Re: Insurance Parity Issues
Albert J Garney
Description
Collection
Title:
Re: Insurance Parity Issues
Creator:
Albert J Garney
Date:
12/28/2011
Text:
Greeting everyone:
My apologies as I step up on the soap box here:
I have to agree with Wil's assessment on the diabetic situation. A big
problem we have in Virginia is Medicaid's lack of coverage for patient over
21 for orthotic devices. I have a situation right now that a diabetic
patient with active charcot and wounds almost lost her leg below the knee
last week. After IV antibiotic and non weight bearing, she is doing better.
Dr wrote for a CROW boot but in the state of Virginia, this will not be
covered because the CROW is an orthotic device and Virginia Medicaid does
not pay for item for patient over the age of 21.
So there is where the clinician trumps the business man. I'm going to
provide the CROW per doctors orders. Most likely never see a penny for our
efforts, but I know that we have done the best for the patient as she is in
limb salvage mode. Without the device she will certainly become a amputee.
So here is the kicker, Virginia Medicaid won't pay for the CROW but if she
is an amputee, they are able to find funding for the prosthetic device.
The best we can do as the O&P community is to monitor these policies and be
pro-active when something comes down the line that is not in favor of our
patient or our livelihood. We cannot afford to react to policies after some
legislator put something in place. We all need to be at the table to
lookout for our interest and understand the consequences of bad laws and
regulations as being seen across the country.
Regards and Happy Holidays
Albert J Garney, CPO
Prince William Orthotics and Prosthetics, LLC
8644 Sudley Rd
Suite 305
Manassas, VA 20110
www.pwop.net
703-368-7967
-----Original Message-----
From: Orthotics and Prosthetics List [mailto:<Email Address Redacted>] On
Behalf Of Wil
Sent: Wednesday, December 21, 2011 6:28 AM
To: <Email Address Redacted>
Subject: Re: [OANDP-L] Insurance Parity Issues
Dear Colleagues and Guests,
Of course this turns my stomach, but I believe Jim's assessment is more fact
than fiction. I can remember many years ago when some insurance companies
did not offer coverage for braces or artificial limbs, period. In those
days, organizations like Easter Seals, Muscular Dystrophy, March of Dimes,
family members, etc., basically funded the needs of those with disabilities
of one kind or another. Over time, that changed, until recently where policy
restrictions like Jim describes are reappearing. In the meantime, the
agencies who funded these services in the past have largely been ignored and
are probably barely able to survive as non-profit organizations. Put mildly,
it is a reflection of our society's change from all about us to all about
me.
Because of the federal government's recent crackdown on the diabetic
population, amputations will rise in the near future. Let that statement go
on the record. As a result, the money saved with denial of certain diabetic
services will eventually be spent 100-fold, or more, costing each and every
one of us more money out of our tax pocket.
Wil Haines, CPO
MaxCare Bionics
Avon, IN
On 12/20/2011 2:26 PM, Jim DeWees wrote:
> Thanks to those that responded to my post about the Parity issues and
current policies.
>
> Just to add a little more, someone from the Indiana Dept of Insurance did
return my phone call, and we spoke this morning. He basically said that I
need to file an official complaint with their Consumer's Services division,
which I can do online, with the information. Then within 24 hours someone
there will review my complaint and see if there is indeed some violation,
and then notify the insurance company of this complaint and give them a time
frame to respond back and give the Insurance Dept some reply about this
complaint.
>
> IF they find that there is indeed a violation, there is not a lot that the
state can do to an insurance company, other than to notify them that they
are in violation. They might be able to fine the company, or make some kind
of negative mark on them somehow. BUT from what I learned today is that
there is little or nothing that they can do to MAKE an insurance company
play fairly or follow the laws.
>
> I spoke with someone in the Consumer's Service division, and she told me
to file the complaint online, and then that opens a case where they can
investigate. There are only 4 people working in this department, and she
told me that she cannot recall any cases regarding this Parity issue. I
found that interesting, because the ACA was here in Indiana, and they found
several amputees that were willing and eager to express their stories about
how they had been treated unfairly by their insurance companies....etc.
But, since July 1, 2008 (when this law was put into place), in over 3 years
now, there has been NO complaints or issues with prosthetics filed with the
State.
>
> I filed the complaint online, and have no idea of when (or IF) I will ever
hear back. In the meantime, the patient has also filed a formal complaint
over this, and they have read the Parity Law for Indiana, and know exactly
what the violation is.
>
> Here is a small part of the bill:
>
>
> Code § 27-13-7-19 : Indiana Code - Section 27-13-7-19: Coverage for
> prosthetic devices
>
> ....the coverage
> required under subsection (c):
> (1) may be subject to; and
> (2) may not be more restrictive than;
> the provisions that apply to other benefits under the individual contract
or group contract....
>
>
> So having a $4000 annual cap is restrictive compared to other benefits
on their policy.
>
>
> So, this battle is just now beginning with this insurance company, and it
will be quite interesting to see IF the state CAN do anything, or IF the
state WILL do anything.
