JAG (SORRY PALADY, FIBRO FOG KICKED IN)

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Retired Mom
Veteran Member


Date Joined Feb 2010
Total Posts : 1753
   Posted 3/30/2010 3:43 AM (GMT -7)   
I'm sorry to have to start a new thead on this, but I saw where you responded to mine and I didin't wan't you to miss the information.
 
Be vary careful with the insurance on the RFA.  Apparently the insurance company denied because they said it was not an approved practice.  The other injections were approved.   I DID get stuck with the bills....so be wary of the sign here clause they are handing you.  So far, it's about $5000.00 out of pocket.  I simply do not have it.  Also, this doctor is a participating physician and on the "good" list for the insurance company.
 
When I was talking the the PM yesterday, he commented that there would be a lot more denials like this now but didn't elaborate.  Please, please, please make sure everything is done.  They (the dr's office) assurred me BEFORE the procedure that the precert had been done and approved.  After I received my response from insurance (about 2-3 months later), they still assurred me that I had been pre-approved and would have no problem.  As of yesterday, the other denial came in and I am still responsible.  I'll be filing an appeal today, but who knows what that will do....
 
All the best!


Formerly PrayingForRealRelief...
 
DDD, CHRONIC PAIN SYNDROME, TLIF L5-S1 2009 (failed), FIBRO, MINEYER'S (SP?), VERTIGO, MIGRAINES, GERD, SLEEP DISORDER, NISSEN FUNDOPLICATION (failed), DEPRESSION, EXTREME ANXIETY DISORDER, OCPD, PTSD, CHRONIC MUSCLE SPASMS, HUMAN GROWTH HORMONE DEFICIENCY, VITAMIN D DEFICIENCY, CARPLE TUNNEL SYNDROME, EXTREME IDIOPATHIC HYPOGLYCEMIA FROM AGE 12
 
 
 
 

Post Edited (retiredmom) : 3/30/2010 1:27:31 PM (GMT-6)


PAlady
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Date Joined Nov 2007
Total Posts : 6795
   Posted 3/30/2010 11:31 AM (GMT -7)   
Hi, Retired,
I think you must have been referring to someone else because I'm not getting an RFA. I can't offhand recall the member but he/she may be on your thread (is it bsjag?).

I agree I'd never have a major procedure done of any kind without a precertification number from the insurance company. Now it sounds like you may have that, and if so that should strengthen your appeal because RFA's aren't new, so if they're now saying they're not an approved practice, something must have changed. But if they formally approved it by precertification, then they should have decided that before their approval.

Insurance companies are notorious for denying things and hoping people don't appeal. So you go for it! But make sure to keep all your paperwork - keep copies of everything, and if you can find a precert. number use that in every correspondence with them.

Now also make sure that your insurance plan didn't change somewhere in between when the procedure was precertified and when you had it. Insurance plans are usually renegotiated with employers annually, sometimes starting Jan. 1, sometimes July 1, or even on other dates. So if your insurance plan had previously approved it, but then the plan changed in that time period between approval and when you had the procedure, that could be an issue. Make sure that's not the case. Approval can be because the insurance company is no longer approving a procedure itself - for anyone - or an employer changed its plan, usually to something less expensive, and therefore certain procedures, etc. that were covered are no longer covered. That's why checking even with your insurance the day before a procedure never hurts.

The hospital or doctor should do this, but they technically aren't the responsible party. If you read all the fine print when you sign most insurance and billing forms the bottom line is you're responsible for what the insurance does not pay.

I'll be curious to follow this and see what happens for you. If the insurance company itself is screwing with you (and you're sure your plan didn't change via your employer) you can always file a complaint with your state's insurance commissioner. Insurance companies hate that because it brings scrutiny to their practices - but make sure all your ducks are in order before you do that.

Good luck!

PaLady

bsjaguar
Veteran Member


Date Joined Jun 2009
Total Posts : 974
   Posted 3/31/2010 4:17 AM (GMT -7)   
Thanks for replying, Mom! I had previously been scheduled for the rf on March 5th but had to reschedule due to my husbands work schedule to April 12th. The lady at the docs office wasn't aware of the change and called me on March 4th to tell me that the pre-cert wasn't through and that I'd have to sign a waiver before having the procedure. I informed her of the change and asked her to get the pre-cert moving because I would not have the procedure done without it. Hopefully it will be through by April 12th but if not, I guess I'll have to wait a little longer.

