Re: Re:Insurance appeals process

[Guest guest]

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Subject: Re: Re:Insurance appeals process

To: uterinefibroidsegroups

Date: 12 Jun 2000 07:27:12 PDT

Strange... Blue Cross-Blue Shield in Central Virginia (Trigon) says that they

will cover UFE as long as the procedure is agreed to by the " primary care "

ob-gyn and/or primary care physician. When I was considering having UFE done,

the first thing I did was contact my carrier to find out if the procedure was

covered. I know several women that have had the procedure paid for by Trigon Key

Advantage Blue Cross-Blue Shield and at least one woman who won an appeal with

Trigon Blue Crross-Blue Shield Helathkeepers (the HMO branch). My IR says that

80% of the UFEs he has done were on BC-BS patients. I was under the impression

that BC-BS was the same all over. Guess not.

Rhonda

>

> Judy,

>

> That would be great to list the web sites or other references to use

> for appeals to insurance companies to try and get them to cover the

> UFE procedure. I have Blue Cross & Blue Shield and they said they

> would not cover UFE's " yet " because it is considered experimental,

> but may cover it in the future. I think maybe they just need to be

> educated more about it. Possibly the IR's could help with an

> information letter for us to present to the insur. co.'s as well...it

> would certainly be to their advantage. I plan to make an appt. with

> Dr. Spies this week and I will discuss this with him. I will watch

> for Carla to hopefully post your suggestions on the NUFF website.

>

> Connie

>

>

>

>

> > For your info, preliminary results of a study at town

> > University

> > Medical Center indicate that UAE should not affect the fertility of

> > women under 45. These results were presented at the annual meeting

> of

> > the SCVIR (Society of Cardiovascular and Interventional Radiology)

> > last March in San Diego, CA by B. Spies, MD (chief of

> > interventional radiology and vice chairman of radiology at

> town

> > University Medical Center in Washington DC). WebMDHealth ran a

> story

> > on his research on March 27, 2000 (see

> > http://my.webmd.com/content/article/1728.56006). In the article,

> Dr.

> > Spies is quoted as saying " Preliminary data [on 66 patients] show

> > that

> > there is no statistically significant change between levels of

> > follicle-stimulating hormone before beginning the treatment and six

> > months afterward. " Follicle-stimulating hormone is important for

> > regulating ovarian function. Of course, this study will still need

> to

> > go through the peer-review process when Dr. Spies gets ready to

> > publish his teams' results in a medical journal--it's encouraging

> > news

> > though.

> >

> > I ran across this article while putting together my appeal to

> > HealthPartners (St. , MN) for denying me coverage of UAE for

> > treatment of a 7 cm fibroid (they said it was too experimental). A

> > hysterectomy was given as my other choice (which I didn't find

> > acceptable--I'm 40 and don't want to undergo major surgery when

> there

> > is another option I can try first). As a Ph.D.-level

> > Environmental Research Scientist, I've done a lot of my own

> research

> > into fibroids and treatment options. For my particular case, I

> think

> > UAE is the way to go. I have assembled a lot of Web-related

> > references for my appeal. I will forward this list to Carla Dionne

> > for use on the National Uterine Fibroids Foundation Web site.

> >

> > Judy

>

>

> ------------------------------------------------------------------------

> Accurate impartial advice on everything from laptops to table saws.

> http://click./1/4634/7/_/4009/_/960776575/

> ------------------------------------------------------------------------

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------- End of forwarded message -------

Rhonda lin Newsome, MPP

Research Associate

Virginia Commonwealth University

Survey and Evaluation Research Laboratory

P.O. Box 843016

Richmond, VA 23284-3016

(voice)

(fax)

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[Guest guest]

gdehnel@... wrote:

> That would be great to list the web sites or other references to use

> for appeals to insurance companies to try and get them to cover the

> UFE procedure. I have Blue Cross & Blue Shield and they said they

> would not cover UFE's " yet " because it is considered experimental,

> but may cover it in the future. I think maybe they just need to be

> educated more about it. Possibly the IR's could help with an

> information letter for us to present to the insur. co.'s as well...it

> would certainly be to their advantage. I plan to make an appt. with

> Dr. Spies this week and I will discuss this with him. I will watch

> for Carla to hopefully post your suggestions on the NUFF website.

