Am I good? Bad? Or is BCBS-TX just that slippery?

[jss]

I had a two level ADR in Barcelona in Nov 2009. BCBS-TX denied my request for reimbursement three times, citing a different reason each time.

Denial 1: They denied the initial request claiming that my surgery was not "medically necessary".
Appeal 1: I responded with a 68 page appeal chronicling my decade long struggle with cervical problems and citing the written testimony of five doctors that I'd seen in the prior year that all prescribed ADR.

Denial 2: BCBS-TX's reply to that appeal took three months and denied my request a second time, this time stating that multilevel ADR was "investigational".
Appeal 2: I reciprocated with a 100 page appeal in which I showed that multilevel ADR has a 19 year history which includes thousands of successful outcomes, and has been studied and discussed from multitudinous angles in dozens of clinical studies involving hundreds of patients and resulting in dozens of peer reviewed articles; all of which converge on the safety and effectiveness of multilevel ADR.

Denial 3: Today I received a denial of that appeal in which BCBS-TX simply states that "The medical review unit has reviewed the claim and has determined that the procedure does not meet our medical policy criteria." They could have retorted with, "Just because." It's the same thing!
Appeal 3: You'd better believe that there will be one!

Strangely I am experiencing some kind of satisfaction at three denials because each is for a different reason; implying that both of my appeals "convinced" the review board that their previous denial was unjust for the grounds that they cited. At some point they're going to run out of new reasons to deny and have to begin using the same reason over and over.

Oh well... I'm going to let their verbage ruminate for a few days and then get to work on appeal number three. If there is a place on this pig that is BCBS-TX that has not been smeared with butter fat, I'm going to find it! Do I know how to have fun or what?

[Researcher]

jss,

Who did you submit your appeals to? Did you try to recommendations of Laurie Todd? Below are BCBS-TX names I came up with quickly. The challenge is that these executives move around a lot and you need to do last minute checks before sending your appeals, so I can't guarantee that these are correct today. The point is that you can't just send it to the Appeal Department. You need to follow the rules in the THE PLAN and send it to the Appeals Department, but that is not who needs to read it. The execs below are the ones that need to read it, with a copy to the state medical association for accountability. They are the ones that sometimes file class action lawsuits against the insurance companies. Another thing; 20 to 30 pages max, no attachments. No one at BCBX-TX will ever read one word of an attachment, certainly not an executive. I can help with phone/fax/email information if you run into roadblocks.

Scott Serota
President & CEO
Blue Cross Blue Shield Association

Allan Korn, MD
Senior Vice President/Chief Medical Officer
Blue Cross Blue Shield Association

Darren J. Rodgers President
Blue Cross Blue Shield of Texas

Eduardo Sanchez MD, MPH
Vice President and Chief Medical Officer
Blue Cross Blue Shield of Texas

Dr. Allan Chernov
Medical Director, Health Care Quality and Policy
Blue Cross Blue Shield of Texas

Louis J. Goodman, PhD,
Executive Vice President/Chief Executive Officer
Texas Medical Association

A good place to start with for insurance industry contacts is Jigsaw.

See http://www.jigsaw.com.

You will have to join to see the whole BCBS Texas list (free to join). To get access to phone numbers, etc., you will have to spend some money, but it will be worth it. They do not always have all the numbers, but it's a good start. Here is a link to the BCBS Texas contacts. Pay attention to the date of the contact information. Always work with the most recent.

Blue Cross Blue Shield of Texas Inc. Company Directory of Business Contacts from Jigsaw

Another good place to look is the American Association of Preferred Provider Organizations. I can email you a copy of their member list. Just send me a PM.

Phil

[Justin]

Denial 3: Today I received a denial of that appeal in which BCBS-TX simply states that "The medical review unit has reviewed the claim and has determined that the procedure does not meet our medical policy criteria." They could have retorted with, "Just because." It's the same thing!
Appeal 3: You'd better believe that there will be one!

Strangely I am experiencing some kind of satisfaction at three denials because each is for a different reason; implying that both of my appeals "convinced" the review board that their previous denial was unjust for the grounds that they cited. At some point they're going to run out of new reasons to deny and have to begin using the same reason over and over.

Oh well... I'm going to let their verbage ruminate for a few days and then get to work on appeal number three. If there is a place on this pig that is BCBS-TX that has not been smeared with butter fat, I'm going to find it! Do I know how to have fun or what?

Jeff, this is beyond frustrating. I've been in your shoes before (appealing for insurance coverage for artificial disc replacement surgery). I appealed and had an "expert" of my choice on my side: I choose Dr. Fenk-Mayer (the orthopedic surgeon that works with Dr. Bertagnoli). She was "at" my appeal via phone from Germany and they still denied my case.

Unfortunately, those individuals involved in the appeal process have no idea what they are denying. They just know they have to deny, deny, deny. I hate to say this, but the nurses at my appeal were grossly unqualified to render a denial. I'm not even sure how they were able to sit on the appeal board.



The "expert" on the insurance side is paid a healthy kick-back (this is solely my opinion, of course) to deny cases. It's a very shady set-up.

Anyway, seeing your case and how hard you have worked for one appeal after another reminds me of my case. Don't let this appeal get you down. Your game plan to take a few days off is key. Clear your head and keep fighting the good fight. Please let me know if I can help or provide any materials you may need.