I am really counting on this nerve ablation because it is my only chance for relief from this constant lower back pain. I guess the only other option would be surgery to remove the osteophytes but bone spurs always grow back so even surgery wouldn't be a life long fix. I've been dx'd with facet syndrome and have bone spurs all along my spine so after we get the lumbar spine better we can hopefully try to get my cervical spine done. This area is getting worse with my left should & arm aching and my ability to lift my arm with even light weight in my hand is getting very difficult. The symptoms remind me of before I had my cervical fusion but the disc are OK from the MRI results. It's just these stupid bone spurs. My osteoarthritis is all inherited from my father. My sister has issues too but she didn't do as strenuous work her whole life so her's hasn't progressed as much as mine has.
---Jag---
 
DDD, osteoarthritis, facet syndrome, fusion surgeries C-5/7 & L-4/5 both in 2006, torn meniscus surgeries left knee 2000 & 2002, buldging disc L-2/3


bsjaguar
Veteran Member


Date Joined Jun 2009
Total Posts : 974
   Posted 3/31/2010 4:25 AM (GMT -7)   
Mom, I wanted to add that I'm sorry to hear about your insurance problems. The whole thing just stinks. I remember after my lumbar fusion the anesthesiologist turned out to be out-of-network and the insurance company tried to help me out by adding him to some generic network. By trying to help me out it was going to cost me more money but trying to get this through their thick skulls was nearly impossible. They just kept saying, "but we're trying to help you". Idiots, I ended up getting the managers personal phone number and after that I'd just call her direct with any issues. I'm sure she was hating on me but after having surgery, being on all the meds and everything else you have to deal with after surgery I wasn't feeling very friendly.

Anyway, I wish you luck with your appeal & You Go Girl!!!!! Don't let them push you around.
---Jag---
 
DDD, osteoarthritis, facet syndrome, fusion surgeries C-5/7 & L-4/5 both in 2006, torn meniscus surgeries left knee 2000 & 2002, buldging disc L-2/3


PAlady
Veteran Member


Date Joined Nov 2007
Total Posts : 6795
   Posted 3/31/2010 11:50 AM (GMT -7)   
Jag,
It sounds like you know how to deal with these insurance folk. LOL But when I was going through a precert issue (taking a long time) I learned after calling around in my insurance company network a bit that there was a way for the patient to get a precertification number if you had all the correct procedure codes. I got the codes from my docs office. Now I wouldn't recommend this instead of the doc's office getting a precert, as it would be easy to maybe miss a procedure code for an adjunctive procedure (like anesthesia, for example) but you would find out if they even approve RF's to begin with. AND you would also learn if your doctor's office has even called. I found out that it was my doc's office that was the hold up - that my chart was likely sitting on a stack, and it really ticked me off because it held up my procedure at the time. So even calling your insurance you might be able to find out a few things and if they're the hold up, or if your doc's office has even called. I'd hate to see you postpone the April date just because your chart sat on a desk too long.

PaLady

Retired Mom
Veteran Member


Date Joined Feb 2010
Total Posts : 1753
   Posted 3/31/2010 11:53 AM (GMT -7)   
I mailed it just a few minutes ago. I REALLY hope things go well and I can honestly say the the RFA helped me quite a bit. If I can ever get this insurance thing fixed, I'm going to let them do the one that they couldn't do the first time. The muscle and mechanical pain are still there, but the nerve pain is not. That stabbing, shooting, take you to your knees pain was gone from the nerves a couple of weeks after the procedure (except in the spot they could not do). It does hurt terribly, but it's worth it in the end!!! (at least for me)

I'll keep my fingers crossed for you!
Formerly PrayingForRealRelief...
 
DDD, CHRONIC PAIN SYNDROME, TLIF L5-S1 2009 (failed), FIBRO, MINEYER'S (SP?), VERTIGO, MIGRAINES, GERD, SLEEP DISORDER, NISSEN FUNDOPLICATION (failed), DEPRESSION, EXTREME ANXIETY DISORDER, OCPD, PTSD, CHRONIC MUSCLE SPASMS, HUMAN GROWTH HORMONE DEFICIENCY, VITAMIN D DEFICIENCY, CARPLE TUNNEL SYNDROME, EXTREME IDIOPATHIC HYPOGLYCEMIA FROM AGE 12
 
 
 
 


bsjaguar
Veteran Member


Date Joined Jun 2009
Total Posts : 974
   Posted 4/1/2010 1:55 AM (GMT -7)   
I have my monthly appt with my PM on April 5th so I can check with them then to see if the pre-cert is through. Also, for anyone out there reading this, even if your doctors office says that a procedure has been approved it's still not a bad idea to call your insurance office just to double check.

Thanks so much for the info regarding your RF, Mom. After my diagnostic injections I was so surprised that the muscle spasms going all along sideways & up/down my lower back then into my hip were almost gone. I never in my wildest dreams expected that much relief just from one little old nerve. I'll keep my fingers crossed for you on the appeal and that you will be able to continue with your other needed RF procedures.

Ya, PaLady, I can get around insurance companies fairly well after 8 surgeries. You definately have to stay on top of things.
---Jag---
 
DDD, osteoarthritis, facet syndrome, fusion surgeries C-5/7 & L-4/5 both in 2006, torn meniscus surgeries left knee 2000 & 2002, buldging disc L-2/3

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