Re: - Insurance, and a little OT as an example

[Guest guest]

Ann,

Very well put and thorough!!! Thank you!

Mikell

[Guest guest]

Ann,

Thanks for the advice. In the 2 1/2 months that I had to wait for my lap/hyst I

did go round & round w/ the claims dept and our co. HR director got on the phone

w/ our benefits coordinator as well. I was told by everyone that:

1. my ins only covers one Lap per lifetime (so I better make it count)

2. anything to do w/ the fallopian tubes MUST be coded as infertility (I had a

blockage on my left side)

3. since the procedures were completed at the same time, they wouldn’t split the

coverage. (ie. Bill the lap as infertility and the hyst as something else)

Now that the damage is done, any suggestions on if/how I could appeal now?

Ann Chavie ann_chavie@...> wrote:

,

This may have been discussed recently already, but I haven't been

following the board as closely as I would like to. My apologies in

particular if you've already addressed this issue as it pertains to

you.

Anyhow, health insurance should NOT be treating MA diagnosis and

surgeries as diagnosis and surgery for the treatment of infertility.

Tests such as HSGs, MRIs, 3d ultrasounds, etc. and surgeries such as

metroplasties (the whole gamut, from lap/hyst resection procedures, to

vaginal septum resections, to the rare case of abdominal procedures -

i.e., Strassman, Thompkins, etc.) are for the diagnosis and treatment

of BIRTH DEFECTS.

Congenital abnormalities generally are not (and in some cases, CAN NOT)

be excluded from coverage, and should be covered at a higher or full

rate, NOT at the same reduced rate that infertility treatment may be

covered at. Surgery required for MAs is for the purpose of returning

the body to " normal " function.

Think of it this way - heck, if the insurance person denying coverage

is male, use this as an example! Some male babies (~1 out of 300) are

born with hypospadias, a condition in which the opening of the urethra

(where urine exits from the penis) is in the wrong place.

Reconstructive surgery involves, in short, putting the opening in the

right place (and creating as cosmetically normal-appearing penis as

possible). If the opening of the urethra is substantially far back on

the penis (or even scrotum), or if it has a severe bend in it, then it

may interfere with urination, sexual intercourse and fertility. So,

does correction of this malformation make it a treatment for

infertility? I THINK NOT! Does it make a difference that surgery for

this condition is typically done between 6 and 18 months of age while

surgery for MAs is typically done as an adult? I THINK NOT!!

While some insurance companies may balk and ultimately not give you any

more coverage, DO NOT let them do this without a fight. In most cases,

framing your issue to them as something OTHER than infertility can be

very successful in getting more coverage.

I can't say this strongly enough. PLEASE, everyone who is still

undergoing diagnostic procedures or looking at resections, MAKE SURE

that you are getting the full amount of benefits that you are entitled

to.

* Make sure that your insurance companies are processing claims for

the dx and tx of a congenital anomaly, and NOT for infertility.

* Make sure that your doctors are coding your treatments and tests for

the dx and tx of a congenital anomaly, and NOT for infertility.

* If need be, emphasize other NON INFERTILITY issues that you may have

in conjunction with your MA to support that this is a congenital

anomaly that warrants proper diagnosis and correction. Do you have

painful periods? Do you have debilitating cramps? Is sex painful? Do

you also have endo and concurrent endo issues?

* If your insurance company still insists that your dx and tx are for

infertility, APPEAL the decision. Have your claim and condition

reviewed by a MEDICAL PROFESSIONAL at the insurance company (not a

claims processor). I believe that our founder, Beth, actually had an

insurance company nurse who helped her get the coverage she was

entitled to, and went so far as to check to make sure she was doing ok.

* Have your doctor intervene in this process if necessary - DO NOT BE

AFRAID TO ASK. Your doc may even have someone on staff who is

experienced in dealing with insurance issues.

* If your employer has a decent HR department, check with them to see

if they have an advocate whose JOB is to intervene on your behalf in

insurance disputes.

< >

Whew. Sorry about the length of this. I just hate to see people not

receive the benefits that they are entitled to (and that they are

PAYING FOR) because some drone thinks that any treatment beyond an

annual exam and any testing beyond an annual pap smear automatically

means infertility which automatically means no or reduced coverage.

< >

Ann

__________________________________

Yahoo! Mail - PC Magazine Editors' Choice 2005

http://mail.yahoo.com

Share bookmarks: http://groups.yahoo.com/group/MullerianAnomalies/links/

Share files:

http://groups.yahoo.com/group/MullerianAnomalies/files/

The Congenital Uterine Anomalies Home Page:

http://www.wegrokit.com/uterineanomalies/

es/

The Congenital Uterine Anomalies Home Page:

http://www.wegrokit.com/uterineanomalies/

[Guest guest]

,

While I'm an attorney, I don't specialize in insurance. With that

said, I would recommend that you get your hands on the actual policy

document - NOT just the summary of benefits, but the full, actual

insurance policy. Who is your insurance carrier? If you want me to

take a look at it, scan it and email it to me.

I can't believe that your insurance policy explicitely states that you

are entitled to only one laparoscopic procedure. What if you had a

suspected hernia, and then appendicitis? Both of these are treatable

via laparascopic procedures. Would they require you to have full

abdominal surgery for the second procedure? Even though such a surgery

would require a more extensive surgical process, more time in the

hospital, more drugs (i.e., more antibiotics, more painkillers), and

have a higher complication rate?

I also have problems with anything involving the fallopian tubes being

mandatorily coded as fertility. What if it were an ectopic pregnancy

(which, also, would be diagnosable and treatable by laparoscopic

surgery)? How about a ruptured cyst? Ovarian cancer? Each of those

have to do with the fallopian tubes, and how could any of those

possibly be considered " infertility " ???

