View Full Version : I'm mad as hell and.....
05-16-2002, 11:26 AM
Well my ignorant insurance company has struck again. The following is why we must continue to teach the public that there is a potential for a cure and we aren't happy little plegics content with our lot in life.
Received a note from my insurance company that they won't pay for my standing walker. They said "it was a convenience and not medically necessary." I was so mad I cried. I suppose they would prefer I sit in this chair until my legs atrophy. So I said to myself, "I'm mad as hell and I not going to takes this anymore." I'm going to write the Chronicle again and by the time I'm through Humana is going to wish they had never heard of me. I am just thankful that I can pay for the walker myself. I worry, however about those out there who can't. I guess you could say I have a bee in my bonnet.
Everyone please continue to write, write, write and send it to as many publications as possible.
Debbie do you have a lawyer? You were in a Car Accident right? If you don't have a lawyer, get one! You will get nothing but bullshit and grief without one.
Without a lawyer you get 100% of NOTHING. With a lawyer you get 80% of SOMETHING. Which do you want?
I've seen my Insurance Company try to pull some unbelievable things. 100% illegal and wrong and all it took was a letter and threat from my lawyer... magically 2 days later everything is approved, money is in the bank, etc.
05-19-2002, 09:37 PM
Debbie, do you have a letter of medical necessity from your doctor? If so, skip the lawyer. You are already paying for a congressman and 2 senators at the national level. Call all 3 and also call and make an appointment to meet with your state representative and senator/s. You can get at least one to come to your home. And make a copy of EVERYTHING and copy it to your state's insurance commisioner. HMOs have to answer all complaints filed with the state commission and they just hate people like you. http://sci.rutgers.edu/forum/images/smilies/biggrin.gif Go get em!!
05-19-2002, 11:30 PM
Husband is C4 incomplete (walking), accident 23 Feb 02. We have been told by Blue Cross/Blue Shield (Federal Employees Program) that our policy does not have benefits for inpatient rehabilitation, as they consider that to be skilled nursing - which is only paid out in the inpatient setting if we already have Medicare Part A. So, they will pay the hospital only for his therapies, up to the limit of 50 PT and 25 OT ... as of the beginning of May all our outpatient therapy benefits have been exhausted (hmmm, coincided with his discharge) and any therapies through the end of this calendar year will be out of pocket.
I sympathize with you. I believe that the only ones who realize how bad things truly are with our system are the ones who need it, and find that it isn't there. Having worked in health care "quality improvement" for fifteen years, I know I honestly had no idea what it was like to be on this side of the fence ... until this happened to us. It is deplorable that health "care" has sunk to this level. It isn't possible for me to straddle this fence any longer. Something has got to be done, and I am royally pissed.
05-20-2002, 01:57 PM
Germany, I got a second inpatient rehab stay 2 years after my first on the FEP. Because this is federal no state insurance commissioner can help you. You have to call your US senators and representative. Are you trying for inpatient in Germany? If so, talk to the patient representative at the rehab and get an estimated cost of stay. That will give you wiggle room since rehab is much cheaper in Germany than here (US). As long as a doctor orders the stay who is a member of the plan, you should get your stay. And even if you have Medicare Part A the FEP is first payer then Medicare and last TRICARE (if you are also retired military). Your FEP book should have the info on Medicare in it. And the disabled person does not get Medicare until the 2nd anniversary of getting SSDI. And I'm not too sure that Mewdicare will pay for care in Germany even if you are there as a member of our government. Normally it only covers costs in the US and Puerto Rico.
05-20-2002, 04:45 PM
I intend to fight Humana as much as possible. Read the info on this thread from some very knowledgeable, caring, people and good luck.
05-21-2002, 12:02 AM
The denial by BCBS is not based on any clinical findings or a cost analysis - merely the "fact" that our policy has no benefits for inpatient rehabilitation - even though it was ordered by a doctor at an approved facility (yes, German). The IP denial was for my husband's first and only rehab stay following acute care (also at a German hospital) and he was discharged two weeks ago. We are civilians, not retired military - and access to many of the speciality clinics (including neurosurgery and physical medicine) at Landstuhl RMC (Army hospital) are closed to anyone except active duty right now because of medical staff shortages. You are very correct that his stay at a German facility was much less expensive that stateside, as charges at the German hospitals are based on a per diem rate for the nursing ward he was on - no individual charges for each pill or pad or catheter, etc. His stay at the rehab hospital cost 13,000 Euro (just under $13,000), at a charge of 400/day that included absolutely everything - all meds, beds, two separate hours of PT each day, one hour OT, treadmill, swimming pool, gym, massage ... anyway, I am not sure how to fight against something that really is clearly stated in my FEP booklet "skilled nursing benefits are only paid if policyholder has Medicare Part A" - and we don't and we won't ... although his cord was crushed between C4-C6 his remaining deficits just 3 months post injury are primarily upper body weakness (bilateral - used to bench 120lb dumbells and now barely the 15 lbs ones)), mostly sensory loss (left side) but also motor loss in his hand and fingers (right side) - the worst problem right now is pain and he is being treated with Valoron-N and just started Neurontin. Every doctor he's seen (and there have been many) says he shouldn't even be alive, much less walking and functioning as well as he is .. so you won't see many complaints from me, just a lot of empathy for everyone else. Anyway, thanks for the help from you, and Debbie. Later, Beth
05-21-2002, 11:16 AM
When I came through Landstuhl on my way back to the states there was no neurosurgery/neurology ward. I was in orthopedics but still had a neuro for care. The place was due to close and they had RNs cleaning floors. Nice to see they've got funding again.
