ANA Discussion Forum
General Category => Hearing Issues => Topic started by: Catflower on March 14, 2008, 08:09:05 am
-
The hospital just called to inform me that BC/BS stated that insertion of the implant and the processor were not a covered service.
Do any of you that have had success with getting BC/BS to pay happen to know the procedure code that was submitted to the insurance?
-
Catflower -
The code should be 69714 (implant, temporal bone with stimulator).
Try calling your doctor or audiologist and have them appeal the BC/BS decision. My audiologist said many insurance companies deny it the first time because they really don't know what it is - but when they send in the medical documentation and a letter from the doctor and audiologist explaining the medical necessity, he's always had it approved.
My insurance company stinks as far as I'm concerned, and if they paid for my BAHA - I would think BC/BS would - they're much better.
Good luck. Sometimes you have to really fight for what you want - it shouldn't have to be that way.
Lori
-
Catflower -
I too have heard that sometimes insurance companies deny coverage the first time, but approve it the second. As Lori pointed out, its oftentimes a matter of educating them as to what you are asking for and why you need to have it.
My insurance company was totally unfamiliar with BAHAs - had no idea what they were or why I would need one - but I found out that they cover Cochlears and used that as part of my case. BAHAs are to unilateral deafness as Cochlears are to bilateral deafness. Once they knew what a BAHA was and got the information from my doctor they decided they would cover it. They also requested a copy of my medical records - probably to make sure I truly was SSD - which is a little amusing to me because they just paid for my AN surgery about 9 months ago and got the surgical reports that say I'm completely deaf in my left ear. Go figure.
Hang in there; I'm hoping this turns out in your favor,
Jan
-
Catflower -
The code should be 69714 (implant, temporal bone with stimulator).
Try calling your doctor or audiologist and have them appeal the BC/BS decision. My audiologist said many insurance companies deny it the first time because they really don't know what it is - but when they send in the medical documentation and a letter from the doctor and audiologist explaining the medical necessity, he's always had it approved.
My insurance company stinks as far as I'm concerned, and if they paid for my BAHA - I would think BC/BS would - they're much better.
Good luck. Sometimes you have to really fight for what you want - it shouldn't have to be that way.
Lori
Lori, thanks for the information. Is that the procedure code or the ICD-9 code?
-
Catflower
It has to be coded like Lori said. I have BC/BS and it paid, less my deductable. Get your doctor to recode it and you should be fine.
Ellis
-
Very encouraging news from Ellis. Hope this helps solve the issue, Catflower.
Let us know how it goes,
Jan
-
Catflower -
I actually don't know what type of code it is. They just referred to it as a billing code or something. Sorry - I've never understood medical billing. ???
Lori
-
Catflower -
I actually don't know what type of code it is. They just referred to it as a billing code or something. Sorry - I've never understood medical billing. ???
Lori
I don't understand the coding either. The only thing I know is that you darn well better have something that can be coded or your SOL. >:(
-
Exactly! And I am beginning to think they're making up the codes as they go along and not telling anyone else about them. Must be a "secret" code!
-
Catflower -
good to see that you say "SOL" also. It's a term I picked up from my father, who used to swear to us when we were kids that it meant "stuck on a log". He also used to say "TS" which he told us meant "tough sailing" ;D
Ah, childhood memories - can't beat 'em.
Any word from the insurance company today?
Jan
-
Catflower -
good to see that you say "SOL" also. It's a term I picked up from my father, who used to swear to us when we were kids that it meant "stuck on a log". He also used to say "TS" which he told us meant "tough sailing" ;D
Ah, childhood memories - can't beat 'em.
Any word from the insurance company today?
Jan
The finance person from the hospital called yesterday. She gave the code Lori mentioned to their "coder" and they are resubmitting it to the insurance using that code. I hope I hear something this week. I'm scheduled for April 8 and that will be here before we know it.
-
I don't know why they bother hiring "coders" when we have to do all the work ourselves. You should send them a bill for services!
I'll keep my fingers crossed for you!!
Lori
-
ICD-9 codes are for diagnoses, and CPT codes are for procedures or treatments. The BAHA code is a CPT code. I will do some digging when I am at work tomorrow (I work for an allergist), and see if I can get some codes of both sorts that maybe we should all know.
Tamara
-
Here's the latest on my insurance saga: The hospital finance person called this morning to tell me the insurance approved the procedure using the code Lori said to use. I asked if that included the processor. She's checking on that now and is to get back to me. I also told her to make sure it's all in writing.
-
Yay! One step at a time!! Stick to your guns - you're almost there!!
Lori
-
Catflower -
yes, definitely get it in writing. I have heard of some insurance companies covering the surgery, but not the processor. Doesn't make sense to me ??? I mean, the surgery without the processor doesn't do anyone any good.
Hang in there,
Jan
-
I mean, the surgery without the processor doesn't do anyone any good.
Except maybe me... ;D
Catflower - good going! It sounds like you have turned the corner, now you just need to get the details ironed out. Must have been the CPT codes. You have avoided the "tough sailing" while "stuck on a log".
Steve
-
Catflower make sure they are using AN as the diagnosis code and not a generic reduction in hearing code. This could make all the difference. You have to make sure the procedure and diagnosis are the right codes and the people they hire to do the billing usually use generic codes if they do not know the specific circumstances of your case. Maybe Tamara can get that code for you. Good luck and keep us all posted. 16
-
I just talked to Blue Cross (in Oregon) and they told me that they will pay for the BAHA surgery under major medical, but they won't pay for ANY of the BAHA device except with their hearing aid benefit ($450, for something that I think costs around $10,000!).
