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Thread: insurance coverage + shriners

  1. #1
    Join Date
    Jun 2012
    Posts
    15

    insurance coverage + shriners

    Well i called BCMH this morning (Ohio's government plan for children with chronic medical conditions). Unfortunately while a lot of his pediatric orthopedic colleagues are BCMH providers. the doctor Ashleigh is seeing is not one of them. Which means they would not cover any of her care if she continued to go to him. stinks!

    So i called our insurance company to see if i could get an idea on how much they would cover of her surgery and hospital stay. They said that the type of surgery she is having has to be pre-approved and considered a medical necessity. If it is pre-approved they would cover 90% of the care up to $10,000 and then 100% after the initial $10,000. She said the care would include the surgery, inpatient, labs, ect.

    First question: Has anyone had their insurance company deny the fusion surgery? If so what was the degree of your curves. And if they later approved it what were your curve degrees then. I'm just worried about the insurance co saying her curves aren't bad enough.

    2nd question is about Shriners. I know that you don't have to pay any money. But how does that work. Do they go through insurance companies and just pick up what the insurance won't cover, or do they not work with insurance companies. If the insurance company says 'no' to the surgery. Does that mean Shriners won't do the surgery, until the insurance co, approves it.

    Christina mom to 4 girls. Ashleigh-13 Scoliosis (3 curves C-20/30deg, T-55deg, L-45deg) & Type 1 diabetes.

  2. #2
    Join Date
    Jan 2007
    Posts
    228
    Quote Originally Posted by madileigh View Post
    Well i called BCMH this morning (Ohio's government plan for children with chronic medical conditions). Unfortunately while a lot of his pediatric orthopedic colleagues are BCMH providers. the doctor Ashleigh is seeing is not one of them. Which means they would not cover any of her care if she continued to go to him. stinks!

    So i called our insurance company to see if i could get an idea on how much they would cover of her surgery and hospital stay. They said that the type of surgery she is having has to be pre-approved and considered a medical necessity. If it is pre-approved they would cover 90% of the care up to $10,000 and then 100% after the initial $10,000. She said the care would include the surgery, inpatient, labs, ect.

    First question: Has anyone had their insurance company deny the fusion surgery? If so what was the degree of your curves. And if they later approved it what were your curve degrees then. I'm just worried about the insurance co saying her curves aren't bad enough.

    2nd question is about Shriners. I know that you don't have to pay any money. But how does that work. Do they go through insurance companies and just pick up what the insurance won't cover, or do they not work with insurance companies. If the insurance company says 'no' to the surgery. Does that mean Shriners won't do the surgery, until the insurance co, approves it.

    Christina mom to 4 girls. Ashleigh-13 Scoliosis (3 curves C-20/30deg, T-55deg, L-45deg) & Type 1 diabetes.

    Yes, that is a problem with CCS as well; they only pay for certain doctors. I can't answer your first question, but your second one is one you can ask Shriner's about directly. Just give them a call, they are very nice and will answer your questions over the phone. It is my understanding Shriner’s used to refuse insurance payments and were therefore able to focus only on what the patient needs--not on what the insurance company deems the child needs according to costs. Due to changes in the economy, they recently began accepting insurance payments, but they still provide treatment whether your child has insurance or the company agrees to pay for the treatment. There is no out-of-pocket payment at a Shriner’s Hospital. --Anyone, please correct me if I am wrong.

    Now if someone can help her with her first question?

    A Mom

  3. #3
    Join Date
    Jan 2008
    Location
    Oregon
    Posts
    1,163
    Hi,

    First, I truly doubt your daughter's surgery would not be approved as a medical necessity--as I recall her largest curve is 55 degrees, right? So I would not be too worried about that. You may be able to call your insurance co and find out the specific criteria for surgery to be covered (ie curve over 40-50 degrees etc).

    As far as Shriner's, they bill insurance and accept whatever payment is received as payment in full. They do not seek pre-approval or anything beforehand, as far as I know (at least it was that way 2 years ago when my dd had surgery). In my daughter's case, her procedure, VBS, was not covered, but my insurance co. paid over $17,000 of the $30,000 charged just for the 10 staples. You will never see a bill from Shriner's.

