RE: Re: 2 DOC bands- Denial overturned, but still out of network.... yada yada yada.....

[Guest guest]

,

Thanks for the resources. I will try to

work on this more after I get the kiddos to bed- and see how far it gets me J

-Skye

From: Plagiocephaly

[mailto:Plagiocephaly ] On

Behalf Of

Sent: Monday, May 15, 2006 1:31 PM

Plagiocephaly

Subject: [Norton AntiSpam]

Re: 2 DOC bands- Denial overturned, but still out of network.... yada

yada yada.....

Skye,

Hi! Where do you live? Is there an in-network provider within 70

miles? If so do they have the level of training and experience as the CT

clinic (I'm assuming it's a DOC band because of the locations mentioned).

If there is no comparable in-network alternative then they may have a clause

for how to cover. My Bluechoice (BCBS - SC) I think has a 50-70 mile

radius then you can go out of network for in-network coverage. Where are

they getting their reasonable fee from. If this is the only provider then

how can they say it is not reasonable.

1) Out of Network:

a) Determine if there were in-network

options within 50 miles. Some insurance companies have a 50-70 miles

radius rule. Once you prove you meet the requirements, you get in-network

coverage.

Determine if the in-network options

are qualified and offer the service needed.

i) Very few orthotic companies offer

cranial remolding.

ii) Some offer cranial remolding but see

very few patients each month, have no formal/extensive training, or are new to

the process.

(1) For comparison the Charlotte, NC Cranial Tech office casts

50-60 new patients each month (per conversation with clinician in Oct 2004).

(2) Cranial Tech requires extensive in house

training prior to treating infants. They also do refresher courses each

year. They will provide you with the details or check their website, www.cranialtech.com

(3) Does the in-network band have

documented research (DOC band I believe is the only one that does)?

c) Have your dr write the RX for the

specific band/helmet you want. Have the dr indicate in the letter of

medical necessity why this particular band is required.

i) A very severe case

ii) An after surgery case, currently

only DOC band is FDA approved, even though others are used.

iii) A specific headshape that requires

special treatment. For example, the scaphocephaly shape is rare and would

be best treated by someone with that specific experience.

iv) Have the insurance company check to see if they have any

facilities in network that do (wording is important) DYNAMIC ORTHOTIC

CRANIOPLASTY.

v) continuation of treatment may be an argument

Feel free to email me offline for specific help. filyaw @

bellwouth.net (get rid of the spaces)

na, DOC Grad Feb 04

Kiersten, DOC Grad April 06

www.thefilyaws.com/plagio/plagio.html

>

> Hi! I am new to the group, but not really. We are on band #2 for

> Sawyer (now 9 months) and I have used the group's resources in the

> past. I haven't posted before because I always had a clear path as

> to what to do next. Today I feel overwhelmed and I coul duse some

> help. Here is our story:

>

> We moved from Indiana

> to Savannah

when my son was 2 weeks old. Unfortunately, the move

> (w/ a 2 year-old and 2 week old) made us so busy that the

> torticollis and

> plagiocephaly were not diagnosed until about 4 months (we also had

> some pediatrician challenges). In December we had Sawyer casted for

> his 1st band and just went ahead and paid it. I had tried to get it

> precertified, but the doctor's office was not helpful, and of course

> BCBS would not allow me to talk to anyone in the department.

> Surprise, surprise, they denied coverage.

>

> My sister is a dear, and she wrote an awesome appeal letter (which

> is posted) (I just did not have the energy or time). Blue Cross

> overturned the denial while Sawyer was just getting band #2. (I may

> have forgotten to mention that I had to drive him to

> Atlanta/Charlotte which is almost 5 hours away weekly- thus the

> fatigue.)

>

> The last 2 months have been crazy with the insurance company saying

> there was a problem with how it was being processed, but that it

> would get worked out. I finally talked to someone today and she

> said that all the other people were wrong. The insurance will only

> consider 2/3 of the fee as reasonable and then they will apply our

> less than generous out-of-network benefits. I have been looking for

> appeals on the UCF (usual customary fee) and processing the helmets

> as out-of-network, but I haven't seen much. Does anyone have any

> experience or advice. I feel like I have just had it, been steam-

> rolled, but I REFUSE TO LET THEM WIN!!!!! Even if only on principal!

>

> I guess I am just glad that I didn't open the letter until after

> Mother's Day! Hope you all had a nice day and got to enjoy some

> family fun.

>

> Thanks for your time.

> -Skye

>