>

> Connie

Blue Cross & Blue Shield are 2 different insurance carriers. Blue Cross in

California now covers UAE. Blue Shield in California does not. Each state

has its own Blue Cross and Blue Shield companies and each one of them makes

an independent decision as to whether or not they will cover UAE. They are

educated about this procedure. I've read their reports. They are VERY

educated about this procedure. They have a national Technology Evaluation

Center (Committee) that works for a National Association organization that

the majority of Blues voluntarily " belong to " across the nation. This TEC

evaluates procedures thoroughly and makes policy statements about those

procedures. Most of the Blues follow those policy recommendations. Some,

however, do choose to stray when their own TAC (technical assessment

committee) evaluates and determines a different assessment of any given

procedure. Blue Cross in California only recently decided to " stray " from

the fold and cover UAE. Even so, I had already switched to United

HealthCare because, after an entire adult lifetime of choosing Blue Cross or

Blue Shield as my carrier, this issue so upset me that I can no longer trust

either of these plans for my own private coverage for me and my family.

In California, many IRs have testified on behalf of UAE to the Blue Shield

TAC. I have testified to the Blue Shield TAC. I have also spoken to a

member of the National Association's TEC. It was meaningless testimony.

Even the technical testimony of IRs was held as meaningless. The Blue

Shield of California's Scientific Advisor did a slip-shodden job of

reviewing the literature and evaluating the technology and no one on the

committee even cared. No matter how " politely " it was pointed out to them

by Goodwin, et al.

I, personally, was rudely interrupted numerous times by an apparently

disgusted committee member who wasn't even remotely interested in hearing a

word I had to say. I developed a thick packet of handouts for the committee

that included many letters of testimony, statistics, a detailed bibliography

and my own testimonial letter. They were not distributed or read as far as

I could assess. I picked up the " tossed aside " copies after the meeting and

went home thoroughly disgusted and distressed.

My assessment of Blue Shield and their TAC? They honestly don't give a

rip. They're not interested in the data. Their technical advisor had so

many conflicting and outdated items in his report that it was truly

unbelievable AND they were not interested in hearing corrections from ANYONE

on the floor. Their decision regarding the procedure was made well before

the meeting and their disrespect over individual's testimony was

outrageous. About half the committee got up and left before UAE was even

presented on the agenda (after it was moved to the end of the day and not

presented until around 4 p.m.). One committee member nodded off during the

meeting. Even so, I was " reassured " that a voting quorum was indeed still

present and capable of rendering a decision.

Blue Shield will cover this procedure after first denying it IF you can

submit a convincing set of circumstances and have the time to go through the

appeals process. Submitting a convincing set of circumstances for the

initial pre-cert isn't good enough. They want you to wade through the

appeals process before they approve this procedure. They want to send it

out for " independent review. " Regardless of your immediate health

condition.

Blue Cross has always covered UAE under appropriate medical conditions.

Blue Cross paid for my UAE 19 months ago without a whole lot of questioning

at all. Of course, that was before the volume of women requesting it

escalated to such a number that red flags started going off and the brakes

were applied. (That was also before gynecologists decided UAE was

potentially a real threat to their practices and mounted a lobbying campaign

to discredit the procedure as " experimental and investigational. " ) At that

point, Blue Cross went the route of denial and review. However, today,

after a recent policy review, it's covered once again in California.

Blue Shield just had their 2nd TAC meeting for the year on June 7. UAE was

not even on the agenda again. If you want to try and affect change, write

to them and demand it be placed on the next TAC meeting to be held this

fall. Don't forget to include your own testimony about UAE and demand it be

part of the record for their next review as well. Here's the address:

Blue Shield of California

ATTENTION: Rideout, MD

Chief Medical Officer

50 Beale Street

San Francisco, CA 94105-1808

In addition, it's important that you send a copy to the National Association

of Blues as well:

Blue Cross Blue Shield Association

Technology Evaluation Center

225 N. Michigan Ave.

Chicago, IL 60601-7680

Of course, if they don't receive letters IN VOLUME, they will assume it's

not that big a deal. Also, please send a copy of any letter you write to

Senator Barbara Boxer. She's taken an interest in this procedure and a

woman's right to appropriate medical care through her insurance provider

and, I'm certain, would like to know what you think about Blue Shield's lack

of coverage on this item.

Senator Barbara Boxer

ATTENTION: J. Vizcaino

Director of Constituent Services

1700 Montgomery Street, Suite 240

San Francisco, CA 94111

Get your pen and paper out ladies. Enlist the letter writing aid of every

one you know as well. It's the only way things will ever change. This

issue isn't about " technology assessment. " It isn't about me or you or

insurance companies protecting us from some evil new medical technology.

It's over 9 years beyond that. It's about money and medical turf.

