OT: "half" surgery complete! Fighting health insurance companies

[rnhood]

Hard to say. I'm not in a position to argue the merits and data between the endoscopy and microdiscectomy approaches but, I would guess we have more data on the micro approach over the endo approach. If it were me, and insurance would cover microdiscectomy, then I would go for it without thinking twice. The endo procedure is not nearly as common, due to whatever reasoning.

The percutaneous procedure is rarely used anymore. Many people who had this procedure ended up needing a fusion after a few years, if not sooner.

Your spine surgeon seems to be well qualified and skilled. But the insurance company uses data to drive their policies. They don't make decisions based on one doctor. My advice is to pursue a microdiscectomy, assuming all conservative approaches have been exhausted and more than one year has elapsed.

[AngryScientist]

My son (2YO at the time) fell off a couch and cut his forehead on one of his toy trucks.

My wife rushed him to urgent care and they refused to stitch his head, saying he required a plastic surgeon since he was a kid and it was on his face. We were given no choice, only go to the hospital and use the on-call P.S.

We have by all regards good insurance and the bill we received was literally insane. No person deserves to make the hourly wage the surgeon was demanding, dot period, for literally 20 minutes of his time.

My wife went to battle with the insurance company and the surgeon's office for many months of negotiations. In the end we came out OK, but it took a lot of phone calls and time. What we discovered was a bunch of clerical BS that chokes the system and ultimately costs people and insurance companies a lot of unfair money IMO.

Yes, you have some leverage, but you have to be relentless and pursue your best interests. Be realistic and logical. Keep a record of everything.

There is no reason it has to be this hard, but it is. Sigh.

[thwart]

As someone who sees some of the inner workings of denials, appeals and such…

It’s a systemic problem. Folks in insurance companies are not innately evil. They are only the messengers, trying to preserve some profit margin while covering what is generally felt to be ‘clinically proven’ care. That said, the average CEO salary in this industry seems obscene… a good part of that money should have gone to the nurses caring for the millions of COVID patients over the past two years.

Modern medicine, with all of its pharmaceutical wonders and technological breakthroughs, has just become unbelievably (and unsustainably) expensive. There is certainly not an easy solution to that problem.

Pro tip: If you appeal a health insurance company decision, do it in person. It’s worth your time.

[rnhood]

A bad cut on a child's face can possibly scar him for life. It's a tough call imho. A skilled plastic surgeon will often stitch the wound from the inside out, and ultimately leave virtually no evidence of a cut or scar. It's s difficult make a medical judgements on an internet chat room. It often boils down to supposition. But if it were my child, I would not have hesitated to follow their advice and see a PS. That would especially be true if the child was a female.

[buddybikes]

Originally Posted by thwart

As someone who sees some of the inner workings of denials, appeals and such…


Pro tip: If you appeal a health insurance company decision, do it in person. It’s worth your time.

I wish... I live in RI and my employer (large computer company) insurance is Anthem CA :-(

[benb]

We had to fight for a few things the last few years. One was for PT. The other was also for an OT for my kid.

What we’ve noticed is everything to do with appeals has zero computer. They haven’t modernized any of this part of they system and use this as a way to constantly lose your appeal or forget about it. Nobody can transfer you to another department and everyone always needs you to print out a new form and snail mail it to a random PO Box.

What actually helped was going through a patient advocate type service. But that’s a separate benefit I happen to have through my employer. I have no idea how hard or expensive it is to get that separately. But it definitely worked. They got an independent doctor/nurse on the phone to talk to the insurance and almost immediately we got our appeal granted. It was almost like the insurance was denying it cause they didn’t understand why treatment was necessary or we’re trying to play dumb.

[ridethecliche]

Re: comments regarding the plastic surgeon's outrageous rate.

Hospitals function incredibly bizarrely to the point where you can have an in network hospital with out of network physician groups or physicians that work there. This makes no sense to me but is often the root of some of the wild bills. NPR has does a few articles on this.

The system is absolutely convoluted and overly complicated and our healthcare expenditure for non care related items is atrocious.

