Insurance denied pre-cert and appeal. ADR lawyers?

[adalexander]

I am supposed to have an ADR on December 18th but my insurance denied the pre-cert. My dr's office appealed and was denied. I want to have an attorney write a letter to the insurance company but I want to find an attorney who knows something about this. Anyone know someone?

[mmglobal]

adalexander,

I hope you don't mind, but I moved your post to a thread of it's own. This is an important discussion that I didn't want lost in another thread about a different subject.

Unfortunately, your insurance company holds all the cards and has very little or no risk in denying, denying, denying.

djscal had to go after his insurance company for withdrawing payment after the fact... he may be of some help. Maybe others will know. There is a lot of discussion about insurance issues on adrsupport.org - you may find some useful info there.

good luck... let us know how it goes.

Mark

PS... many have fought the battle for many months and finally gave up and self paid for surgery... it's not as much as you might think...

[Eddie G]

They will try to wear you down with denials and BS excuses. Don't accept that. Don't give up! That's what they are counting on you to do.
My case was WC so I had more luck getting my company doctors to fight for me than I did having my lawyer write letters. I would think that the more ADR friendly doctors you have on your side the better. Send them a stack of letters from these doctors and if you do have to go to court, you have ammunition to fight these @$$holes. It's a shame we are just numbers to them and it's their job to save their company money, not to give you healthcare. Whatever you do, be diplomatic and keep good records.

My pain management doctor just ordered an MRI. It was just denied by my company nurse. She says I should still have pain and Dr. Goldstein would have to order it. WELL WE WANT TO SEE WHAT'S GOING ON IN MY SPINE AFTER IT WAS OPERATED ON! IS THAT SO MUCH TO ASK? The first word to pop into her head is ALWAYS "no". (I feel bad for her husband)
So I'll have to wait a few weeks to see my surgeon. Oh well, I'm used to it.

[dshobbies]

I too was one of those that gave up and went to Germany at my own expense. In restrospect, it was the best decision... however, I do believe that Paulette was successful in getting her ins co to pay for Dr. Delamarter after getting a lawyer's advise on some how to's. Paulette, are you there?

Dale

[chasswen]

i too lost all apeals with blue crap. it took 8 months of fighting with them and its seems as they were reading from a book. like calling msoft for tech support. as a matter a fact i was dened the first time by a gyn i am like WTF!!
i provided them with 50 pounds of docs. to no avail.
and i even asked my boss to change my health insurance to aetna a yr ago and being told we cannt do that {small company less then 10 employees.} aug we borrowed agaisnt the house and when to dr b in bogen germany {NO REGRETS} and it seems that i was out of time as L4-L5 was begining to fuse. so i had zero time left to fool with insurance companys. then i returned to work oct 23rd and shorty after i learn we were changing insurance companys to guess who? AETNA GRRRRRR!!!! i still havnt gotten over that as yet or may never get over it.
we are in process of creating letter to blue crap asking for payment for surgery 31,500.00 usd we starting with sending letters to blue cross worldwide and the local blue crap we were insured with. because i am and will take these pricks to court over this as if i were a fed employee blue crap has to pay theres a clause with the goverment. so what does that leave the privite insured second rate humans. this double standard must be stoped. if we here in the usa cannt rely on the FDA call then why are they here now if we asked for a device not approved blue crap would say its not FDA approved. and now as we all are seeing and this is nothing new asking for a fda approved device they are still dening coverage so what good and all this money being wasted on the FDA?
i surely see a class action law suit coming in the horzion.
sorry for the vent but something has to be done with the double standard here with insurance companys mainly BLUE CRAP.
chuck

[Maria]

I'm wondering whether this is a Worker's Compensation Insurance Denial or Medical Insurance Denial. I think either are difficult to deal with however, I had received a number of WC Utilization Review denials for surgery and it took approximately 2 years to get an authorization for a hybrid surgery (fusion at L5S1 and ADR at L4).

Originally I had been told in 2003 I could have a 2 level ADR during Prodisc trials but I was afraid at that point to have surgery. In 2005 I was told the WC legislation in CA. had changed and this surgery would no longer be authorized by UR and it wasn't so then the battle for 2 years to get a surgery that had already been previously authorized done so again.

The State of CA.Work Comp Board sent me to 2nd surgical opinion (even tho I already had 5 opinions in favor of surgery) to determine whether this surgery was warranted. Mark accompanied me as a Patient Advocate and I believe his presence/assistance was greatly helpful, esp. since the surgeon and he went over films in detail rather than just having some things pointed out to me very briefly or not at all while surgeon may have reviewed films in office w/o my presence even (as is often done w/WC).

Appeals can be lengthy and one must be tenacious/dig heels in~ there are those here that have made headway with regular medical insurance and WC. When all else fails or if the process is taking way too long and/or you just
want to try to get on w/your life, if at all possible, the option of going abroad is there and significantly cheaper than cost of the surgery here in the States.

[dshobbies]

Chuck and others,

I too gave up as time was running short. My pain levels were increasing and I feared a rupture, etc.

I thought about getting a lawyer, especially since a 3 level fusion was actual contra-indicated, but in the end, I decided I didn't have the strength and wanted my efforts directed into me, not the legal system.

I agree that frustrating doesn't even come close, especially for those not fortunate enough to tap into their homes or other resources for funding to get the job done. I've done much venting myself and have been met with the same sympathy I'm now offering you.

Let me leave you with this thought. Had BC covered my surgery, I would have had it done here, by a doctor far less qualified than Dr. B and then cared for by a medical staff far less attentive than those in Germany. I would also have had a 4 level hybrid procedure instead a 3 ADRs and though I sustained severe nerve damage, who knows what else would have happened. I have no regrets, other than my financial burden, but if that's what it took for the best and the care I received, then so be it.

Fair, of course not but sometimes our prayers are answered in mysterious ways.

Take care, Dale

[chasswen]

dale
i have no regrets going to germany and the care i recieved there was second to none truely World Class. and if i had to do it agian i would be running to the airport.
chuck
p/s i just finsihed scanning copys of those bills to send to blue crap. and copys to blue cross worldwide what disturbs me is the double standard they have and it really needs to be fixed.
blue worldwide pays in europe blue usa brokers dont WTF!!