Re: It's not about lying, guys.

[Guest guest]

Chris...

If that's truly the way it works, and the insurance company

understands the same thing the doc does, and if everybody is playing

the same shell game by the same (mutually understood rules) I have no

problem. If the doc writes something that SEEMS to comply with an

insurance company coding, but is actually something else...I still

gotta say...that's not telling the truth. And if CIGNA is rejecting

these more than it's accepting them at JRI...but paying as much as

75% for a BHR Belgian resurf, I have to ask some serious questions.

(But, I must be honest: many people have said I'm too rigid about

such things.)

Whatever my issues might be...you seem to to doing quite well...and

that makes you an exemplar of what's possible, however we pay for it.

All the best,

Alan

> As I understand the whole " coding " deal, when a procedure is

> submitted it has a numbered code. If the Resurf is submitted as a

> miscelaneous (or mutant/experimental) procedure, it's not handled

by

> with the same scrutiny as an accepted procedure.

[Guest guest]

Alan,

To be honest, the reason I was concerned enough to ask Chuck

about the possible " deception " involved with he coding was to be

sure that I didn't end up with the bill after they got " caught " . As

well, I wouldn't be comfortable being a thief, even if it was a

stinking insurance company that I was hornswaggling. And to be sure,

something transpired between the time I was resurfed (billed as a

THR but with the device disclosed) and now, cuz they sure don't want

to bill it that way now. But I suppose I get defensive about it when

it seemed to be implied that either I or Dr. Amstutz office would

knowingly lie or steal. Cuz it just didn't go down like that, and I

doubt it ever did at JRI. It just doesn't add up that a mogul (sp?)

like Dr. A would do something slimy like that, and I feel it may

impune his good name to suggest as much. (not that you did, but some

have). It's als about the facts in here.

C+ Amstutz 4-15-04

> > As I understand the whole " coding " deal, when a procedure

is

> > submitted it has a numbered code. If the Resurf is submitted as

a

> > miscelaneous (or mutant/experimental) procedure, it's not

handled

> by

> > with the same scrutiny as an accepted procedure.

[Guest guest]

You lucked out by having Aetna insurance. Aetna is one of the few

insurance companies that has accepted resurfacing as an alternative

to THR. See Aetna Clinical Policy Bulletin Number 0661 (availble as

a link here in surfacehippy or below).

http://www.aetna.com/cpb/data/CPBA0661.html

Fred

Dr. Gross, C2K 1/21/04

-- In surfacehippy , " Roche "

wrote:

> As I understand the whole " coding " deal, when a procedure is

> submitted it has a numbered code. If the Resurf is submitted as a

> miscelaneous (or mutant/experimental) procedure, it's not handled

by

> with the same scrutiny as an accepted procedure. I talked to Chuck

> about it at JRI, and they always submitted it as a tip replacement

> with an experimental device. It was disclosed from day one. It's

> just a way of using a different door to enter the approval/refusal

> process. It is, in fact, a hip joint replacement. And if the

device

> is disclosed, where is the deception? Mine was handled that way,

and

> I assure you that I feel no fear of cosmic payback. My hip joint

was

> replaced with a C+, and AETNA knew what device Dr. Amstutz would

use

> before he even scheduled me. While I understand your apprehension

to

> invoke Karma, I would encourage you to understand that the

reputable

> surgeons performing the resurfs are not likely to use skullduggery

> to dupe insurance monsters. I could be wrong. Maybe a Doctor could

> elaborate. But I will tell you that I did have the chance to sit

and

> talk with Chuck, and (if my poor feeble memory serves correctly)

the

> above was the basic jist. And besides...people with bad hips

> shouldn't ride on high horses.....(sorry, I couldn't resist). OK,

> Alan and , I'll take my ass whoopin' like a man now.

>

> C+ 4-15-04

[Guest guest]

You lucked out by having Aetna insurance. Aetna is one of the few

insurance companies that has accepted resurfacing as an alternative

to THR. See Aetna Clinical Policy Bulletin Number 0661 (availble as

a link here in surfacehippy or below).

http://www.aetna.com/cpb/data/CPBA0661.html

Fred

Dr. Gross, C2K 1/21/04

-- In surfacehippy , " Roche "

wrote:

> As I understand the whole " coding " deal, when a procedure is

> submitted it has a numbered code. If the Resurf is submitted as a

> miscelaneous (or mutant/experimental) procedure, it's not handled

by

> with the same scrutiny as an accepted procedure. I talked to Chuck

> about it at JRI, and they always submitted it as a tip replacement

> with an experimental device. It was disclosed from day one. It's

> just a way of using a different door to enter the approval/refusal

> process. It is, in fact, a hip joint replacement. And if the

device

> is disclosed, where is the deception? Mine was handled that way,

and

> I assure you that I feel no fear of cosmic payback. My hip joint

was

> replaced with a C+, and AETNA knew what device Dr. Amstutz would

use

> before he even scheduled me. While I understand your apprehension

to

> invoke Karma, I would encourage you to understand that the

reputable

> surgeons performing the resurfs are not likely to use skullduggery

> to dupe insurance monsters. I could be wrong. Maybe a Doctor could

> elaborate. But I will tell you that I did have the chance to sit

and

> talk with Chuck, and (if my poor feeble memory serves correctly)

the

> above was the basic jist. And besides...people with bad hips

> shouldn't ride on high horses.....(sorry, I couldn't resist). OK,

> Alan and , I'll take my ass whoopin' like a man now.

>

> C+ 4-15-04

[Guest guest]

> I must be honest: many people have said I'm too rigid about

> such things.)

That's okay, Alan - get that hip fixed and you won't be anywhere near

as rigid as you are now ;-).

As I understand it, the total hip arthroplasty CPT code (27130, I

think) is defined as a replacement of both articulating surfaces of

the hip joint.I don't think there's anything in the code definition

which specifies the use of a stemmed device. Whether the insurance

companies *understand* it to mean " a replacement of both articulating

surfaces of the hip with a conventional, FDA-blessed, stemmed device

that requires lopping off the femoral head and then pounding a 6 inch

spike down the center of some poor bastard's femur " is another matter

entirely.

I've come to the conclusion that insurance companies are run by

sadistic lunatics who are clearly a danger to themselves and others.

Steve