Anyone have health insurance issues for OATS procedure?
BCBS of South Carolina considers it Investigational. I'm in Pending status right now. I'm praying for approval as it is my last option at this point to fix my ankle. I feel like I"m the only one whose insurance company has issues with this procedure. What was your experience like with insurance paying for OATS procedure?
Re: Anyone have health insurance issues for OATS procedure?
I have UHC but had no issues with them covering the OATS procedure, although they did require pre-certification beforehand (the surgeon's office did that) because it was inpatient surgery.
I did have the drilling done in Oct 07 which failed which is why I needed OATS, but never heard from the OS or UHC if that was a factor in them covering it.
Re: Anyone have health insurance issues for OATS procedure?
That is good to know. My dr. was shocked that the insurance company considers it investigational. I don't think he ever had any issues with it before either. I also had the drilling 2 years ago and it didn't work. I'm hoping since I've already had failed surgery and the MRI clearly shows it is back again, that they will cover it. I don't know how long I'll stay either. My dr. said he'd keep me overnight since I have some issues with anesthesia, his nurse said it was 23 hr observation so that it will be considered outpatient, but when I look at my insurance website for my pre-authorization status it says pending for inpatient hospital. I'm also having a cadaver tedon transfer to reconstruct ligaments as well as the OATS procedure. It seems like I haven't read about many if any people going home the same day after this.
Re: Anyone have health insurance issues for OATS procedure?
I just found out today that I've been denied. Now what? I'm left messages with the insurance company to see what can be done. The lady at the dr. office who does precertification just said that "You need to decide if you want to pay for this out of pocket." Big help she is.
Re: Anyone have health insurance issues for OATS procedure?
I am sorry to hear that it was denied. I am surprised too as I thought if the dr can prove the medical need for it, it wouldn't be a problem.
I would talk to your insurance co to see if perhaps its just more justification they need (some form or letter of some sort) that your OS could supply to further justify the need for it. Then I would talk to your OS, not the person who does the pre-cert for his thoughts on next steps.
I am so so sorry to hear this. Please keep us posted on how it goes and perhaps in the meantime, some folks on here could lend some advice on how they forged through this.
Re: Anyone have health insurance issues for OATS procedure?
Well, here is where I stand. I'm back in pending during state 2 appeals. My dr. is going to dictate a letter today. IT should be transcibed tomorrow and hopefully faxed over tomorrow or Thurs. The insurance person at BCBS said that it will probably be denied again and then I need to move on to an external review. So, I'm off to research what I need to do for that while I wait to be denied again. BCBS seems to be standing by their policy of not covering investigational procedures even though the rest of the world doesn't consider it investigational. I am so frustrated because I'm in so much pain and this seems like my last hope for a normal feeling ankle, I'm only 39 so it isn't like I'm so old I can get an ankle replacement.
Re: Anyone have health insurance issues for OATS procedure?
Kris,
I would definitely fight this. I have BCBS with the Federal gov't. It seems that it would be the same coverage even though you're not through the feds. Montana and Idaho BCBS do consider this procedure experimental but medically necessary with a Dr.'s recommendation. So my whole procedure was covered. I did get a pre-service review done just to make sure they were okay with OATS since I had never had any other procedure (no drilling). You can use me as an example if you'd like. I had OATS knee to ankle done in Boise, ID under BCBS of Idaho and it was covered totally - inpatient. This seems to me to be a very inconsistent policy by BCBS. And I've had excellent results so the procedure is definitely worth the risk if you have no other choices. I'm also 39 and I couldn't live with my OCD anymore!
Re: Anyone have health insurance issues for OATS procedure?
Abby,
I saved the BCBS Montana statement for OATS. They have much different wording that SC which states it is Investigational and therefore will not be covered. It was denied for being a plan exclusion.
I'm going to fight this. I'd love for it to be approved internally, but I think it won't be. I think since they state it is investigational and their policy is to NOT cover investigational procedures then I'll have to take it to the state external review. The good news there is that a specialist will look at the info and can over rule BCBS policy about investigational procedures.
