Insurance Follow-up
Jim DeWees
Description
Collection
Title:
Insurance Follow-up
Creator:
Jim DeWees
Date:
6/13/2008
Text:
Thanks to all those that took the time to reply to me.
From what I got from most people was that the primary insurance is the one that makes the determination of medical necessity and what they will allow and provide, or cover. And, then the secondary Medicare coverage will only pay their portion of what has been determined as necessary for the patient.
In this case, and from my understanding, Anthem in Indiana does NOT cover any microprocessors, and that is final. If it is a situation where the patient has an Anthem policy that is funded by Anthem, then they will deny it the first time, then you can appeal it, and get another denial, and then you can appeal that decision again, and there will be a board or committee that will make the determination whether or not the device is necessary, which is an independent panel, and quite often they will make the decision that Anthem MUST pay for the device, but this is MONTHS of paperwork and fighting.
But in a case where the Anthem policy is a self funded policy, which is what this patient has, the appeals process is totally different, and the body of members that will listen and consider the appeal, is a panel of people that are employed by the company that is funding the policy, and they will most likely rule that their policy is very clear and enforced. And, once that decision is made, it is final and there is nothing more to do about it.
In another situation, I had a patient come to my office for an AK socket change. He wasn't getting a new knee joint, or a new foot, or anything else. He has Anthem through his wife, who is also employed by the state. I made the socket change, had the pre-cert and everything in order, making sure that EVERYTHING was in order with them. When it was billed and transmitted, I got a denial letter from Anthem, and they wanted more information to justify his new socket. They wanted his level of function (which was already on the claim as a modifier, K3, and also the side, LT on every code), and wanted information on a knee joint, why he needed the knee joint and justify that, and also information to justify the type and category of foot that was being used. HE IS NOT GETTING A KNEE OR A FOOT, and there were no codes dealing with a foot or knee.
I talked to the Anthem person, and she said they will NOT re-process the claim until they get this information on a knee and a foot, as requested. I explained it to her until I was totally frustrated and angry with her, and she never understood this.
This patient also has Medicare as secondary (based on disability) and they paid nothing on this either, because it was not approved by Anthem. Anthem did pay for a few of the codes (which were on a separate claim, which DID get processed without problems, but it was the lesser of the claims of course...and Medicare did pay their portion which brought the payment up to the medicare allowable).
This is the type of information that the State Dept of Insurance is wanting from ALL of us, to show them what kind of crazy things we are facing in this field. They KNOW it is bad out there, and the insurance companies are doing more and more nasty moves to keep from paying claims, especially here in Indiana. The big Anthem headquarters is right in Indy, about 3 - 4 blocks from the state capitol. I have had a few conversations with the director of the Dept of Insurance here, and he wants me to submit all these situations to him for them to collect concrete examples of the illegal and unethical practices of insurance companies, especially the one sitting close to his office. Every year it is in the news about the CEO's salary and his annual Bonus. THis past year I think it was about $58 MILLION in a bonus. Last year it was a little less (like $52 Million) and in 2005 it was like $43 Million I think it was. This amount of money for a BONUS is crazy and plain wrong.
I am not against people making money, or being financially rewarded for hard work or something. If someone designs something wonderful and everyone in the world buys one and wants this thing, and pays money for something like that, then that person deserves to make a ton of money.
BUT, it doesn't take a rocket scientist to figure out that the ONLY way an insurance company can make that much money and that high of a profit, is to CHARGE the people too much money every month for their premiums, and also to PAY less out to providers. We have all seen the premiums going up and up, in a huge way. But when is the last time we, as providers, have seen an increase in what we are getting paid.
Anyway, this in another entirely different story to get onto.
The bottom line is for anyone that has clear evidence of foul play from insurance companies, and denials that make no sense at all, like requesting information for services not being renderred, PLEASE become good friends with you state Dept of Insurance people. They can take action against insurance companies, and even to a point of them losing their license or ability to provide insurance inside their state. I can't imagine that ever happening, but what a big deal if it did happen. But, they can clamp down on the insurance companies and threaten them that they better play nicer, or they can be kicked out of the state. That might help make some improvements.
So, back to the original issue at hand, it seems to me that there is NO way to provide this device to this patient as long as he is carrying Anthem as his primary, when Anthem doesn't cover any of these devices.
The other suggestion that I got was that his wife does NOT have to legally have her husband (the patient) on her policy, and that she can drop his coverage. It makes sense to me, but does anyone know if that is true and allowed by Medicare Coordination of Benefits? Will we all get in trouble if he drops Anthem and goes on Medicare primary when his wife could have benefits for him??? This will prevent a divorce in the family....
Also, it is my understanding that in Indiana, Medicare does cover these knees as long as they are medically necessary. But, I did get a couple replies that said in other states, that Medicare will NOT pay for these items. I don't have any first hand experience of billing Medicare for a Rheo knee at this point in time. Will Medicare pay for these devices?
Also, we did pass the parity bill in Indiana, and I don't know what actually passed (I cannot find it online anywhere, or anything on it except that it passed and was supposedly signed into law...), and I have yet to see if it is going to make any difference here at all, or is it just the same business as ususal.
Thanks again.
Jim DeWees, CP
_________________________________________________________________
Enjoy 5 GB of free, password-protected online storage.
