Here I linked to an article in the times that discussed Medicare’s decision not to cover ADR surgery in patients over 60. As it turns out, this is not good news for ANYONE needing ADR, and possibly even fusion. Here’s why.

During my last check up, Theresa mentioned that the pace of their surgery schedule has really slowed as many/most insurance companies are now not paying for the type of surgery I got, that is, ADR combined with a fusion. They’ve narrowed the range of what is covered by adding the stipulation that there can be no other existing conditions, so if a patient needs ONE disc replaced and that’s it, ok. People like me who needed a fusion and a new disc would be shit out of luck. Thank goodness that I got my surgery when I did, as I can’t even think what the outcome might have been if I’d had to wait for even a few more months.

On top of that, I’ve been reading with interest the health care proposals of the three leading democratic presidential candidates (Clinton, Obama, and Edwards). They all seem to include/favor the formation of some kind of “institute” that would research the most effective treatments for the most common (read:expensive) health care issues.

From the NYTimes:

"Along these lines, the three leading Democratic candidates have quietly come up with nearly identical ideas. Deep inside their health care plans, Mrs. Clinton, Mr. Edwards and Mr. Obama have each called for the creation of a national institute to figure out which kinds of medical care actually work. This institute would sort through the scientific research on, say, spinal fusion and help people understand when it may make sense and when it’s likely to be just another big medical expense that doesn’t solve anything."

As back pain is one of the major health care costs, lumbar fusion and I suppose ADR, though the article didn’t specifically mention it, would be researched for their efficacy. Apparently there are some studies that show that fusion is, in some cases, no more successful in treating back pain than other methods. While this is true, and I'm not advocating that anyone and everyone who requests a spinal fusion should be able to get one, I am afraid that the insurance companies will seize on any study that supports a conclusion that means they don’t have to pay for a procedure. The Times article goes on to state that Medicare and the insurance companies would then use the research to “determine when a procedure or a drug would be covered” (read: they’d use the research to deny coverage).

Of course, this is all just my opinion, and wouldn't it be nice if I were proven wrong, but if there's anything I've learned in the past year or so, it's that insurance companies are pretty predictable when it comes to cutting what they cover and putting more of the insurance premiums we pay into their own pockets.

Medicare Denies ProDisc Coverage

From today's Times: This is not good news.

Health Careless II

Got a call from someone named Melissa, Melinda, Melanie, whatever, some minion of Maureen (yes, this tactless clerk has minions). She was calling to tell me that the claim that was submitted to Aetna for the three level replacement was ... wait for it ... denied. She started to tell me that if I wanted, I could appeal. That was when I stopped her.

"Listen, I think you are missing some information," I tell her. I explain that we already knew about the insurance company denying the claim, as we'd been notified last week when we got our online statement from Aetna, but we didn't sweat it because Dr. B. had just told us that he was resubmitting two new configurations to them that had a good chance of being approved (since we'd be paying out of pocket for some of it). I was more than a little concerned because

a) When we saw Dr. B. on the 25th, he said they were going to get to work on it "right away." A week later is "right away?"

and

b) Maureen and her posse are the ones that are supposed to be up on all the insurance company stuff! That's what they do, that's their job. How come they didn't even know that there had been a change to what was being submitted? It didn't sound to me like they were working in the same office I'd been in the previous Friday. It also didn't sound like any of the new configurations we'd talked about with Dr. B. had even made it to the insurance company yet.

MM (Maureen's Minion) shuffled some papers around and said she didn't have my papers in front of her (then why was she calling me? To recite the same gloomy crap she says to every one else?)but that she would "look around" and get back to me.

I hung up and called Theresa, Dr. B's NP. Normally I wouldn't call her, since she hates talking to patients, but figured I would get her voice mail and so wouldn't have to have any actual interaction with her and of course I was right. I told her that I'd been to see Dr. Balderston last Friday (like she hadn't seen me hobbling down the hall with my cane and looked right through me, yeah) and that we'd discussed resubmitting two new configurations of the surgery to the insurance company, and why did Maureen and her minions not know of it since they were the ones that were supposed to get working on it "right away" last week?

I also told her that she was to tell that whole office, Maureen and all of her minions, to lose my phone number, that the last thing I needed was these women calling with all this negative news on top of everything else. Just call me when you've got it together, ok? Why do I have to be reminded every step of the way that I'm being shafted by the insurance company? I gave her Tyler's number to call back as I'd just as soon not have her get back to me, adding that she didn't seem to anxious to talk to patients either.

About a half an hour later, Tyler gets a call from a very apologetic Maureen, saying that she had just gotten the paperwork (explaining the various steps in between my appointment and her and her minions) and that it would be submitted tomorrow. Since we are coming up on the December 6th date that Dr. B. had penciled in for my surgery, the absolute last date we could get approval and still make that date is this Friday, the 10th.

So now I'm in another set of knots waiting for Friday, wondering if they'll hear back from the insurance company in time so the surgery won't have to be delayed again, and if it does have to be rescheduled, let's hope, for all our sakes, that someone besides Maureen or her minions calls to let me know.

The Queen of Denial

Maureen should not be allowed to talk to patients.

As I said here, according to Maureen, my clain with Aetna will be denied/rejected/refused/disallowed/declined. Then once I get the letter saying a resounding and predicted-numerous-times-by Maureen "NO," I have to decide how I want to appeal. Of course, as you may have read in the last post, this news threw me into a panic. I don’t know the first thing about appealing anything to an insurance company. Do I get an attorney? I’ve seen this kind of thing in movies and on Dateline, no one wins appeals against insurance companies!

So I asked Tyler to call and see what he could find out; he always has better luck getting info. For some reason, none of the staff in Dr. B’s office seem neither to want nor be even slightly equipped to actually communicate with patients. He spoke with the ever elusive Theresa, Dr. B's NP, who tried to immediately transfer him back to Maureen. Once he was allowed to get a sentence out, here’s what she told him about the whole process:

Every insurance company is rejecting any claim for more than one level of ADR. Once they reject mine, Dr. B has attorneys that will handle the appeal and on top of that, he sits on a board that advises insurance companies about the need for surgery, so he's confident that he'll be able to get two levels. In addition, he has several different permutations of the procedure that I need that will get appropriate payment for the hospital (such as charging a bit more for one disc to help offset the cost of the second, etc.) so that I will be assured of getting the two discs I definitely need. If worse comes to worst, Tyler said that we will pay out of pocket for the second disc (buy those t-shirts, people!). It’s all very confusing, not made any less so by the machinations we have to go through to get someone who will actually take the time to look at the big picture and then explain it to us. I guess it is really too much to ask to have someone be a little encouraging and optimistic when speaking with patients who are terrified and in pain, unlike Maureen, the humorless Queen of Denial.

Update

I just had a call from Maureen. She said she heard from the "nurse" at Aetna and that they were sending my file to the Medical Director for review. What does that mean? Maureen said she would be "very very surprised" if the claim was approved because Dr. B. put in for a three level replacement. She said she has never ever seen any insurance company pay for more than one level.

So what's next? She said once they deny it, I'd get a letter saying so and telling me what the appeal process is so that I can proceed with my appeal. My appeal. I asked what that meant and she said that they'd sent all the clinical information to them and on the appeal it was up to me to say what I think the appeal should be. Then she hemmed and hawed and tried to get off the phone. Can anyone explain this?

I'm lost, and sick with discouragement.