    I agree with AMom to just call Shriner's billing dept and speak to them. They are very willing to help you, and I think you will find that Shriner's simply does not work like other hospitals. As AMom stated, they do whatever is best for the child, and worry about the costs later. If your daughter needs the surgery they will do it regardless of what your insurance co says. Your daughter would receive top-notch care there. You might also want to talk to Family Assistance if you need help with travel/lodging costs if needed.
    Gayle, age 50
    Oct 2010 fusion T8-sacrum w/ pelvic fixation
    Feb 2012 lumbar revision for broken rods @ L2-3-4
    Sept 2015 major lumbar A/P revision for broken rods @ L5-S1


    mom of Leah, 15 y/o, Diagnosed '08 with 26* T JIS (age 6)
    2010 VBS Dr Luhmann Shriners St Louis
    2017 curves stable/skeletely mature

    also mom of Torrey, 12 y/o son, 16* T, stable

  4. #4
    Join Date
    Jun 2012
    Posts
    15
    Thanks i was going to call or e-mail, but there I wasn't sure which number or E-mail to use. I'll look and see if I can find one for billing. The closest orthopedic shriners hospital is 2 hours away, which isn't terrible. I need to call or e-mail and also see if they have the knowledge and equipment to deal with a child with type 1 diabetes. She would need BS monitoring during the surgery and of course her insulin needs would need to be adjusted after the surgery, so she doesn't drop low (worried about the no food after the surgery. We use fast acting sugars to bring up low blood sugars).

  5. #5
    Join Date
    Jan 2008
    Location
    Oregon
    Posts
    1,163
    Hi,

    I would be really surpised if they couldn't deal with the diabetes, but you definitely have a right to be concerned. Don't worry about when she can't eat, they can easily give IV dextrose solutions when needed. I remember another woman whose neice had type I DM and had spinal surgery, and she did just fine. She uses an insulin pump, and as I recall was allowed to use it post-op.

    I would recommend calling the main hospital number and ask to speak to the Care Coordination department, and see if they can help you get your questions answered. You can also find an application on the main Shriner's Hospitals page, and you can fill it out and send/fax it directly to the hospital nearest you. You do not need a sponsor who is a Shriner, just leave that part blank.

    Best of luck,
    Gayle, age 50
    Oct 2010 fusion T8-sacrum w/ pelvic fixation
    Feb 2012 lumbar revision for broken rods @ L2-3-4
    Sept 2015 major lumbar A/P revision for broken rods @ L5-S1


    mom of Leah, 15 y/o, Diagnosed '08 with 26* T JIS (age 6)
    2010 VBS Dr Luhmann Shriners St Louis
    2017 curves stable/skeletely mature

    also mom of Torrey, 12 y/o son, 16* T, stable

  6. #6
    Join Date
    Aug 2004
    Location
    ny
    Posts
    1,809
    Quote Originally Posted by leahdragonfly View Post
    As far as Shriner's, they bill insurance and accept whatever payment is received as payment in full. They do not seek pre-approval or anything beforehand, as far as I know (at least it was that way 2 years ago when my dd had surgery). In my daughter's case, her procedure, VBS, was not covered, but my insurance co. paid over $17,000 of the $30,000 charged just for the 10 staples. You will never see a bill from Shriner's.

    I agree with AMom to just call Shriner's billing dept and speak to them. They are very willing to help you, and I think you will find that Shriner's simply does not work like other hospitals. As AMom stated, they do whatever is best for the child, and worry about the costs later. If your daughter needs the surgery they will do it regardless of what your insurance co says. Your daughter would receive top-notch care there. You might also want to talk to Family Assistance if you need help with travel/lodging costs if needed.
    All true, Gayle. Even if an insurance carrier deems a surgery unnecessary, that will not change the course of the care the child receives at a Shriners hospital in any way, shape for form, nor will it cause any delay in receiving treatment. The child will receive the care that he or she needs - and it will then be for the appropriate dept. at Shriners to decide if they want to pursue the claim with the insurance carrier. From what I can see, they are not overly aggressive in that regard. They will recoup what they can but they don't seem to push the insurers too hard (maybe they should, since insurance carriers get away with murder when it comes to avoiding payment) - but the focus at Shriners remains on the patient and doing what is best for them...period.
    mariaf305@yahoo.com
    Mom to David, age 17, braced June 2000 to March 2004
    Vertebral Body Stapling 3/10/04 for 40 degree curve (currently mid 20's)

    https://www.facebook.com/groups/ScoliosisTethering/

    http://pediatricspinefoundation.org/

  7. #7
    Join Date
    Jun 2012
    Posts
    15
    thanks everyone. i've downloaded an application and have started filling it out. but before i send it in I want to wait until after her july 6th appointment with the ped. orthopedic surgeon she is currently seeing. I want to discuss some questions with him. before making our decision.

  8. #8
    Join Date
    Jan 2008
    Location
    Oregon
    Posts
    1,163
    Best of luck with everything--let us know how things are going.

    Take care,
    Gayle, age 50
    Oct 2010 fusion T8-sacrum w/ pelvic fixation
    Feb 2012 lumbar revision for broken rods @ L2-3-4
    Sept 2015 major lumbar A/P revision for broken rods @ L5-S1


    mom of Leah, 15 y/o, Diagnosed '08 with 26* T JIS (age 6)
    2010 VBS Dr Luhmann Shriners St Louis
    2017 curves stable/skeletely mature

    also mom of Torrey, 12 y/o son, 16* T, stable

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