OATS is not a gauranteed surgery - Foot Problems Message Board

K_Lana · 05-11-2009, 08:57 AM

Dawn,
I responded to your other post about the insurance thing. I would seek legal advice for this if the insurance company denies another peer to peer when they didn't give you an actual peer review. Also, your previous dr. was a dipstick by letting this go and not addressing it.
I'll be curious to see how this goes. I'll say a prayer they approve it soon.

akirka · 05-11-2009, 02:09 PM

Ok - here's a thought for those having insurance problems:

I know this may sound crazy but here it goes:
So my OATS surgery cost $9,000
My hospital stay cost $12,000
My PT was ~ $6,000
My appts/casts/misc cost ~$3,000

So out of pocket my foot would have cost me $30,000 with no insurance.

Margaret's insurance would not pay for the donor bone and that cost here I think $7,000 but the rest was covered.

Kim's insurance wouldn't pay for the surgery itself but the rest of it.
I think her Dr. worked with her to get her bill down to $3,000

Other people have had surgery and then won their insurance cases later on. So worse case scenario would be paying ~$30,000 out of pocket and probably far less with no insurance. If the insurance pays most of the cost but doesn't cover certain procedures you might be paying $5,000 to $10,000. I know that's a lot of money - believe me, people in MT do not make large wages, but it's still do-able to get a functional foot. Now if you were getting a heart transplant for a 1/2 million that wouldn't be possible, but this surgery cost the price of a new car and we're willing to pay that for a hunk of metal. I think we should be willing to go for the cost with our own bodies. What do you guys think? It's sad that the insurance denials make you go there but it's just a thought.

kimberp · 05-11-2009, 02:22 PM

Just to clarify on Abby's email ...

Total cost of my OATS (autograph) was $27,000 of which all was paid except for $3,000 which was listed as my surgeon's cost ... so $24,000 was paid and 8 months later I still see paperwork going back and forth between my doctors office and the insurance co trying to get the $3,000 covered. My doctor's office has yet to come to me for the $3,000 but according to my insurance company they can't if I didn't agree to pay it before the surgery.

I'll keep you posted should I receive a bill for the $3k, but nothing so far.

It makes no sense to me at all how they would pay the $24k and call the remaining $3k 'investigational.' I am thankful they paid what they did but don't understand the logic.

Kim

K_Lana · 05-12-2009, 09:12 AM

I had the same thing happen. My surgery costs were closer to $50k with various other procedures, week long hospital stay, ER visit, etc. But they covered everything and then denied the $3k or so for the OATS, even after saying they would. My dr. office billed another code after I had the first code they wanted approved. They are still working out details like Kim's are, but the thing is, they did pay for the rest of it. It is kinda weird they pay for the rest of everything and then deny the reason for the surgery. Maybe it is the actually getting the plugs from the knee they aren't paying for just like Margaret's didn't pay for her allograft. Maybe if we showed up with our own allograft our took our own plug out (not that that is possible, but you kwim) then we would never have insurance woes?

akirka · 05-12-2009, 11:45 AM

Kim,

I know the thought of going back in is crazy!! I shouldn't even suggest the thought of that!! I was just thinking they could do a little arthroscopic tiny hole with a micro camera and just look around a bit. Yeah, easy for me to say when it's not my foot!

In Star Trek they could just put a little nanobyte in you and it would make it's way to your foot and do repairs on it's own. Or just land on the imaginary Lost island and it will miraculously be healed! Too bad were still in a barbaric age of bone saws and such. Eww, just the thought of what we've done to our bones makes me shutter a bit ...

So the point of my last post would be that if my insurance denied me I would go through an appeal, have the surgery and then let the appeal work out. Then pay whatever comes out in the wash. They can't take your foot back and that is the primary goal to get the best treatment you can! Everybody's tanking in the economy so why not join the masses with Dr. bills?

I'm in a weird mood today ... must be the rain slogging my brain ....

Abby