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Thread: For Anyone Having Issues with Insurance Denial

  1. #1
    Join Date
    Sep 2003
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    For Anyone Having Issues with Insurance Denial

    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Dilbert
    I'm sarcastic... what's your super power? --Unknown
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    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation
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  2. #2
    Join Date
    Mar 2010
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    Thank you, Linda. I'm not having trouble with denial of surgical coverage, they just flat out won't let me get a second opinion.

  3. #3
    Join Date
    Aug 2010
    Location
    Florida
    Posts
    225
    Thank you, Linda. This ought to be a "sticky" on the forum, if you know what I mean.
    Stephanie, age 56
    Diagnosed age 8
    Milwaukee brace 9 years, no further treatment, symptom free and clueless until my 40s that curves could progress.
    Thoracolumbar curve 39 degrees at age 17
    Now somewhere around 58 degrees thoracic, 70 degrees thoracolumbar
    Surgeon Dr. Michael S. O'Brien, Baylor's Southwest Scoliosis Center, Dallas TX
    Bilateral laminectomies at L3 to L4, L4 to L5 and L5 to S1 on April 4, 2012
    Foramenotomies L3 through S1 in August 2014

  4. #4
    Join Date
    Jun 2011
    Location
    Southern CA
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    Quote Originally Posted by rohrer01 View Post
    Thank you, Linda. I'm not having trouble with denial of surgical coverage, they just flat out won't let me get a second opinion.
    So your insurance plan wants you to have a very expensive surgery without a second opinion?
    Melissa

    Fused from C2 - sacrum 7/2011

    December 8, 2014 - Another Broken Rod Surgery

  5. #5
    Join Date
    Nov 2011
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    6
    Quote Originally Posted by rohrer01 View Post
    Thank you, Linda. I'm not having trouble with denial of surgical coverage, they just flat out won't let me get a second opinion.
    Rohrer, You are in Madison right? We are too and are having the same problem. Grrr. Let me know if you get anywhere.

  6. #6
    Join Date
    Mar 2010
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    2,755
    Quote Originally Posted by mjpj View Post
    Rohrer, You are in Madison right? We are too and are having the same problem. Grrr. Let me know if you get anywhere.
    I don't live in Madison, but my insurance will only let me see Dr. Tribus, who is in Madison. I like him as a person, but as a doctor he seemed quite forgetful, at least the last time I saw him. I was very frustrated and left in tears. He wants to wait until my curve is at least 60* even though I am in pain and progressing. I'm not quite sure what my measurements are, as the radiologist said I had progressed and measured me less than the Dr. did. Yes, my insurance will pay for surgery when Dr. Tribus gives the okay. NO second opinion allowed. I think that's just crazy!

  7. #7
    Join Date
    May 2012
    Location
    El Centro, CA & Baja California, Mexico
    Posts
    193

    no second opinion - not expesive surgery

    Quote Originally Posted by mabeckoff View Post
    So your insurance plan wants you to have a very expensive surgery without a second opinion?
    You see that these are smalll insurances (as all of them are about making money). They will not allow a second opinion because they have to pay all over again and in your case you can do it but with out of pockie.

    The surgery is not that expensive, the bill tends to be around the $1M mark that is produced by the hospital is only paid a very small piece as per their agreemen a contracted amount.li
    Gardenia
    Baja California, Mexico & El Centro, Ca
    pre-surgery 75 and 89 - post ?
    Dr. Bridwell Nov 27, 2012 @Barnes Jewish @62yrs
    T11 to Sacrum Dural leak at L2 & L3 ccmail4g@gmail.com

  8. #8
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    May 2009
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    3,745
    i do not understand...how is a million dollars
    not expensive....????? don't the insurance companies have to
    pay a hundred thousand...at least...?

    jess

  9. #9
    Join Date
    May 2012
    Location
    El Centro, CA & Baja California, Mexico
    Posts
    193

    $1M in hospital billing

    I might not understand your question, Jess.

    The hospital gets billed $1M (adding different stuff, including an aspirin at $25 years ago for my mom at the hospital) The contracted amount is sometimes as little as single digit percentage. I have been billed so far for xrays, visits, labs etc and the amounts negotiated is amazingly low.

    Now, if one does not have insurance then you pay the hospital bill. Or, you live with the pain.

    gardenia
    Gardenia
    Baja California, Mexico & El Centro, Ca
    pre-surgery 75 and 89 - post ?
    Dr. Bridwell Nov 27, 2012 @Barnes Jewish @62yrs
    T11 to Sacrum Dural leak at L2 & L3 ccmail4g@gmail.com

  10. #10
    Join Date
    May 2009
    Posts
    3,745
    i was saying that a million dollars is a lot for surgery....
    i do not know of other surgeries that cost more than
    that...
    the fact that insurance companies get away with paying
    a small percentage of the bill, to me, doesnt change the
    fact that the total cost of scoliosis surgery is very expensive...

    jess

  11. #11
    Join Date
    May 2012
    Location
    El Centro, CA & Baja California, Mexico
    Posts
    193

    I just read it somewhere

    It is not only for the surgeon but the operation room, anesthesia, monitoring of the spinal cord, tests, xrays, hospital stay, etc.

    Yeah, it seems high but I have also read that the insurance ends up paying like $200K average. And, I was quoted that a gram of the BMP is very costly when you need multiple amounts.

    I wonder if people who had recent surgery would add up and share their billed cost versus the negotiated cost.
    Gardenia
    Baja California, Mexico & El Centro, Ca
    pre-surgery 75 and 89 - post ?
    Dr. Bridwell Nov 27, 2012 @Barnes Jewish @62yrs
    T11 to Sacrum Dural leak at L2 & L3 ccmail4g@gmail.com

  12. #12
    Join Date
    May 2009
    Posts
    3,745
    yes, i realize it includes everything...
    i do not know how that price compares to open heart
    surgery, for example...
    if someone does not have insurance, scoli surgery
    is prohibitivly expensive

    jess

  13. #13
    Join Date
    May 2012
    Location
    El Centro, CA & Baja California, Mexico
    Posts
    193

    United Health Care pre-authorization DENIED- REVERSED!!!!!

    UPDATE: Dr. Bridwell upon my plead, called the insurance for a Peer to Peer appeal. Got UHC to reverse and approve my surgery. Thanks everyone who responded in sympathy.

    I had started looking at different places with different techniques and demanding the insurance to give me a list of approved methods and surgeons (fortunately did not get there).

    I was going to complain about the high cost of having the OPEN CHOICE when actually I was not going to be given any choice. But Thank You all for your prayers for saving my back and my impending war with the insurance company.

    I am now Scheduled for Nov 27th after the doctor office erased my name off the schedule...

    ----------0-------------

    Well, I just got the expected call this morning.

    I called my insurance and the next step is a PEER to PEER call, I got an indication that BMP denial is very hard to reverse. But, I am not giving up....
    Last edited by gardenia; 09-18-2012 at 11:57 PM. Reason: Status Change
    Gardenia
    Baja California, Mexico & El Centro, Ca
    pre-surgery 75 and 89 - post ?
    Dr. Bridwell Nov 27, 2012 @Barnes Jewish @62yrs
    T11 to Sacrum Dural leak at L2 & L3 ccmail4g@gmail.com

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