Insurance Company Issues

[Lisa]

Hi - this is my first visit and post to the site. I had the hip resurfacing on May 14 and am thrilled to be on the road to recovery. But my question concerns a colleague who would like to have the procedure but has been told by the insurance company that no coverage is available because this is still an experimental surgery. Where might we find documentation that is is not experimental??? Any directions to websites or other resources would be appreciated, and any suggestions on how to deal with this issue would be great!!! thanks.

[Pat Walter]

Hi
Congratulations on your new hip resurfacing.  I hope things continue to go well for you.  You hip and activities just keep getting better and better as the months go on. There seems to be plateuas as you get better.  4 months and 6 months both seemed to be places in time where I made a great deal of progress.

Hip resurfacing certainly is no longer experimental surgery. The rest of the world has been doing hip resurfacing in the current form for more than 9 years. I have a story of one of Mr. McMinn's first patients and she has had her bhr for 15 years. http://www.surfacehippy.info/katieellis91.php

I have a number of insurance appeal letters listed on my website.  Also a lot of information.  Before the FDA approval, many people had to fight very hard to get their surgery covered by the insurance companies.  I did not have insurance and had to go to Belgium for surgery, so I can't help you personally. But if you read the different posts, you will get a good idea of what you need to do.

http://www.surfacehippy.info/insuranceappealinfo.php

I hope that gives you some help.

Pat

[momzer2]

Hi - this is my first visit and post to the site. I had the hip resurfacing on May 14 and am thrilled to be on the road to recovery. But my question concerns a colleague who would like to have the procedure but has been told by the insurance company that no coverage is available because this is still an experimental surgery. Where might we find documentation that is is not experimental??? Any directions to websites or other resources would be appreciated, and any suggestions on how to deal with this issue would be great!!! thanks.

Lisa,
Funny that you have had the same issue as me.  I am scheduled to have my surgery in September.  I decided to go this far out because my doctor informed me that the insurance carrier I have hasn't approved any birmingham hip surgeries to-date.  Pretty sad that they think it is still experimental.  It definitely is not.  It is FDA approved.  I see that Pat has given you a link to support this.  Thank goodness for Pat and her knowledge!!!  kudos to her.  Would your friend's insurance by chance be Personal Care?  Have your friend check with his human resources department to see if they are self-insured.  If they are then he/she can likely have the insurance companies decision overridden by his employer.  This is probably what I am facing.

Karen

[Lisa]

Thanks Pat and Karen - I have conveyed your feedback to my colleague. Apparently this insurance company (do not know the name yet, btw) stated they also use Hayes criteria (a mathematical formula designed to be understandable to about .00001% of the population;-) to make decisions. This would be unrelated to the "experimental" issue though. They have their grievance board appointment this Thursday, and I hope the material on your site will help their case.

This is a very interesting site - I hope to become more familiar with it and participate. It is nice to connect with others who have had the procedure. I have another question, but will start a new thread. Thanks again for your help. Karen - good luck; I hope you gain insurance coverage and have this great surgery!

[Pat Walter]

Hi Lisa

Unfortunatly, the insurance companies are not all easy to deal with.  If your collegue can't win the insurance battle, don't forget some of the very best surgeons in the world are availble for hip resurfacing surgery if you are willing to travel.

I did not have health insurance and the BHR was not FDA approved in the US when I wanted my hip resurfaced. I spent $16,000 to go to Belgium with my husband and get my hip resurfaced with Dr. De Smet.  Actually many insurance companies are now paying for surgery with Dr. De Smet.

It was the best investment I ever made in my 63 years of life.  It was in my own health to get the best hip surgery available.  I could have had a free old fashioned THR at a hospital in Columbus, OH, but I would not accept that.  I found enough  credit on our credit cards to pay for my surgery.  Many other people have traveled to Dr. Bose in India for $10,000 to $12,000 total cost.  He is one of the very best in the world. 

So no one has to settle for less than a hip resurfacing if they have a little money and are willing to travel.  Hundreds of us have done so and could not be happier.  All of us would go back in a heart beat if we needed another hip resurfaced.

Pat

[Lisa]

Pat - I'm going to send your suggestions to them. I feel both sad and angry that so many people have to deal with insurance companies that are just out to make money, and whose decisions reduce quality of life for ther "insured". I am fortunate to have a good insurance company right now, which is why I could have the surgery. Thanks.

[momzer2]

Hi all,

Well, it's official.  I received my denial from Personal Care for my upcoming BHP.  I knew it would be.  I am armed to the teeth, though, with information and have an appt. with our HR rep. for health system.  She's really nice and is just amazed that they would have denied me.  Anyway, I meet with her next Friday...  I'll let you know what happens.  Wish me luck.

Karen

[Pat Walter]

Good Luck Karen

Many have fought the battle of the insurance companies before you and have won.  Sometimes with a lot of effort and many appeals. 

Stick with it - persistance helps with insurance companies!

Pat

[Lisa]

Well, my colleague's insurance company apparently dropped the "experimental" excuse and moved on to (supposedly) making their determination based on age. They said that the person must be under 55 or over 65. My colleague is 60. Is it not unethical for an insurance company to make such determinations when they have no basis? Can another appeal be filed or should they try the insurance commission (which is actually an organization for insurance companies)? None of us are real familiar with these issues, but we are getting quite an education. Thanks...

[Pat Walter]

Hi

I would appeal again.  Many people had to appeal several times.  That is the one way of winning - by wearing the insurance company down. 

That is a lame excuse on their part since the over 55 group has the most hip resurfacings.  See my chart of the information people have sent me http://www.surfacehippy.info/agesurvey.php

Insurance companies are crummy to work with and you have to keep writing and appealing.  I had a landslide at our house and actually wrote a letter everyday to the president of the insurance company sent by registered mail all summer.  It took a huge effort on my part to get them to act on the claim.  Eventually they paid off our house under the policy that they had no intention of paying in the begining.

It isn't fair to have to fight with them, but that's what it takes in most cases. Unfortunatly, or perhaps fortunately, that is why many of us end up flying to India or Belgium for surgery if the insurance company won't pay.

Good Luck and keep fighting. It's the only way to win with insurance companies.

Pat

[momzer2]

Hello all,

This is especially for Pat and Lisa.  Guess what?  Yep, My surgery has been approved!!!!!   It is scheduled for 9-18.  I am so happy and relieved.  My husband is good at the internet searching thing.  He found the spokesperson for the BHR implant from Smith and Nephew.  He e/m me actual policy info. from Humana, Cigna, Aetna, United Healthcare, and one other.  Anyway, our HR person ALSO contacted the company and they mailed her the same stuff.  She presented it to our override committee at the hospital and they overrode the ins. co. decision.  Personal Care actually wanted 10 years of study trials in the USA before they consider it NOT experimental.  What morons.  Anyway, my employer said that was crazy.  So I got my approval.  Thanks to you both for your info. and support.  I'll let you know how it goes.  Wish my luck (I am a little nervous).

Karen

[Pat Walter]

Hi Karen

That is great news.  You will get your new BHR and be a Surface Hippy soon.  The time will go by quickly. Please keep in touch and let us know how everything goes.  Maybe write a little story for my Hip Story Page.

Do you mind if I post your information from below on my insurance page?  It might help someone else in the future?

Good Luck!

Pat