Insurance benefits
Jim DeWees
Description
Collection
Title:
Insurance benefits
Creator:
Jim DeWees
Date:
6/12/2008
Text:
Hopefully I can get some help and information from some of you that have been in this situation.
I have a patient that is very active and an excellent candidate for getting a Rheo Knee. He lost his leg about 2 years ago, and has finally been approved for Medicare at about age 55 now. He was covered by Anthem as his primary insurance through his wife's work, and in Indiana Anthem does not allow ANY microprocessors, deeming them as not medically necessary, or whatever else they can find to get out of covering these devices. His wife is employed by the state of Indiana, and Indiana uses Anthem to administer their benefits.
Now, this patient has Medicare benefits, but still has to have Anthem as his primary insurance and Medicare as his secondary (thanks to the wonderful COB - Coordination of Benefits....Hillary-care success story...yikes). As long as his wife is working and has the option of having her Anthem coverage that includes him, then he MUST keep his wonderful Anthem benefits. At least that is what the patient has been told, and also told that getting a divorce from his wife would get him to qualify for only his Medicare benefits. Well, that is not an option in his mind.
I am not 100% sure on how these benefits work and who determines what the patient has to do with his insurance and how that all works.
My concerns are that if Anthem receives and processes a claim for the Rheo Knee, and denies it as not medically necessary, will Medicare also deny the claim, or will they cover this service?
On other claims where Anthem is primary and Medicare is secondary, it is generally the rule that Medicare will pay the remaining balance of the codes up to the Medicare prices. But, that is only IF anthem allows the codes, and then pays their pathetic allowable amounts, and then Medicare pays the rest. On cases where Anthem does NOT allow the codes, for whatever reason, then it seems that Medicare doesn't pay anything on those codes, but that is not always the case that I have seen.
But as we all know, it seems like there is NO rhyme or reason for some of these issues, and there seems to be no set standards that I can figure out, and of course, nobody to talk to that can answer these questions or guarantee that the information is accurate and correct.
So, do any of you out there have any experience in a situation like this, and how did this all end up and was it something that can be covered regarding the Rheo knee, or C-leg or similar device?
Thanks in advance.
Jim DeWees, CP
_________________________________________________________________
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I have a patient that is very active and an excellent candidate for getting a Rheo Knee. He lost his leg about 2 years ago, and has finally been approved for Medicare at about age 55 now. He was covered by Anthem as his primary insurance through his wife's work, and in Indiana Anthem does not allow ANY microprocessors, deeming them as not medically necessary, or whatever else they can find to get out of covering these devices. His wife is employed by the state of Indiana, and Indiana uses Anthem to administer their benefits.
Now, this patient has Medicare benefits, but still has to have Anthem as his primary insurance and Medicare as his secondary (thanks to the wonderful COB - Coordination of Benefits....Hillary-care success story...yikes). As long as his wife is working and has the option of having her Anthem coverage that includes him, then he MUST keep his wonderful Anthem benefits. At least that is what the patient has been told, and also told that getting a divorce from his wife would get him to qualify for only his Medicare benefits. Well, that is not an option in his mind.
I am not 100% sure on how these benefits work and who determines what the patient has to do with his insurance and how that all works.
My concerns are that if Anthem receives and processes a claim for the Rheo Knee, and denies it as not medically necessary, will Medicare also deny the claim, or will they cover this service?
On other claims where Anthem is primary and Medicare is secondary, it is generally the rule that Medicare will pay the remaining balance of the codes up to the Medicare prices. But, that is only IF anthem allows the codes, and then pays their pathetic allowable amounts, and then Medicare pays the rest. On cases where Anthem does NOT allow the codes, for whatever reason, then it seems that Medicare doesn't pay anything on those codes, but that is not always the case that I have seen.
But as we all know, it seems like there is NO rhyme or reason for some of these issues, and there seems to be no set standards that I can figure out, and of course, nobody to talk to that can answer these questions or guarantee that the information is accurate and correct.
So, do any of you out there have any experience in a situation like this, and how did this all end up and was it something that can be covered regarding the Rheo knee, or C-leg or similar device?
Thanks in advance.
Jim DeWees, CP
_________________________________________________________________
Now you can invite friends from Facebook and other groups to join you on Windows Live™ Messenger. Add now.
<URL Redacted>
Citation
Jim DeWees, “Insurance benefits,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/229410.