I don't know how much weight a dr.'s letter gives. I'm hoping he doesn't forget and it gets done today.
Re: Anyone have health insurance issues for OATS procedure?
Kris,
Well OATS is investigational in the BCBS Montana language, but it can also be medically necessary. So why does SC have a problem with the investigational definition if that is really your only option? How frustrating is that! I think Dr.'s have a very important voice in helping approve these procedures. Can you go out of state and be covered? There was not a Dr. that could treat me in MT, but I found a specialist in Boise and was covered by Idaho BCBS. There's no way you can pay for this out of pocket unless you're rolling in dough. My total cost without insurance was about $30,000. That office lady was a little wacko to suggest that. I would ask if there is another BCBS plan you can enroll in during open season that would not have OATS as a plan exclusion. I did wait and changed my BCBS plan last fall from standard to basic and for me that was a huge savings and was worth the wait. That was what worked best for me - maybe there's a better plan for your situation.
Re: Anyone have health insurance issues for OATS procedure?
I thought about switching insurace companies or just adding a second for me during the next year. I think we have the best policy BCBS offers at my dh's work. If I go out of state, wouldn't; my sc insurance still pay?
I wonder if getting another insurance policy would exclude me from coverage for this. Probably or everyone would be doing that I guess. I'm going to see what my dr.'s letter says. Why they didn't send it in the first place is beyond me. I hope he knows what to do and the right paperwork to fill out because their insurance person at the office surely didn't know anything. I'm not sure how external review works yet. I know they can override the investigational thing. I had my hopes up earlier when I was in pending status. I thought it just meant they needed one more form or letter, but I think it just means it is actually being looked at.
I don't know why they consider it investigational. It has been around for awhile, hasn't it?
Re: Anyone have health insurance issues for OATS procedure?
My dr. still hasn't dictated a note for the insurance company. I actually went in there today to get my records. NOt only did they only give me the records for my last 2 visit, but his medical assistant told me it could take all week before he dictates a letter and another week for someone to transcribe it.
I'm serioulsy wondering if I should make another appt. asap with my dr. to see what can be done and maybe to get him moving a bit faster on this.
I really don't know how involved dr.s are with the appeals process.
Re: Anyone have health insurance issues for OATS procedure?
Hey Kris,
I don't know what 'investigational' entails. There must be a certain amount of patients over a certain number of years with a % of success that lets them reclassify OATS as not investigation. I know my Dr. has a lot of confidence using OATS for his patients but he does say there's no real data out there supporting success in the long term. I think the data they have now goes about 7-10 years out. So, it will remain investigation for the time being. But there are a lot of procedures that are investigational but still medically necessary. That's the case your Dr. has to argue for you.
I hate to say it but you may need to wait the 2 weeks for your Dr. to send in the request. There's just no hurrying Dr.'s/Insurance co.'s too much. I called my Dr. office one day and they had 6 surgeries that day. Unless it's a medical emergency they are too bogged down to get these things written immediately. Especially the OS specialists/gurus. You want an exceptional foot and ankle surgeon to do this procedure and they are usually very sought after! Kim understands what it's like to wait for the surgery and try to put up with the pain in the mean time. Maybe she can suggest things?
I'm realizing that my Federal BCBS has extremely good coverage. When I called to change my plan I asked about the 'pre-existing condition' factor, if I could switch and be covered. Well, if you are a federal employee, there's no such thing as pre-existing. This is the coverage Congress has created for themselves and as a lowly forest employee I get the benefits of that. So maybe you're not able to change plans or go out of state. But you can ask. I thought BCBS could cover you in any state as you travel. I would ask about that.
Re: Anyone have health insurance issues for OATS procedure?
Hi Kris,
Sorry to read about your insurance woes. I have Medicare and I don't think the two surgeons I had have billed ( I already have paid my portion for the hospital).