Bottom line - get ahold of the FULL policy. Your HR folks should be

able to help you with that.

Skip the claims department, and ask for - No, DEMAND - an appeal, or a

medically qualified review from your insurance company. Again, not a

claims department person. If that doesn't work, or they won't grant an

administrative review, contact your state's regulatory agency that

regulates insurance providers.

Again, I certainly can't guarantee that you'll get more coverage, but

at least you'll know you've fought the good fight.

I am so sorry that you're having these stupid problems on top of

everything else.

{{{hugs}}}

Ann

--- Carlson firebirdsrule@...> wrote:

>

> Ann,

>

>

>

> Thanks for the advice. In the 2 1/2 months that I had to wait for my

> lap/hyst I did go round & round w/ the claims dept and our co. HR

> director got on the phone w/ our benefits coordinator as well. I was

> told by everyone that:

>

> 1. my ins only covers one Lap per lifetime (so I better make it

> count)

>

> 2. anything to do w/ the fallopian tubes MUST be coded as infertility

> (I had a blockage on my left side)

>

> 3. since the procedures were completed at the same time, they

> wouldn’t split the coverage. (ie. Bill the lap as infertility and

> the hyst as something else)

>

>

> Now that the damage is done, any suggestions on if/how I could appeal

> now?

>

>

>

>

>

>

> Ann Chavie ann_chavie@...> wrote:

> ,

>

> This may have been discussed recently already, but I haven't been

> following the board as closely as I would like to. My apologies in

> particular if you've already addressed this issue as it pertains to

> you.

>

> Anyhow, health insurance should NOT be treating MA diagnosis and

> surgeries as diagnosis and surgery for the treatment of infertility.

> Tests such as HSGs, MRIs, 3d ultrasounds, etc. and surgeries such as

> metroplasties (the whole gamut, from lap/hyst resection procedures,

> to

> vaginal septum resections, to the rare case of abdominal procedures -

> i.e., Strassman, Thompkins, etc.) are for the diagnosis and treatment

> of BIRTH DEFECTS.

>

> Congenital abnormalities generally are not (and in some cases, CAN

> NOT)

> be excluded from coverage, and should be covered at a higher or full

> rate, NOT at the same reduced rate that infertility treatment may be

> covered at. Surgery required for MAs is for the purpose of returning

> the body to " normal " function.

>

> Think of it this way - heck, if the insurance person denying coverage

> is male, use this as an example! Some male babies (~1 out of 300)

> are

> born with hypospadias, a condition in which the opening of the

> urethra

> (where urine exits from the penis) is in the wrong place.

> Reconstructive surgery involves, in short, putting the opening in the

> right place (and creating as cosmetically normal-appearing penis as

> possible). If the opening of the urethra is substantially far back on

> the penis (or even scrotum), or if it has a severe bend in it, then

> it

> may interfere with urination, sexual intercourse and fertility. So,

> does correction of this malformation make it a treatment for

> infertility? I THINK NOT! Does it make a difference that surgery

> for

> this condition is typically done between 6 and 18 months of age while

> surgery for MAs is typically done as an adult? I THINK NOT!!

>

> While some insurance companies may balk and ultimately not give you

> any

> more coverage, DO NOT let them do this without a fight. In most

> cases,

> framing your issue to them as something OTHER than infertility can be

> very successful in getting more coverage.

>

> I can't say this strongly enough. PLEASE, everyone who is still

> undergoing diagnostic procedures or looking at resections, MAKE SURE

> that you are getting the full amount of benefits that you are

> entitled

> to.

>

> * Make sure that your insurance companies are processing claims for

> the dx and tx of a congenital anomaly, and NOT for infertility.

>

> * Make sure that your doctors are coding your treatments and tests

> for

> the dx and tx of a congenital anomaly, and NOT for infertility.

>

> * If need be, emphasize other NON INFERTILITY issues that you may

> have

> in conjunction with your MA to support that this is a congenital

> anomaly that warrants proper diagnosis and correction. Do you have

> painful periods? Do you have debilitating cramps? Is sex painful?

> Do

> you also have endo and concurrent endo issues?

>

> * If your insurance company still insists that your dx and tx are

> for

> infertility, APPEAL the decision. Have your claim and condition

> reviewed by a MEDICAL PROFESSIONAL at the insurance company (not a

> claims processor). I believe that our founder, Beth, actually had an

> insurance company nurse who helped her get the coverage she was

> entitled to, and went so far as to check to make sure she was doing

> ok.

>

>

> * Have your doctor intervene in this process if necessary - DO NOT

> BE

> AFRAID TO ASK. Your doc may even have someone on staff who is

> experienced in dealing with insurance issues.

>

> * If your employer has a decent HR department, check with them to

> see

> if they have an advocate whose JOB is to intervene on your behalf in

> insurance disputes.

>

> < >

>

> Whew. Sorry about the length of this. I just hate to see people not

> receive the benefits that they are entitled to (and that they are

> PAYING FOR) because some drone thinks that any treatment beyond an

> annual exam and any testing beyond an annual pap smear automatically

> means infertility which automatically means no or reduced coverage.

>

> < >

>

> Ann

>

>

>

>

>

>

>

>

>

>

> __________________________________

> Yahoo! Mail - PC Magazine Editors' Choice 2005

> http://mail.yahoo.com

>

>

> Share bookmarks:

> http://groups.yahoo.com/group/MullerianAnomalies/links/

>

> Share files:

> http://groups.yahoo.com/group/MullerianAnomalies/files/

>

> The Congenital Uterine Anomalies Home Page:

> http://www.wegrokit.com/uterineanomalies/

>

>

>

> es/

>

> The Congenital Uterine Anomalies Home Page:

> http://www.wegrokit.com/uterineanomalies/

>

>

>

>

>

>

>

>