[Santorini]

JSS,
I admire your tenacity and hope that you keep at the appeals. It must be draining to compile all the data and write those appeals but they are counting on you to throw in the towel. Glad to read that you are not deterred. I've read so many people on other boards as well who are being denied by BCBS for procedures like fusions. Hard to believe really. I don't like the trend.
Researcher,
Thank you so much for all the helpful information you continue to post. You dig up some incredibly useful information!

[trkdoc714]

Jeff,

The appeal that got me partially reimbursed focused more on "look how much I saved you by not having fusion" and "did you know the success rate for ADR is over 85% while fusion is close to 60%?". This spurred a telephone interview with the investigator. She was uneasy telling me her background wasn't in Orthopaedics or Neurology. I think this fits the pattern for investigators. I doubt they use any type of reference other than the "easier to find" medical reference material.

Good luck on #4. I'm waiting for a decision on my #4 as well.

Bob

[mmarsh]

JSS

Just wanted to give you a thumbs up for all your hard work. At what point do you go to the insurance comissioner? Isn't there a max for appeals? Keep up the good work! I know how difficult it is to put in all the effort into the appeal and have an ENT deny it! How do the ins cos get away with these shenanigans? It would be nice if there were some actual oversight written into the ins bill! Best of luck!

M-

[helmut]

What BS, I am happy for you that you were able to have the surgery independent of such BS. At the end of the day you an make more money being healthy than what the surgery costs you. at least thats how I see it for my case.

[Researcher]

jss,

After reading everyone's words of encouragement, I felt guilty for taking my usual "here's how to fix your problem" path. I applaud your efforts. Hang in there. It's only by persevering together that we will ultimately win over the greed and selfishness in the insurance industry. Alabama just elected a conservative, retired physician as governor. I'm contemplating writing him a letter as soon as he takes office to see how he feels about the fact that BCBS has 80% of the Alabama health insurance market (and I am the furthest thing from a political activist you will ever meet!)

Phil

[Cindylou]

Yes, I know there has to be some limit on the number of appeals. My limit was 3 with HealthPartners. I wrote all 3 appeals as if I was tackling a thesis, read Laurie Todd's book, talked with her incessantly on the phone, and paid her to even help me write my final appeal. Along with my 3rd appeal, I asked for and received an "in person interview" with HR at my husband's place of employment to plead my final case. At the end of the day, I was still denied. Weeks later, out of the blue, the President of my husband's company called him into his office. They decided to pay for half the bill, our of compassion. He also was the one who paid for my roundtrip first class seat, so I wouldn't have to travel coach. I was eternally grateful for all that. However, that said, I was totally stressed out working on those appeals for so long and was relieved to finally put it all behind me. Jeff, some gentle advice, I do agree with Phil/Researcher....I would cut that appeal document in half. It's too long and no one is going to actually take the time to wade through all that. That's just my 2 cents....do what your comfortable with. Good luck with all your endeavors. Cindylou

[jss]

Phil, Justin, Santorini, Bob, MMarsh, Helmut, CindyLou,

I am truly overwhelmed and humbled with the encouragement, support, sharing of respective experiences and offers to help. Thank you all so very much.

I would very much like to hear your relevant experiences and words of advice. I am confident that I can write another "successful" appeal that will get BCBS-TX to respond with a fourth denial for yet another completely different reason. While that does give me some satisfaction, it doesn't get me reimbursed!

I read Laurie Todd's book back in February before submitting my first appeal, and I did use her formula, at least as I interpreted it. I deviated from it on this second appeal only in that I did not copy the appropriate BCBS-TX officials (I forgot all about that point). Thank you all for reminding me; and I will light up the appropriate fax machines this weekend.

Both appeals detailed with BCBS-TX's own numbers that I saved them just under 50% with the double ADR in Spain over a double fusion in DFW. Their thinking seems to be, "Well that's nothing, we can save 100% by denying!"

I do have all of the contact information to BCBS-TX executives on my company's access into BCBS-TX's web site. And I will be using them for my post-second-denial contact to those executives. And it didn't occur to me that my number of appeals might be limited. Thank you for that insight.

Having read all of the suggestions from you blessed souls, here's what I figure on doing starting next week, or maybe the week after;

- Visit with the CEO of my company (this coming Monday). We are a company of about 100 people and are nearing a decision on which insurance company to use next year. BCBS-TX is currently in the lead. If he's willing to make a phone call, it might make a difference.
- Send the appeal to the BCBS-TX executives suggested by Laurie Todd, and to the Texas Insurance Commissioner. It will be the original appeal less the 90 pages of peer reviewed articles (cited in the appeal). It will include a letter of my saga in which BCBS-TX has denied three times with a different reason each time.
- Find out how many appeals I am allowed.
- Re-read Laurie Todd's book, research BCBS-TX documentation that they have cited as grounds for denial, begin thinking about that appeal, etc...

Again, thank you all so much for your encouragement, suggestions and the benefit of your experiences. And please, for any of you willing to take the time to type in your experiences, suggestions and/or random ideas... I will be very grateful that you did and very happy to read and incorporate them into the next step. Any input is very welcome.

Thank you all so very much, Jeff