Originally Posted by rnhood

Hard to say. I'm not in a position to argue the merits and data between the endoscopy and microdiscectomy approaches but, I would guess we have more data on the micro approach over the endo approach. If it were me, and insurance would cover microdiscectomy, then I would go for it without thinking twice. The endo procedure is not nearly as common, due to whatever reasoning.

The percutaneous procedure is rarely used anymore. Many people who had this procedure ended up needing a fusion after a few years, if not sooner.

Your spine surgeon seems to be well qualified and skilled. But the insurance company uses data to drive their policies. They don't make decisions based on one doctor. My advice is to pursue a microdiscectomy, assuming all conservative approaches have been exhausted and more than one year has elapsed.

Per SPORT trial, outcomes at about 1 year were comparable between op/nop op but the operative group got there significantly faster. Depending on what you do in your life, it might be worth just doing it earlier.

I also thought that the standard of care was a microdiscectomy, but it's been a while since I've kept up with literature since I'm in pretty much the polar opposite field.

Originally Posted by thwart

As someone who sees some of the inner workings of denials, appeals and such…

It’s a systemic problem. Folks in insurance companies are not innately evil. They are only the messengers, trying to preserve some profit margin while covering what is generally felt to be ‘clinically proven’ care. That said, the average CEO salary in this industry seems obscene… a good part of that money should have gone to the nurses caring for the millions of COVID patients over the past two years.

Modern medicine, with all of its pharmaceutical wonders and technological breakthroughs, has just become unbelievably (and unsustainably) expensive. There is certainly not an easy solution to that problem.

Pro tip: If you appeal a health insurance company decision, do it in person. It’s worth your time.

Travel nurses were paid exceptionally well during the pandemic and the rates have started normalizing now (i.e. 1.5-2x pre covid rates vs 3x or more pre covid rates). The staffing companies were the ones that made out like bandits though.

For every data driven good thing insurance does, the amount of required paperwork to get approval for normal standard of care medications is bonkers. Sometimes the approval comes just about instantly after you submit the form... it's just there to make you do more paperwork in the hopes that you just give up. Even worse for patients who often don't understand the system or can't do anything about it secondary to the medical issues that they have to begin with.

[schwa86]

Based on what you have described, your plan is probably ERISA - eg your employer self insures and Anthem is working as a third party administrator. This has two implications legally/from advocacy perspective: 1) state government does not have the legal right to regulate their decisions; 2) it’s really your employers call re what gets paid. I’d try to have a frank conversation with your HR/benefits folks.

[buddybikes]

Update. I have some bone overgrowth from fusion in my L4/L5, surgeon submitted using same technique, approved. So I am having surgery on that June 1 to relieve some right side issues. I spoke in detail with my HR as well as Anthem today on other side, they basically told me to stick it. So not sure how I will proceed with this damn disc protrusion.

[old fat man]

Originally Posted by steveandbarb1

Update. I have some bone overgrowth from fusion in my L4/L5, surgeon submitted using same technique, approved. So I am having surgery on that June 1 to relieve some right side issues. I spoke in detail with my HR as well as Anthem today on other side, they basically told me to stick it. So not sure how I will proceed with this damn disc protrusion.

Maybe you love your job, but if not, this seems like good bargaining power. Tell your HR dept you're leaving since the insurance coverage is unacceptable. It's an employee's market these days

[Likes2ridefar]

Originally Posted by old fat man

It's an employee's market these days

Where? Doing what? I’d love to know as you see a few here think I’m evil because I took a job at a big company that was willing to hire me out of university for a decent wage. I’d love to move to something more gratifying and aligned with my world views but ….

I don’t see this market. My wife as a teacher most certainly doesn’t.

