Bad and good news

[blakesmom]

First the bad news, or I guess frustrating...I got my explanation of benefits for Blake's surgery yesterday and about fainted...insurance will definately get appealed for this one, they denied $18,000 of Blake's surgery (they only covered not even $4,000) I just broke down and had a pitty party for me after that one. I will be calling them tomorrow and starting the appeals process, I've never had any trouble with them paying for his other 2 surgeries so now I'm in a state of confusion. I halfway expected this, but what a bomb to drop!!!

ON A LIGHTER NOTE....TODAY WAS BLAKE'S FIRST DAY WITH HIS CAPS/BICEPS LENGTHENING SPLINT OFF AND IT WAS GREAT!HIP HIP HOORAY!!!It was so nice to see his arm so straight and hanging down to the side like his unaffected arm. We started out in the warm water pool this morning for an hour and a half and he didn't let it down much. We put his splint back on and we took it off again for his bath and he kept it off for 3 1/2 hours!! He let it come down to his side and he said "look mommy, now rightie looks like lefty" it brought tears to my eyes!! He is very proud of how natural his arm looks now, won't bend his elbow yet, but I know he will eventually, it scares him. WHAT A GREAT DAY!!!

After I saw how proud he is of his arm, I don't care if insurance pays another penny, it is all worth it to see that million dollar smile!!!Thanks for listening...

Crystal S.

anyone have any advice that has gone through the appeals process? Any is appreciated!! Thanks

[Joann in PA]

Crystal...We just got our explanation of benefits for our sons December surgery. It sounds like the same difference in what was charged and what was paid. There has been a difference for the past surgeries but never anything so vast! I was wondering what would happen with this one too... When we got the preapproval we were told our hmo would pay 100%. Someone told me that because our hmo is affiliated with bluecross/blue shield that they have acceptable amounts already worked out with the providers and that is what is paid and accepted. I sure hope so! This is our sons fourth surgery and after every other surgery the difference in what was paid vs what was charged has been sent to a collection agency by the billing dept but eventually it has always gotten figured out via our insurance company. It is so nerve wrecking though!!!! I'd be interested to hear what you find out. God bless.... joann

[NancyP]

What timing. Friday I went to the mailbox and got a letter from TCH saying that we owed 6600.99. I just about flipped! Our insurance pre-certified everything, and George at TCH said they had worked out fees and everything. Dr. Nath took a huge write off! I called my insurance company, and they have not ever gotten a bill for that amount. Then a call to TCH, blah, blah, blah. I get so tired of the whole mess. We all always struggle for something that never should have happened in the first place!

[francine]

Hi - first of all congratulations on the post splinty 'look' !!! This is just great! I wish Blake an easy rehab and hope that things keep on going forward. What a blessing!!

About the insurance company stuff - We have Aetna US Healthcare and they work out in advance what the acceptible amounts are and TCH has to accept it as their provider - it's not much honestly.

If you hit a wall with the insurance comapny that you just can't get through - contact www.patientadvocate.org. I just got a pamphlet from them and they do this sort of fighting for you.

Good luck - stay strong!
-francine

[blakesmom]

3days before surgery George at TCH called and told me to expect about a $6000 difference for the caps surgery and I called insurance and of course they said TCH is overcharging and that to go ahead with surgery and they would have to send it to medical review. So o.k., I expected some of this and I asked what if we have his bicep done and she said "no problem, we'll take care of it" now we have an $18000 difference instead of $6000. UGH!!!

Blake is doing wonderful day 2 and this morning asked first thing to take his splint off. He is working on 5 hours now with no splint. Get this, he put his arms forward and touched his palms together and said"the doctor screwed up, now my rightie is longer than my left arm" of course it is because of his shoulder sloping, but is is very proud and so am I. Thanks for all of the responses. Still no bending at the elbow!!