On a final note, I've been asked by many to not " inflame " Blue Shield of

California over this issue. If we " talk nice " we can eventually convince

them to approve this procedure. In the meanwhile, more and more women are

desperately turning to hysterectomy even though they don't want a

hysterectomy and want UAE. They have medical situations that require

treatment. Now. Not a month or two from now. And they certainly don't

have the strength to mount an appeal campaign. Quite frankly, I find the

situation shameful. And I'm tired of not saying so.

Even if your own Blue Cross or Blue Shield plan within your own state covers

this procedure, won't you please consider writing a letter on behalf of the

women of California?

Carla Dionne

Executive Director

National Uterine Fibroids Foundation

mailto:carla@...

http://www.NUFF.org

/list/uterinefibroids

Personal email & website:

mailto:cdionne@...

http://www.uterinefibroids.com

" Never doubt that a small group of thoughtful committed citizens can change

the world. Indeed it's the only thing that ever has. " Margaret Mead

[Guest guest]

Carol G Herman wrote:

> At 07:44 AM 6/12/00 -0700, you wrote:

>

> >Blue Cross & Blue Shield are 2 different insurance carriers. Blue Cross in

> >California now covers UAE. Blue Shield in California does not. Each state

> >has its own Blue Cross and Blue Shield companies and each one of them makes

> >an independent decision as to whether or not they will cover UAE.

>

> The above is not true in most states. Originally, Blue Cross covered

> hospital costs, Blue Shield covered physician costs; this limitation is no

> longer recognized. For example, Blue Cross/Blue Shield (BCBSNCA) plan is

> operated under a single carrier (or licensed company). In the National

> Capitol area the distinction is made among PPO, HMO, IPA, Medigap type

> plans, all under the moniker of Carefirst Blue Cross/ Blue Shield, a single

> company.

>

> In most states the two plans have merged into single corporations or

> cooperatives, albeit in a few states the operations are separate (as

> apparently in CA). As well, all plans are federated under the BC/BS

> Association.

My point was simply that each Blue Cross & Blue Shield organization is different

from state to state as anti-trust laws do not allow for them to be one gigantic

corporation. From the Blue Cares website:

" The Blue Cross and Blue Shield organization is not one single company, but

rather a confederation of 50 independent, community-based Blue Cross and Blue

Shield Plans. These Plans collectively enroll 68.7 million people--about one in

four Americans. Unlike large commercial insurance companies, Blue Cross and

Blue Shield Plans are locally based..... Each Plan operates independently in its

own service area.... Blue Cross and Blue Shield Plans are related through their

membership in the Blue Cross and Blue Shield Association, which licenses the

Plans to use the Blue Cross and Blue Shield names and symbols. The Association

also serves as a trade association and as a federal government contractor. "

You can read more about this " association " at:

http://www.bluecares.com

Carla Dionne

Executive Director

National Uterine Fibroids Foundation

mailto:carla@...

http://www.NUFF.org

/list/uterinefibroids

Personal email & website:

mailto:cdionne@...

http://www.uterinefibroids.com

" Never doubt that a small group of thoughtful committed citizens can change the

world. Indeed it's the only thing that ever has. " Margaret Mead

[Guest guest]

At 07:44 AM 6/12/00 -0700, you wrote:

>Blue Cross & Blue Shield are 2 different insurance carriers. Blue Cross in

>California now covers UAE. Blue Shield in California does not. Each state

>has its own Blue Cross and Blue Shield companies and each one of them makes

>an independent decision as to whether or not they will cover UAE.

The above is not true in most states. Originally, Blue Cross covered

hospital costs, Blue Shield covered physician costs; this limitation is no

longer recognized. For example, Blue Cross/Blue Shield (BCBSNCA) plan is

operated under a single carrier (or licensed company). In the National

Capitol area the distinction is made among PPO, HMO, IPA, Medigap type

plans, all under the moniker of Carefirst Blue Cross/ Blue Shield, a single

company.

In most states the two plans have merged into single corporations or

cooperatives, albeit in a few states the operations are separate (as

apparently in CA). As well, all plans are federated under the BC/BS

Association.

[Guest guest]

At 10:07 AM 6/12/00 -0700, you wrote:

> At 07:44 AM 6/12/00 -0700, you

wrote:

>

> >Blue Cross & Blue Shield are 2 different insurance

carriers. Each state has its own Blue Cross and Blue

Shield companies ...

My point was simply that each Blue Cross &

Blue Shield organization is different

from state to state as anti-trust laws do not allow for them to be one

gigantic

corporation. From the Blue Cares website:

And now the new point is clear, and different from the original statement

which clearly stated they are two separate companies in each state.

Your example further explicated this misconception.

My post was solely intended to clarify that while CA may have two

separate companies, most states do not.