kyphoplasty, and the insurance company doesn't cover it?

    What other efforts have been made to alleviate the symptoms?

    Physical therapy, pain blockers, steroids, and other things might provide relief without the risks (and for back surgery, low success rate) of surgery.

    How debilitating is the problem?

    Is it bad enough for surgery with a moderate success rate to be induced?

    What is the likelihood of success from the surgery?

    See above.

    In other words, is the actual procedure medically necessary?

    Those are all questions that have nothing to do with a preexisting condition.

    Done with politics for the night? Have a nice glass of wine with Palate Press: The online wine magazine.

    by dhonig on Sat May 17, 2014 at 07:29:46 AM PDT

  •  ACA QUESTION - RESPONSE (0+ / 0-)

    Thank you all for the great responses; I can always count on the Daily Kos community to help!

    My friend has a silver plan on the exchange; her premiums and deductibles are over 90% covered because she is currently unemployed.  She is not eligible for Medicaid or Medicare.

    She did receive a notice from the insurance's doctors explaining why they turned down the fusion procedure; they also offered other procedures that they would cover.  And the way the wording was written on the denial of the fusion, it seemed to imply that the doctor would simply have to confirm that the procedure was required as her spine became unstable once the disk was removed during surgery.  Bottom line is I believe (and hope) if she can get a hold of a patient advocate at BCBS she'll be able to work through any issues in order to get her surgery.

    Thanks again for the wonderful support!!  

    •  In other words, most of the diary (1+ / 0-)
      Recommended by:
      bluenick

      was either not true or misleading. You might keep that in mind when the next "friend" tells you an ACA story. I know I do.  

    •  So they didn't really deny her... (1+ / 0-)
      Recommended by:
      Villanova Rhodes

      Their medical criteria obviously has procedures that they have deemed as more successful and/or less risky. Sounds like this has more to do with the dr than bc/bs. All they are asking for is letter of medical necessity from the doctor that probably outlines why fusion is being recommened rather than something less invasive/risky.

      I would bet that this doctor gets reimbursed much better for he fusion than something less radical but he knows he shouldn't risk his license and send the insurer a fake letter of necessity.

      Have your friend go to a doctor with more scruples that is more concerned with healing instead of dollars.

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