The one thing that comes to mind is your husband's employment. If your insurance is through him, you should find out if there is a person who handles employee benefits and talk to them. The employer may have some leverage or at least a contact at BCBS worth talking to. After all, the employer is PAYING for benefits and may have a bit more leverage with BCBS. You are receiving the benefits and BCBS doesn't want to pay if they don't have to. When I had coverage thru work I found it much more effective to have work sort it out with the insurance, after all the employer could take their business to another company.
Re: Anyone have health insurance issues for OATS procedure?
Hi Kris,
I'm sorry to hear you are still having troubles, but I am confident once your OS gets the letter written to prove how badly you need this surgery, it will happen. (Just please make sure he knows that its been denied ... perhaps there is a way he could state what he needs to in whatever terms he needs to, to show the dire necessity of this.)
As Abby mentioned, I did have a problem with a delay with insurance, but mine was because my surgeon was just applying to be in the United Healthcare network. It took 8 months from the time everything was submitted to when everything was finalized so of course in the meantime, whenever I saw him it was out of pocket for me ... I had to wait until everything was done which was on May 1 and I scheduled my surgery in May for August.
Unfortunately becoming friends with my OSs office staff (well not friends, but friendly enough from going to him for over a year) and knowing an Executive at UHC who tried to expedite things really didn't move things along - unfortunately insurance co's move along at their own pace. I would absolutely stay persistent with both your OSs office and the insurance co to do whatever you can to move it along - if it means bordering on being a nudge, I would do it - this is your life you are talking about.
I wish I could offer you some comfort and suggestions during this waiting period as I know it is frustrating enough without having to be in pain at the same time. Honestly, I cried alot ... prayed alot and probably yelled at my husband more than I ever had out of frustration ... but don't give up.
Please keep us posted if there is anything we can help you with or even if you just need to vent. We've all done it and still continue to do it, even through our recovery.
Re: Anyone have health insurance issues for OATS procedure?
Hey ya'll,
Thanks for all your responses. I guess it wouldn't hurt to call my dh's HR person at his work to see what she has to say about the insurance. Unfotunately they are a small company so I don't know how much leverage they have.
I don't know how much is too much to bug the OS office and insurance company. It almost seems to me that the dr. hasn't done many letters for investigational reasons. He told me he never had an issue getting an OATS procedure done. I'm assuming he has written letters before. He is fairly young, but I know he has done these procedures and he has done a fellowship where he did them as well. He is fairly new, just 1 year in my state though. So do I hint to his office that it would be most helpful if he also included medical journals reports showing the effectiveness of OATS after failed drilling or do I just assume he'll do that. Do I just ask for a phone call with him or should I call and make an appt?
Do I call my insurance company again and talk to them? I know they don't have his letter as of today because yesterday he hadn't even dictated it yet. Do I go to the OS office and hand them BCBS policies from other states showing they consider OATS a medical necessity in situations like mine?
I don't want to be a pest, but I don't want to just wait and hope things get done either. So if I have to wait 2 weeks, that is okay as long as I know the insurance company has all the info, including journal reports and other BCBS policies to compare theirs to. I'm assuming everything needs to be sent to the insurance company in one nice packet, so I probably shouldn't be sending stuff myself. I don't want the dr. to think he doens't know what he is doing in terms of his letter writing, but I'm not so sure JUST a letter will work. I have to convince BCBS to change their policy for my case.
So how much is too much pestering do you think?
Thanks for the support ya'll. I can't sleep at night because of this. I went from absolutely terrified and horrified at the procedure to acceptance to now anger that it can't be done. I know ya'll can relate to the pain. I'm so angry that an insurance company can think that living with this pain is okay.
I also need to clarify with my dr. what plan B is if we never get this approved. I was going to have a Colville and Brostrom repair done at the same time (allograft tendons to take over for my stupid ligaments and then sew up my wimpy ligaments to make them as good as they can get). This was to help the OATS have a better success since I have so much instability even after a Brostrom repair 2 yrs ago. So it almost sounded from reading my office visit notes that he'd just do a scope to clean up the OCD's and forget the Colville surgery. I need to get that straightened out too. I'm not sure if the insurance approved the allograft either.
