Re: Insurance out of network question - Empire BCBS

[Guest guest]

I don't know if it is an option for you, but my son's Hanger helmet is only going to be $1500, start to finish. We are also going thru insurance battles right now.

From: "heathersmith310@..." <heathersmith310@...>Plagiocephaly Sent: Tue, June 8, 2010 2:24:11 PMSubject: Insurance out of network question - Empire BCBS

We are going through Cranial Technologies for the DOC Band and it's out of network on our insurance (Empire BCBS). They will only reimburse the 'reasonable and customary amount' which was guessed to be about $700. The DOC Band is $3800 though! Does anyone know how to get this reasonable and customary amount to be higher? How does this amount get determined? Any success in a situation like this?Thanks!

[Guest guest]

Our insurance just approved my sons docband from CT. We have BCBS HMO. We got the detailed form that stated they were only paying $1900 and because it is an HMO the rest of the bill gets written off and nobody pays it. Each insurance pre-determines their Usual and Customary fee. I don't know that that is negotiable in any way. From my understanding of medical billing, and please somebody let me know if I am wrong. Medical facilities are required by law to charge the same set price for any given procedure regardless of a person's insurance. They can choose to charge whatever they please but usually base their charge on whichever insurance pays the most. For example BCBS may pay $100 for an office visit and Humana may pay $80 for the same visit. The medical facility would be stupid to set there fee at $80 because then of course they would lose the $20 for every BCBS member. The office may charge $150 for a visit, accept what they can get from insurance and then depending on what your insurance dictates, the patient may be responsible for a portion of the rest or it may get written off. For a self pay patient with no insurance, a lot of offices give a discount if paid up front in full at time of service. Unfortunately with the helmets, a lot of insurance companies view them as cosmetic or simply is not a covered benefit based on the plan which was set up usually by an employer. That is one way employers are able to provide cheaper or free insurance to the employees, cut out certain benefits.

I know it really sucks to think we pay for insurance, and a lot of people pay large premiums, thinking everything should be covered. Since I have learned over time about how medical billing really is, I have coped with the frustration by just accepting it. Fight tooth and nail and then if all else fails, accept it and move on. I now compare medical insurance to my car insurance. If I get into an accident, I know the insurance will step in, maybe not for all of it, but still for a lot. But if my car needs a tune up, oil change, new tire, or some touch up paint, I know State Farm would probably laugh at me if I expected them to pay.

I am not saying not to appeal their decision or try to work something out with Hanger. Write yourself a good letter to both places. Make a few phone calls. I don't understand why some of these providers aren't willing to give bigger discounts for self pay people. Crantial Tech for example is only getting $1900 from my insurance, but if I paid out of pocket, even in full the cheapest I would get off is $3500. You would think anything over the $1900 would be great for them, considering some people, if their insurance won't pay, just can't afford it. Isn't $1900 then better than nothing?

Alright, I am done ranting.

Jen

Insurance out of network question - Empire BCBS

We are going through Cranial Technologies for the DOC Band and it's out of network on our insurance (Empire BCBS). They will only reimburse the 'reasonable and customary amount' which was guessed to be about $700. The DOC Band is $3800 though! Does anyone know how to get this reasonable and customary amount to be higher? How does this amount get determined? Any success in a situation like this?

Thanks!

[Guest guest]

,

There's nothing you can do to change the " usual and customary " amounts set by

the insurance companies. They pay according to their own guidelines. We have

Care First BCBS(DC/MD/VA)and they paid about two-thirds the cost of my

daughter's helmet with a preferred provider(we still had to pay the

difference($1,000) because of special rules with this provider--not written off

as normally would be the case.) If we had gone out of network with Cranial Tech,

the insurance would have only covered one-third of the cost.

Our daughter got such great correction that we are just happy the insurance paid

what it did. Some insurance companies don't cover banding at all.

-Amy

>

>

> Our insurance just approved my sons docband from CT. We have BCBS HMO. We

got the detailed form that stated they were only paying $1900 and because it is

an HMO the rest of the bill gets written off and nobody pays it. Each insurance

pre-determines their Usual and Customary fee. I don't know that that is

negotiable in any way. From my understanding of medical billing, and please

somebody let me know if I am wrong. Medical facilities are required by law to

charge the same set price for any given procedure regardless of a person's

insurance. They can choose to charge whatever they please but usually base

their charge on whichever insurance pays the most. For example BCBS may pay

$100 for an office visit and Humana may pay $80 for the same visit. The medical

facility would be stupid to set there fee at $80 because then of course they

would lose the $20 for every BCBS member. The office may charge $150 for a

visit, accept what they can get from insurance and then depending on what your

insurance dictates, the patient may be responsible for a portion of the rest or

it may get written off. For a self pay patient with no insurance, a lot of

offices give a discount if paid up front in full at time of service.

Unfortunately with the helmets, a lot of insurance companies view them as

cosmetic or simply is not a covered benefit based on the plan which was set up

usually by an employer. That is one way employers are able to provide cheaper

or free insurance to the employees, cut out certain benefits.

> I know it really sucks to think we pay for insurance, and a lot of people pay

large premiums, thinking everything should be covered. Since I have learned

over time about how medical billing really is, I have coped with the frustration

by just accepting it. Fight tooth and nail and then if all else fails, accept

it and move on. I now compare medical insurance to my car insurance. If I get

into an accident, I know the insurance will step in, maybe not for all of it,

but still for a lot. But if my car needs a tune up, oil change, new tire, or

some touch up paint, I know State Farm would probably laugh at me if I expected

them to pay.

> I am not saying not to appeal their decision or try to work something out with

Hanger. Write yourself a good letter to both places. Make a few phone calls. I

don't understand why some of these providers aren't willing to give bigger

discounts for self pay people. Crantial Tech for example is only getting $1900

from my insurance, but if I paid out of pocket, even in full the cheapest I

would get off is $3500. You would think anything over the $1900 would be great

for them, considering some people, if their insurance won't pay, just can't

afford it. Isn't $1900 then better than nothing?

> Alright, I am done ranting.

> Jen

>

>

>

>

>

>

> Insurance out of network question - Empire BCBS

>

>

> We are going through Cranial Technologies for the DOC Band and it's out of

network on our insurance (Empire BCBS). They will only reimburse the 'reasonable

and customary amount' which was guessed to be about $700. The DOC Band is $3800

though! Does anyone know how to get this reasonable and customary amount to be

higher? How does this amount get determined? Any success in a situation like

this?

>

> Thanks!

>

>