>
> > From my perspective, I have not seen ONE case where this parity bill has
helped any amputees here in Indiana. I have seen several cases where this
law has really hurt the amputees. Here is just a couple examples of the
negative impact:
>
> Personally, I tried to change insurance companies for myself, which is an
individual policy for my family. I have had the same company and policy now
for about 5 years, but the network is not that great, and the coverage and
customer service with this company is horrible. I went to one insurance
broker, he thought it would be simple to get me a new policy with a better
company, BUT when we looked at a few companies, I wasn't even allowed to
apply because now it asks if I am an amputee or if I have a prosthetic
limb....and answering this question with a YES makes it so that they won't
even take my application. Two other bigger companies didn't come right out
and ask that question, but during the medical review and the underwriting
process, they denied coverage. I am not overweight, I do not smoke, I take
no medications, blood sugar levels are perfect, blood pressure is perfect,
etc...and they still won't take me...OR my 10 year old son who is missing
his right hand (b!
irth defect, adopted from China).
>
> This past year, the Obamacare deal went into effect where children are
supposed to be able to get coverage regardless of the pre-existing
conditions....BUT the catch to that was that the insurance company must have
the entire family covered, and then if they exclude a parent due to
pre-existing conditions, then they do not have to cover the child. So, my
son could not get any new coverage under this new wonderful law, which
sounded so great on the mainstream media.
>
> Another issue that I have seen 3 times now are patients that have had
personal, individual policies for a few years, and when this law was passed,
they received a letter forcing them to sign a 10 year voluntary waiver of
benefits for anything related to the amputated limb. If they did not sign
that waiver, their policies would be cancelled and their coverage
terminated.
>
> I wrote about this a few months ago, and it ended up in a magazine for
this field, and there was a reply to my article stating that ALL my claims
here are false and innacurate. There is no reason for me to make any of
this up, and if this was all false, then I would have a new insurance policy
that would work much better for my family and me. But, I cannot get new
insurance. So far, my current insurance has not asked for any waiver of
benefits, BUT I have never submitted any claims for any prosthetic services
since I make my own, as well as my son's prosthetic devices. But, my
insurance is based out of Ohio (not based in Indiana) and so I guess this
might not be an issue yet in Ohio.
>
> IF I had to take an insurance policy that did require this voluntary
waiver of benefits, that could be financially devastating. What happens if
I needed some revision surgery for bone growth or something....that would
ALL be out of my pocket, and not covered. That would be several thousand
dollars. Most of my patients could not afford to choke out that kind of
money.
>
>
> Again, this is just my view of what this parity law has caused in my
state. I can't see anything positive about it at all from a personal point
of view, or from my professional point of view.
>
> Thanks again everyone,
>
> Jim DeWees, CP
>
>
My apologies as I step up on the soap box here:
I have to agree with Wil's assessment on the diabetic situation. A big
problem we have in Virginia is Medicaid's lack of coverage for patient over
21 for orthotic devices. I have a situation right now that a diabetic
patient with active charcot and wounds almost lost her leg below the knee
last week. After IV antibiotic and non weight bearing, she is doing better.
Dr wrote for a CROW boot but in the state of Virginia, this will not be
covered because the CROW is an orthotic device and Virginia Medicaid does
not pay for item for patient over the age of 21.
So there is where the clinician trumps the business man. I'm going to
provide the CROW per doctors orders. Most likely never see a penny for our
efforts, but I know that we have done the best for the patient as she is in
limb salvage mode. Without the device she will certainly become a amputee.
So here is the kicker, Virginia Medicaid won't pay for the CROW but if she
is an amputee, they are able to find funding for the prosthetic device.
The best we can do as the O&P community is to monitor these policies and be
pro-active when something comes down the line that is not in favor of our
patient or our livelihood. We cannot afford to react to policies after some
legislator put something in place. We all need to be at the table to
lookout for our interest and understand the consequences of bad laws and
regulations as being seen across the country.
Regards and Happy Holidays
Albert J Garney, CPO
Prince William Orthotics and Prosthetics, LLC
8644 Sudley Rd
Suite 305
Manassas, VA 20110
www.pwop.net
703-368-7967
-----Original Message-----
From: Orthotics and Prosthetics List [mailto:<Email Address Redacted>] On
Behalf Of Wil
Sent: Wednesday, December 21, 2011 6:28 AM
To: <Email Address Redacted>
Subject: Re: [OANDP-L] Insurance Parity Issues
Dear Colleagues and Guests,
Of course this turns my stomach, but I believe Jim's assessment is more fact
than fiction. I can remember many years ago when some insurance companies
did not offer coverage for braces or artificial limbs, period. In those
days, organizations like Easter Seals, Muscular Dystrophy, March of Dimes,
family members, etc., basically funded the needs of those with disabilities
of one kind or another. Over time, that changed, until recently where policy
restrictions like Jim describes are reappearing. In the meantime, the
agencies who funded these services in the past have largely been ignored and
are probably barely able to survive as non-profit organizations. Put mildly,
it is a reflection of our society's change from all about us to all about
me.
Because of the federal government's recent crackdown on the diabetic
population, amputations will rise in the near future. Let that statement go
on the record. As a result, the money saved with denial of certain diabetic
services will eventually be spent 100-fold, or more, costing each and every
one of us more money out of our tax pocket.