<URL Redacted>
From what I got from most people was that the primary insurance is the one that makes the determination of medical necessity and what they will allow and provide, or cover. And, then the secondary Medicare coverage will only pay their portion of what has been determined as necessary for the patient.
In this case, and from my understanding, Anthem in Indiana does NOT cover any microprocessors, and that is final. If it is a situation where the patient has an Anthem policy that is funded by Anthem, then they will deny it the first time, then you can appeal it, and get another denial, and then you can appeal that decision again, and there will be a board or committee that will make the determination whether or not the device is necessary, which is an independent panel, and quite often they will make the decision that Anthem MUST pay for the device, but this is MONTHS of paperwork and fighting.
But in a case where the Anthem policy is a self funded policy, which is what this patient has, the appeals process is totally different, and the body of members that will listen and consider the appeal, is a panel of people that are employed by the company that is funding the policy, and they will most likely rule that their policy is very clear and enforced. And, once that decision is made, it is final and there is nothing more to do about it.
In another situation, I had a patient come to my office for an AK socket change. He wasn't getting a new knee joint, or a new foot, or anything else. He has Anthem through his wife, who is also employed by the state. I made the socket change, had the pre-cert and everything in order, making sure that EVERYTHING was in order with them. When it was billed and transmitted, I got a denial letter from Anthem, and they wanted more information to justify his new socket. They wanted his level of function (which was already on the claim as a modifier, K3, and also the side, LT on every code), and wanted information on a knee joint, why he needed the knee joint and justify that, and also information to justify the type and category of foot that was being used. HE IS NOT GETTING A KNEE OR A FOOT, and there were no codes dealing with a foot or knee.
I talked to the Anthem person, and she said they will NOT re-process the claim until they get this information on a knee and a foot, as requested. I explained it to her until I was totally frustrated and angry with her, and she never understood this.
This patient also has Medicare as secondary (based on disability) and they paid nothing on this either, because it was not approved by Anthem. Anthem did pay for a few of the codes (which were on a separate claim, which DID get processed without problems, but it was the lesser of the claims of course...and Medicare did pay their portion which brought the payment up to the medicare allowable).
This is the type of information that the State Dept of Insurance is wanting from ALL of us, to show them what kind of crazy things we are facing in this field. They KNOW it is bad out there, and the insurance companies are doing more and more nasty moves to keep from paying claims, especially here in Indiana. The big Anthem headquarters is right in Indy, about 3 - 4 blocks from the state capitol. I have had a few conversations with the director of the Dept of Insurance here, and he wants me to submit all these situations to him for them to collect concrete examples of the illegal and unethical practices of insurance companies, especially the one sitting close to his office. Every year it is in the news about the CEO's salary and his annual Bonus. THis past year I think it was about $58 MILLION in a bonus. Last year it was a little less (like $52 Million) and in 2005 it was like $43 Million I think it was. This amount of money for a BONUS is crazy and plain wrong.
I am not against people making money, or being financially rewarded for hard work or something. If someone designs something wonderful and everyone in the world buys one and wants this thing, and pays money for something like that, then that person deserves to make a ton of money.
BUT, it doesn't take a rocket scientist to figure out that the ONLY way an insurance company can make that much money and that high of a profit, is to CHARGE the people too much money every month for their premiums, and also to PAY less out to providers. We have all seen the premiums going up and up, in a huge way. But when is the last time we, as providers, have seen an increase in what we are getting paid.
Anyway, this in another entirely different story to get onto.
The bottom line is for anyone that has clear evidence of foul play from insurance companies, and denials that make no sense at all, like requesting information for services not being renderred, PLEASE become good friends with you state Dept of Insurance people. They can take action against insurance companies, and even to a point of them losing their license or ability to provide insurance inside their state. I can't imagine that ever happening, but what a big deal if it did happen. But, they can clamp down on the insurance companies and threaten them that they better play nicer, or they can be kicked out of the state. That might help make some improvements.
So, back to the original issue at hand, it seems to me that there is NO way to provide this device to this patient as long as he is carrying Anthem as his primary, when Anthem doesn't cover any of these devices.
The other suggestion that I got was that his wife does NOT have to legally have her husband (the patient) on her policy, and that she can drop his coverage. It makes sense to me, but does anyone know if that is true and allowed by Medicare Coordination of Benefits? Will we all get in trouble if he drops Anthem and goes on Medicare primary when his wife could have benefits for him??? This will prevent a divorce in the family....
Also, it is my understanding that in Indiana, Medicare does cover these knees as long as they are medically necessary. But, I did get a couple replies that said in other states, that Medicare will NOT pay for these items. I don't have any first hand experience of billing Medicare for a Rheo knee at this point in time. Will Medicare pay for these devices?
Also, we did pass the parity bill in Indiana, and I don't know what actually passed (I cannot find it online anywhere, or anything on it except that it passed and was supposedly signed into law...), and I have yet to see if it is going to make any difference here at all, or is it just the same business as ususal.
Thanks again.
Jim DeWees, CP
_________________________________________________________________
Enjoy 5 GB of free, password-protected online storage.
<URL Redacted>
Citation
Jim DeWees, “Insurance Follow-up,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/229408.