Re: Anyone have health insurance issues for OATS procedure?
Kim,
Instead of calling them and asking if they have included all these documents, you call them and ask what all goes into a letter of medical necessity. I would just say, I have no idea what's involved in these reviews. What does the Dr. send in? Then you aren't pressuring them but you're still getting your answers.
It is criminal of the insurance companies to deny treatment to people when it is fully covered by many other companies. That's the American way unfortunately. It shows you how many people really suffer until they can get approved for treatment. Or worse, 50 million people in this country don't have any insurance so they just have to live with their conditions!
Re: Anyone have health insurance issues for OATS procedure?
Abby,
That is a great way to approach the question to the dr. I didn't want to sound like I was questioning the way he does his job, but I just wanted to make sure it was done the way BCBS wants it done. It is stupid that drs even have to deal with this instead of doing THEIR jobs. I wonder how much time is taken each day talking to insurance companies. I have a friend whose dh is a peds thoracic surgeon. SHe told me that one time he got a call from a person from the insurance company telling him that he had the wrong diagnosis. She was telling the dr. this! Like the person (not even a dr. or nurse at the insurance compay) knew more than he did about thoracic surgery. It is really stupid how insurance companies do this. I pay my dues each month. I've paid my deductable for goodness sake. Now I expect them to actually pay for something that will ultimately probably save them in the long run.
Re: Anyone have health insurance issues for OATS procedure?
My what a day it has been! At 4:50 all I knew was that the medical review appeals was going to look at my case on Tuesday. My dr. had not yet dictaed a letter and he had gone home for the day. I left 3 messages today with his medical assistant begging her to somehow let him know the note had to be there by Tuesday. I had given up hope and was prepared to fax a note to the insurance company with all my additional info plus letter I wrote and let them know that his letter wouldn't be there in time.
Then, about 15 min ago my dr. called. He said he dictated the letter and asked for a 4 hr turn around with the transciption place, apparently the fastest they can ask for, and that he should have it on his desk on Tuesday. I thanked him for doing this. I was so happy that it got done, finally. He had been in surgery today and yesterday. Anyway, tomorrow I"m faxing all my info and letting BCBS know they should have his letter there on Tuesday. I did ask him, Abby, what he wrote and he told me that it was a complex case cause of the failed surgery, my instabilty, etc, etc, and that this was basically my only solution to a normal life and that I wouldn't get better without the surgery. (I paraphrased here).
So now I have hope again. The insurance company today told me that they send it to another dr. and then if he looks at it and says, "I don't know what to do with this" then it goes to their own external review and they have an OS look at it. I'm also sending over all the other BCBS policies that say it is a medical necessity. So wish me luck!
Re: Anyone have health insurance issues for OATS procedure?
Kris,
What fabulous news, they will get the letter! Doesn't take away all the stress lately but look at it as the first victory and try to enjoy your weekend. I have confidence, based on your paraphrasing, that this will all work out, it just may not be on your time table.
About the stress, watch out for it! The month before my OATS I was so stressed I cracked a tooth (night jaw clencher) and was then in need of a root canal and crown and my endodontist was on a cruise! They were able to get it all done before my scheduled surgery knowing that the surgery would be postponed if I had anything temporary in my mouth. I never imagined I could stress my way to fracturing a tooth!
So my advise is to try to relax about it and think positively! I believe the Doctors and the insurance companies speak the same foreign language (aka medical coding) and will work it out. Probably when they hear from the Doctor they will back down.
Re: Anyone have health insurance issues for OATS procedure?
Kim,
You are out of a cast at 4 weeks? When did you get put in a boot?
Today I faxed over about 60 pages to my insurance company that included a letter from me, medical journal info on the OATS procedure as well as several medical policy pages from other BCBS companies in other states that process OATS as medically necessary.
I guess I'll find out this week. I hope they are either so overwhelmed with info that they approve it or they actually read the pages and see what a backward policy SC has.