Wil Haines, CPO
MaxCare Bionics
Avon, IN
On 12/20/2011 2:26 PM, Jim DeWees wrote:
> Thanks to those that responded to my post about the Parity issues and
current policies.
>
> Just to add a little more, someone from the Indiana Dept of Insurance did
return my phone call, and we spoke this morning. He basically said that I
need to file an official complaint with their Consumer's Services division,
which I can do online, with the information. Then within 24 hours someone
there will review my complaint and see if there is indeed some violation,
and then notify the insurance company of this complaint and give them a time
frame to respond back and give the Insurance Dept some reply about this
complaint.
>
> IF they find that there is indeed a violation, there is not a lot that the
state can do to an insurance company, other than to notify them that they
are in violation. They might be able to fine the company, or make some kind
of negative mark on them somehow. BUT from what I learned today is that
there is little or nothing that they can do to MAKE an insurance company
play fairly or follow the laws.
>
> I spoke with someone in the Consumer's Service division, and she told me
to file the complaint online, and then that opens a case where they can
investigate. There are only 4 people working in this department, and she
told me that she cannot recall any cases regarding this Parity issue. I
found that interesting, because the ACA was here in Indiana, and they found
several amputees that were willing and eager to express their stories about
how they had been treated unfairly by their insurance companies....etc.
But, since July 1, 2008 (when this law was put into place), in over 3 years
now, there has been NO complaints or issues with prosthetics filed with the
State.
>
> I filed the complaint online, and have no idea of when (or IF) I will ever
hear back. In the meantime, the patient has also filed a formal complaint
over this, and they have read the Parity Law for Indiana, and know exactly
what the violation is.
>
> Here is a small part of the bill:
>
>
> Code § 27-13-7-19 : Indiana Code - Section 27-13-7-19: Coverage for
> prosthetic devices
>
> ....the coverage
> required under subsection (c):
> (1) may be subject to; and
> (2) may not be more restrictive than;
> the provisions that apply to other benefits under the individual contract
or group contract....
>
>
> So having a $4000 annual cap is restrictive compared to other benefits
on their policy.
>
>
> So, this battle is just now beginning with this insurance company, and it
will be quite interesting to see IF the state CAN do anything, or IF the
state WILL do anything.
>
> > From my perspective, I have not seen ONE case where this parity bill has
helped any amputees here in Indiana. I have seen several cases where this
law has really hurt the amputees. Here is just a couple examples of the
negative impact:
>
> Personally, I tried to change insurance companies for myself, which is an
individual policy for my family. I have had the same company and policy now
for about 5 years, but the network is not that great, and the coverage and
customer service with this company is horrible. I went to one insurance
broker, he thought it would be simple to get me a new policy with a better
company, BUT when we looked at a few companies, I wasn't even allowed to
apply because now it asks if I am an amputee or if I have a prosthetic
limb....and answering this question with a YES makes it so that they won't
even take my application. Two other bigger companies didn't come right out
and ask that question, but during the medical review and the underwriting
process, they denied coverage. I am not overweight, I do not smoke, I take
no medications, blood sugar levels are perfect, blood pressure is perfect,
etc...and they still won't take me...OR my 10 year old son who is missing
his right hand (b!
irth defect, adopted from China).
>
> This past year, the Obamacare deal went into effect where children are
supposed to be able to get coverage regardless of the pre-existing
conditions....BUT the catch to that was that the insurance company must have
the entire family covered, and then if they exclude a parent due to
pre-existing conditions, then they do not have to cover the child. So, my
son could not get any new coverage under this new wonderful law, which
sounded so great on the mainstream media.
>
> Another issue that I have seen 3 times now are patients that have had
personal, individual policies for a few years, and when this law was passed,
they received a letter forcing them to sign a 10 year voluntary waiver of
benefits for anything related to the amputated limb. If they did not sign
that waiver, their policies would be cancelled and their coverage
terminated.
>
> I wrote about this a few months ago, and it ended up in a magazine for
this field, and there was a reply to my article stating that ALL my claims
here are false and innacurate. There is no reason for me to make any of
this up, and if this was all false, then I would have a new insurance policy
that would work much better for my family and me. But, I cannot get new
insurance. So far, my current insurance has not asked for any waiver of
benefits, BUT I have never submitted any claims for any prosthetic services
since I make my own, as well as my son's prosthetic devices. But, my
insurance is based out of Ohio (not based in Indiana) and so I guess this
might not be an issue yet in Ohio.
>
> IF I had to take an insurance policy that did require this voluntary
waiver of benefits, that could be financially devastating. What happens if
I needed some revision surgery for bone growth or something....that would
ALL be out of my pocket, and not covered. That would be several thousand
dollars. Most of my patients could not afford to choke out that kind of
money.
>
>
> Again, this is just my view of what this parity law has caused in my
state. I can't see anything positive about it at all from a personal point
of view, or from my professional point of view.
>
> Thanks again everyone,
>
> Jim DeWees, CP
>
>
Citation
Albert J Garney, “Re: Insurance Parity Issues,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/233104.
