help with insurance

[admin]

I am trying to get in network benefits for my daughter to have the trianle tilt. Is there a sample letter or does someone have one that I could get some ideas on. The insurance is asking me why we are going to Texas when there are doctors in Ky that treat this. I just wanted a good letter to fax them. Thanks in advance for any help. Feel free to email. Kim

[jennyinsandiego]

has she had any treatment from Houston before? They have always approved our traveling based on continuity of care. Also in our case (for the first surgery) our primary care doc was very supportive and went before the board of doctors that approves this sort of thing. It was a bunch of local docs (who didn't know you could operate)the insurance companies use to approve referals and the like. Good Luck...it can be a full time job. Even after paying for 3 surgeries and however many other procedures, the insurance subrogation dept is still trying to put a lien on her settlement (even they have no right to it in our state) What a headache!

[admin]

I'm very curious how anyone is able to get insurance to pay for the triangle tilt. Most insurance plans exclude "experimental or investigatory" treatment and have requirements for a treatment to be considered "proven". It doesn't sound like the triangle tilt meets any of these requirements.

[admin]

My insurance paid 100% of the surgery without a problem.

[BIGJAVSMA]

While I consider us very lucky to have the insurance plan we do have. They paid for primary at MCH and therapy with no questions asked. I still get forms from them asking if anyone can be held responsible for these bills. Like a car accident or workmans comp. I told them no it wasn't a car accident and Jody couldn't have been hurt on the job. Our lawyer told us to send him the letters, what a lot of people don't know is that once your insurance pays for something, you DO NOT have to pay them back, in most states. As far as getting coverage, I would try calling the docs in TX and asking for help. Also get a case worker at you insurance comapany. That way everytime you call you can speak to the same person.
Good Luck.

Oh, and ask them if there is any BPI specialist that they will cover. Maybe you could look into other docs. If that is an option for you. I know how hard it can be to finally pick one and then have to change.

MArlyn mom to MAnny 6 and Javier almost 2 ROBPI

[BIGJAVSMA]

I just remembered something else... There are 2 docs in VA that do primary, one only accepts cash and the other did an eval on Javier and recommended Miami or TX instead. He was a neurosurgeon, but not a BPI spoecialists. Maybe you could try going to the local docs and getting them on your side.

MArlyn

[admin]

I ASK FOR A CASE MANAGER AND WAS DENIED. HOW CAN THEY DENY A CASE MANAGER? THEY SAID THAT ONE WAS NOT NEEDED. I EXPLAINED HOW MANY PEOPLE I HAVE TALKED WITH AND HOW MANY DIFFERENT STORIES I HAVE HEARD, BUT I DIDNT MATTER.

[ptrefam]

Our neurosurgeon wrote a letter to our insurance saying he did not do bpi surgery. That Dustin would need to go to Mayo in MN. Since there was not an inhouse Dr. that specialized in BP we were approved. Maybe your drs would do that for you?
Sue

[Allison]

Null, there is nothing new about the procedures included in the triangle tilt.
They include osteotomy, ostectomy and capsulodesis. All three procedures have CPT codes and are FDA approved.

The biggest problem I have encountered in helping families out is that many employers
are reducing their costs by giving their employees low-end health insurance policies that don't
allow for out-of-network physicians. Families with the higher-end policies don't
have these problems and the surgery is usually paid for at 100%.

There are many families that have successfully negotiated with their employer's human resources
and insurance broker to pay an additional monthly fee to have a higher-rated policy.
Once that's done and out-of-network benefits are re-established, the family's problems
in getting insurance to cover surgeries completely goes away.

Null, I am appalled and personally insulted that you wrote this inflammatory post about the very doctor
that gave my son amazing results. Freedom of speech allows you to write whatever you want, but let me
tell you that what my child had before and what my child has now are light years apart.
Anytime you are in Allentown, PA, feel free to visit and see for yourself and then maybe afterwards you can
post more respectfully.

[katep]

Allison,

Just because CPT codes exist that can describe a procedure does not mean that it has proven results for the condition being treater or is medically necessary, two things that most insurance plans require for reimbursement.

Say I have carpal tunnel, and my doctor wants to treat it with a forearm osteotomy. It is unlikely that my insurance is going to pay for it because, even though forearm osteotomy is an established procedure *for some conditions*... carpal tunnel is not one of them.

Kate