I also heard that Blue Cross reneged on a patient after he'd already had the surgery, and he was stuck for the whole bill. I am suspicious, because Blue Cross also told me that there is NO preauthorization for this--they do a review AFTER the procedure to decide whether they'll pay or not. How backward is that? You consider whether to jump off a $20,000 cliff and they say, "We'll decide for sure whether to catch you AFTER you've already jumped."
I'm waiting to hear the verdict from my other insurer, Kaiser. I'm not too hopeful about that either.
The CPT code that my doctor's office told me would be used is 69714, which is supposed to include the surgery and device.
-
Nancy T -
I think the cost of the BAHA processor is around $4,000 but I'm not sure - haven't seen that bill yet. $10,000 seems kind of high.
The hospital where I had my surgery - approximately 2 weeks ago - billed my insurance company roughly $25,500 and my neurotologist billed them $6,095. I had local anesthesia, so there is no anesthesiologist bill.
The review post surgery does seem very strange. My insurance company told me verbally that they would cover both the surgery and the processor and sent me a letter stating the same thing, but with the added clause that "this isn't a guarantee of payment". The typical insurance company equivalent of CYA ;D
They have had my claims for at least 10 days now and I can see on their website that they are discounting both the hospital and doc's charges but they are still holding onto the payments. They are saying that the claims are "pending further review".
I'm anxious to see if they give me a hassle about issuing the payments. I'm going to give them about a week and then call to see what the problem is.
Jan
-
Jan--yes, I think that's what Blue Cross meant--that they will say they'll cover it, but not guarantee payment until the claim is reviewed. I guess insurance companies can find reasons not to pay (hopefully they wouldn't do that!).
I have been confused about the cost of the device, but I think I've finally figured it out--I think the EXTERNAL processor, the snap-on part, is what costs around $4,000, while the total cost for whole device--the implant, abutment, and processor, in other words all the hardware--is around $10,000. This is what the insurance person at the doctor's office told me and what I saw on the BAHA users' forum.
I'm having a hard time thinking about how I could come up with that kind of money, short of taking out a second mortgage! If I'd known in 1999 (when I lost my hearing) that eventually there would be this expensive, non-covered device approved four years down the road that might help me, I might have started saving some money for it--or I might have thought about suing the doctor(s) who missed my sudden hearing loss and thus my best chance of saving hearing! (Although I seriously doubt I would have sued them, as I'm not litigious and it probably wouldn't have made any difference anyway.)
And even when I found out about the BAHA three years ago, I was told by an audiologist that my insurance would probably cover it within a year or two. If I'd known they wouldn't, I might have started saving THEN. Plus, I wouldn't have made the large contributions to a free medical clinic that I have been making for the past 3-4 years--I would have put that toward a BAHA fund!
Now, I don't know... plus we have taken out big loans for college tuition for two kids and paid more out of pocket for tuition and living expenses--paying $10,000 or $20,000 for the BAHA would be very difficult. At our stage of life particularly, with my husband nearing retirement and with my own health somewhat uncertain, I am really hesitant to take out another big loan.
Well, we'll see what happens with the other insurance and/or possibly appeals. Sorry to ramble...
Jan, I sure hope your insurance company pays as expected, without any nasty surprises for you! Best of luck with your healing and BAHA, too!
Nancy
-
I am still fighting ...gave them the code and they said they would get back to me ... that
was a week ago and when I called yesterday they say they are researching further options... >:(
they are stalling and wasting my time and hoping I will go past my insurance roll over date and they
won't have to pay as much... right now I am covered 100% with just $30 co-pays for specialist visits,
$15 for regular doctor visits and $100 co-pay for any surgery... after June 30 the surgery co-pay
jumps to $2000 plus a $300 co-pay on surgeon which right now there is none... and stuff would be
covered at 80% instead of 100%
they did tell me again that the surgery it's self was covered just not the hardware
and I could go ahead with that part of it as they researched ... which I read as code for
you can have surgery and be stuck with a big bill for implant and processor and have to
sell your first born to pay for the thing...
My first born is 29 , in good health and is a hard worker ... wonder if he will bring enough?
and yes I am in a bright cheerful mood this morning :)
-
The latest news from the hospital is that the insurance will cover the entire BAHA process. The lady in finance is saving all emails and correspondence for back-up if necessary. Now that this is resolved I'm getting nervous. April 8 will be here soon.
-
Catflower -
that's excellent news! Congratulations!
Don't be nervous, you'll do great!
Jan
-
Yesterday I received a copy of the doc's bill from my BAHA surgery and thought I'd share the billing codes he used.
The first code is 69714 (mentioned previously in this post) "Implant, Osseointegrated w/o Ma" - I have no idea what Ma refers to.
The second code is 15120 "Skin Split Graft, Face/Neck/Ear.
Hopefully this will be helpful to those of you still dealing with your insurance companies.
Jan
-
Good news, Catflower!
Don't be nervous - dealing with the insurance company is the worst part of the whole BAHA surgery! Once you've tackled that, the rest should be smooth sailing!
Lori
-
Good news, Catflower!
Don't be nervous - dealing with the insurance company is the worst part of the whole BAHA surgery! Once you've tackled that, the rest should be smooth sailing!
Lori
True, so true ;D