[buddybikes]

Originally Posted by old fat man

Maybe you love your job, but if not, this seems like good bargaining power. Tell your HR dept you're leaving since the insurance coverage is unacceptable. It's an employee's market these days

Be hitting official retirement age 65 in 43 days, so that's out of question. I don't plan to retire, but certainly wind down in sight, fortunately my boss is allowing me to do this at full pay (long lunches etc) due to my specialized skills. Will get through this first surgery and have good heart to heart with surgeon on options for my L5/S1 maybe simple as different CPT code or I hit another neuro in his group for microdiscectomy rather than endoscopic.

[stackie]

Disclosure: I'm an anesthesiologist. I see these things done daily. I've also had the microdiscectomy.

1. Don't be afraid of the micro discectomy. It's a great procedure and IMHO the visualization is better with micro vs endoscopic. The meticulous neurosurgeon only does micro. The ortho spine surgeon does endoscopic. Just saying.

2. The micro discectomy is 100% outpatient. Takes a couple hours and I was back to 100%, walking out of hospital. Most are that way. General anesthesia is very safe. The endoscopic procedure still gets an anesthesiologist and sedation. Honestly more risky from anesthesia standpoint.

3. That said, my ortho surgeon just texted me back that he gets Anthem BC to cover the endo discectomies. He says it is a complicated approval and he feels like he has it easier as we have a surgicenter here that is pretty efficient and economical so the insurance company likes the pricing.

4. Sorry, likes2ride, but the insurance companies can be so unprofessional. I recently had a company who we are not contracted with ask us for a discounted rate for a huge procedure. I gave them 15% off our standard rate. Their negotiator came back with "Would you take $50/ASA?" No salutation, nothing. That's less than any of our actual contracted payors. I said, "NO". And, "You will address me with a proper salutation, you are not negotiating for an used car on Craigslist." She, then comes back with "Jonathan ( not my name ), will you take $75/ASA". "NO". "We are done negotiating. We would love to care for your patient. Now, it is your responsibility as the insurer to pay for the care that you contracted to provide for your customer". They sent over the contract to sign the next day. Still had to make them adjust that to Dr vs Mr.

4. Re physician prices. What's your child's scar free face worth? That plastic surgeon on call dropped everything and headed in to the ER to evaluate and treat your kid. Maybe left their child's activity? So, maybe they weren't able to go do that century ride that weekend? And, not having a nice glass of wine with dinner. And let's not forget that the same plastic surgeon probably does a breast reconstruction post mastectomy for pennies on the dollar for MediCare later that same day. I'm embarrassed at what I have to charge private pay patients because MediCare pays so little. I make significantly less than any electrician/plumber/carpenter taking care of MediCare patients. I'd love to be able to charge less for my work for private pay, however, I do have a family to support as well. Don't get me wrong. I do OK. I live in an expensive area, but have a modest house. No fancy vacations. I work hard. Take a lot of call. I generate about 50% more work units than the average anesthesiologist in the USA. Will probably work til 70. I don't make what a successful realtor, general contractor, or financial advisor makes, and your life is truly in my hands. Let's not begrudge someone their living until you've walked in their shoes.

I'm all for single payor. However, what we we do with all the people employed by the insurance companies? I really feel for the CEOs. Would they be able to find gainful employment in other industries that would pay them the 10-100 million dollar salaries they are accustomed to? Think of them. Please read the sarcasm font there.

Jon

[Likes2ridefar]

I am 100% on board they are a part of the problem.

But what about the ~70% of morbidly obese people in this country heavily relying on maintenance and surgeries that drive up costs for all?

Doctors keep patching them up, full knee replacements for 80yo that have been sedate for years, etc.

[benb]

Originally Posted by Likes2ridefar

I am 100% on board they are a part of the problem.

But what about the ~70% of morbidly obese people in this country heavily relying on maintenance and surgeries that drive up costs for all?

Doctors keep patching them up, full knee replacements for 80yo that have been sedate for years, etc.

They make a lot of money for the insurance + hospital system though.

Yes for sure lifestyle is a huge problem but from the business side it is not really a problem.

It's even more obvious IMO in the way research on prescription drugs seems to focus on maintenance prescriptions for lifestyle related issues versus cures for infectious diseases, vaccines, new antibiotics, etc..