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Getting Insurance to PAY for ESWT

Posted by Gail on 8/06/01 at 07:06 (055606)

We are going up against Blue Cross Blue Shield Health Option HMO here in Florida since they have refused to pay for the OssaTron on the basis that it is 'experimental and investigative' and is confined to research settings.

My husband is an attorney and we will take it all the way to arbitration if necessary. I am 36 years old and have had p.f. for a year with no relief from orthotics or corisone injections.

Does anyone have any success stories to share about getting insurance to cover this procedure? What data did you use?

It seems really obvious to us that it is neither investigative nor experimental with FDA approval and 31 locations nationally in outpatient/hospital settings.

Re: Getting Insurance to PAY for ESWT

johnW on 8/06/01 at 08:20 (055613)

The Blues have agreed to pay in California, Michigan and Illinois. Perhaps this ccould support your arguments.

Re: Getting Insurance to PAY for ESWT

Andrea R. on 8/06/01 at 09:22 (055621)

Gail,

If the health insurance is through your employer check to see if the employer is 'self-insured.' If they are then BCBS is only the administrator of the insurance then your employer would have the final word.

I had success getting one of my regular prescription drugs changed from a non-preferred ($70) down to a preferred ($30). I got some runaround from the benefits coordinator in Human Resources but by going to the head of HR, sending a letter from my doctor saying that this was the only medication that could treat the condition and my writing a letter stating that this was not a new drug and there was no alternative, I succeeded.

Good luck, and keep us informed.

Andrea

Re: Getting Insurance to PAY for ESWT

BrianG on 8/06/01 at 09:34 (055623)

Good luck Gail,

Sorry I don't have a success stories, but I'm glad you are taking on BC/BS. I took on my HMO for a lousy MRI. I wish you the best. Please keep us updated, as many will be taking this same route.

BCK

Re: Getting Insurance to PAY for ESWT

Dr. Zuckerman on 8/06/01 at 10:26 (055630)

Sure would liketo have this in writing or have an Explanation of Medical benefit which shows payment. All Blue shield policy will state that there is no guarantee of payment until a claim is submitted, and then it will only be paid in accordance with the benefits of that specifice policy. Each and every policy could be different.

It isn't helpful to say that this plan will pay without actual EOB's showing the payment. Remember read and understand off forms that you signs before any ESWT treatment. If you insurance company doesn't pay then you the patient will be responible for payment. Just the facts is all we are looking for.

Re: Getting Insurance to PAY for ESWT

Ed Davis, DPM on 8/06/01 at hrmin (055650)

A version of the Patients' Bill of Rights just passed the House (version approved by President Bush) and is going to the Senate--this will certainly help in situations like this.

By the way, there is a lot more to treating plantar fasciitis than cortisone and orthotics. What else has been done for you?
Ed

Re: Getting Insurance to PAY for ESWT

Genelle C. on 8/06/01 at hrmin (055715)

I've just begun the fight here in Colorado with BC/BS, didn't know it was going to be so difficult. Would like to hear a success story.

Re: Getting Insurance to PAY for ESWT

johnW on 8/06/01 at 08:20 (055613)

The Blues have agreed to pay in California, Michigan and Illinois. Perhaps this ccould support your arguments.

Re: Getting Insurance to PAY for ESWT

Andrea R. on 8/06/01 at 09:22 (055621)

Gail,

If the health insurance is through your employer check to see if the employer is 'self-insured.' If they are then BCBS is only the administrator of the insurance then your employer would have the final word.

I had success getting one of my regular prescription drugs changed from a non-preferred ($70) down to a preferred ($30). I got some runaround from the benefits coordinator in Human Resources but by going to the head of HR, sending a letter from my doctor saying that this was the only medication that could treat the condition and my writing a letter stating that this was not a new drug and there was no alternative, I succeeded.

Good luck, and keep us informed.

Andrea

Re: Getting Insurance to PAY for ESWT

BrianG on 8/06/01 at 09:34 (055623)

Good luck Gail,

Sorry I don't have a success stories, but I'm glad you are taking on BC/BS. I took on my HMO for a lousy MRI. I wish you the best. Please keep us updated, as many will be taking this same route.

BCK

Re: Getting Insurance to PAY for ESWT

Dr. Zuckerman on 8/06/01 at 10:26 (055630)

Sure would liketo have this in writing or have an Explanation of Medical benefit which shows payment. All Blue shield policy will state that there is no guarantee of payment until a claim is submitted, and then it will only be paid in accordance with the benefits of that specifice policy. Each and every policy could be different.

It isn't helpful to say that this plan will pay without actual EOB's showing the payment. Remember read and understand off forms that you signs before any ESWT treatment. If you insurance company doesn't pay then you the patient will be responible for payment. Just the facts is all we are looking for.

Re: Getting Insurance to PAY for ESWT

Ed Davis, DPM on 8/06/01 at hrmin (055650)

A version of the Patients' Bill of Rights just passed the House (version approved by President Bush) and is going to the Senate--this will certainly help in situations like this.

By the way, there is a lot more to treating plantar fasciitis than cortisone and orthotics. What else has been done for you?
Ed

Re: Getting Insurance to PAY for ESWT

Genelle C. on 8/06/01 at hrmin (055715)

I've just begun the fight here in Colorado with BC/BS, didn't know it was going to be so difficult. Would like to hear a success story.