I don't get why they would consider rehab as skilled nursing, Beth. I understand why they would want to--means they don't get hit with long term nursing home care. Are you standard BCBS or the new "basic" which is more like an HMO? I'll try to find my book because I had no problems with them paying for 4 months inpatient at a civilian place once we flew home on one of the Nightengale flights at Ramstein. We did have a case manager/RN working on coordinating all my care.
Well, I'd stick with the German system for outpatient if you can afford it. Inpatient rehab here runs about $15,000 a week depending on injury level. I just loved getting 2 one page bills for a 6 week acute stay over there. http://sci.rutgers.edu/forum/images/smilies/smile.gif One for the Luftwaffe evac helicopter and the other for the entire hospital thing and that started at the first small hospital, included a private clinic CT, ambulance to a 2nd hospital, all the time in ICU (different rate than the neuro ward) and then the rest of the time on the neuro ward and a private clinic MRI. We spend too much time in the US making sure each patient is billed only for their bandaids and asprin. Bean counters raise the costs of everyone. My total bill was $25,000 USD. I know that wouldn't even get me halfway through the 10 days in ICU over here.
Good to hear he's walking on his own. Hope things continue to improve.
05-22-2002, 01:35 AM
Sue - LRMC is now the primary hospital in this theater, since they closed Wiesbaden - we also get the transfers from ongoing conflicts on this side of the globe. Steve was initially treated in the ER at Landstuhl, but was transfered to Homburg because LRMC's one neurosurgeon was not on call at that time. Very good move, based on the (lack of) initial quality of care received in the ER. Regarding our FEP policy, we're Standard Option. According to the Director of the Overseas Division, the rehab care Steve received at Heidelberg required a special set of nursing skills above and beyond acute care - hence, "skilled nursing". Benefits in DC made the determination, even though his clinical care was being monitored by case management division in VA. Anyway, I'm requesting a review and will let you know how it turns out. Thanks! Beth
05-22-2002, 10:23 AM
Good luck on the review, Beth. I have the feeling some clerk got your first request and shoveled it over to regular nursing home care for extended stays--like an MS patient, no family and in need of caths, bowels, etc. I'd copy things to your home state US congressman too. I got mine busy when my PPO doc wanted me back in rehab, another PPO hospital, and the FEP said no. The congressman's help got me in and I stayed for 4 months. They're probably counting Homburg as a rehab because he did get PT and OT but I doubt it was the kind aimed at rehabilitation American style. How to live as a gimp. So he'll need to learn all the body stuff from turning, sores, how to cath (doesn't matter if he can go on his own), bowels, etc. http://sci.rutgers.edu/forum/images/smilies/wink.gif
We had this same discussion with insurance when hubby ordered a new chair, got a call asking why a cushion was needed, after all the chair had a seat in it. His pt has a strange sense of humor and sent the person at the insurance company 5 color pictures of massive stage 3 rear end pressure sores. The poor woman happened to open that one when she was eating lunch at her desk. The cushion was approved.
05-25-2002, 02:41 PM
Deb et al - Do you have your insurance company's complete explanation of benefits? If not, I would encourage you to do so; you have a right to other than just the summary of benefits that most consumers are given. You should read about durable medical equipment (DME)benefits (standing frame) and the appeals process. Your goal, with your doctor's assistance, should be to educate them about the unique 'medical necessity' as it relates to persons with SCI.
When applying for any DME it is most important to accompany that with a 'certificate of medical necessity'; this has a place to list medical problems, explain why a particular request is being submitted, the length of time a device is needed (continuous, life time for SCI). It is most important to use terms that do connote that there are medical benefits, i.e. therapeutic outcomes vs. 'exercise', etc. There is a good explanation of this at a site: www.wheelchairjunkie.com (http://www.wheelchairjunkie.com) , then go to 'Show Me the Money'. You can also find very useful guidelines re: appeals at www.patientadvocate.org (http://www.patientadvocate.org) CRF
05-26-2002, 01:02 PM
Just wanted to thank everyone for their suggestions. I found out from my old company that they purposely chose Humana and DME equipment just for me. I believe they will get it straightened out for me.
Thanks again everyone.