My Maryland ACA Carefirst Blue Choice HMO is covering claim in South Carolina

[Pat Walter]

Note: I am posting this from the temporary forum for Danny
I hope my post gives a path to navigate doctor offices and your HMO insurance to get coverage in other states where hip resurfacing is offered.  As you may know HMO insurance contracts limit the territory to a local region of contracted doctors for your plan.  In the case of my Blue Choice HMO I recognized no contract wording that gave direction for seeking coverage outside of the territory because the service wasn't available in-network.  Dr Thomas Gross said that because I tried in-network to get a resurfacing, and upon his determination that I was an excellent candidate, he could submit an application with my Maryland HMO for his services in South Carolina.
To me it made sense that an agreement outside of the Insurance contract was possible and binding, also made sense that if I couldn't get an operation in my territory there should be some accommodation by the Insurer to provide the service elsewhere, and if I met resistance I had 2 agencies to appeal, the ACA Marketplace appeals board, and my state's insurance administration.

I have an Affordable Care Act Plan (ACA) a Carefirst Blue Choice HMO.  I called 3 doctors from google searches and the list of hip resurfacing doctors here at surfacehippy.info that were In-Network in Maryland and 3 Northern Virginia Counties that compose of my HMO territory and found that NONE were actively and regularly performing hip resurfacing.  I am one not to let Doctors or any other profession bill for a job interview or what they call a consultation and I tell them that, someone at the office or the Practioner should be able to give you 10 minutes to answer questions.  It usually works for me.  Dr. C. Anderson Engh's office in Virginia said he averaged 500, but would not clarify over what time period, further questioning revealed they had not done any in the past month or 3 months.  A google search found Dr Marc W. Hungerford whose website describes all the benefits of a resurfacing over a total.  When I called Hungerford's office, they said they stopped doing them because Insurance didn't want to pay. 

I chose Dr Michael Jacobs who might have done one maybe in the last year, and had been awhile before that, but certainly was not regularly and actively performing hip resurfacings.  He seemed to be my only choice in the hmo so I made an appointment with him.  Upon examination he turned down for a hip resurfacing.  So I made an appointment for a total hip replacement with Dr Jacobs and sent my information and xrays to Dr Thomas Gross in South Carolina.

A few weeks later Dr Gross called me and said I was a candidate!  His office would help get Authorization, but I had to do some of the leg work too, and expect some resistance from the Insurer.

Here are some points I found important for getting out of state service , I did not take issue with Dr Jacobs that he turned me down.  I needed him to decline me so I could use a surgeon who was actively and regularly and successfully performing hip resurfacing.  I had a good idea that i was a good candidate because my femoral head was not crushed, and even if yours is crushed, mail your info to Dr Gross or your choice of surgeon who is actively doing resurfacings for their opinion.  I tried 3 doctors who had past experience in hip resurfacings, I went through examination with one that indicated the possibility of a resurfacing and was turned down.  I made appointment for total hip replacement surgery with the doctor and their hospital, so I have a proof that he wouldn't give me a hip resurfacing.  If I had it to do over, I would have asked Dr Jacobs for a document that says he is denying me or I am not a candidate for a hip resurfacing.

The billing clerks at Dr Gross' office wanted me to do all the work.  They hadn't been successful getting Authorization from an out of state HMO in awhile.  They directed me to Call Blue Cross "Member Services" number on insurance card 855-444-3121 and ask the first line of customer service "for approval on out of area service because I could not get a hip resurfacing in my hmo network of Maryland DC and Northern Virginia."

I got lucky and was directed to Utilization Management (UM) Department 800-443-5434 who told me to have the Providing Doctors office (Dr Gross) call them to fill out a "Pre-Services Review Request for Authorization Form" Include the Doctors, Facilities and all to be reimbursed. and provide supporting documentation a case review write up that Dr Gross did stating "compelling reasons"; I was an excellent candidate, the conservative nature and benefits of a hip resurfacing compared to a total hip; the other advantages of a resurfaced hip that I could lead an active lifestyle and better sustain falls; the fact that I looked and was turned down by Dr Jacobs and to his knowledge he did not know of a surgeon in the Maryland area that was accomplished in this operation; therefore the patient has to go out of network to have this conservative hip replacement.

I'll make a point when talking with the Insurer, don't call this an "Appeal" or "Pre-Certification Authorization" those are different departments, the correct department for Carefirst was "Utilization Management" and it may be the same for other Blue Cross Blue Shields.  Also, maybe in insurance terms an "Appeal" can happen after a claim is submitted but the claim is denied. The "Pre-Certification Authorization" was a different department, I don't recall what they do.

2 weeks later, a day before covid shut down non emergency operations in Maryland, on March 22, 2020 I got verbal approval.  So I don't think coronavirus shut downs in Maryland had influenced a change in policy for the HMO contract.  My next advice is to get it in writing.  I later had to get a document "Notification of Authorization" from the UM Department so I wouldn't have to sign a waiver of rights that would have had me on full responsibility of this $28,000 operation.

The "Notification of Authorization" stated "following services approved: CPT code 27130 and related covered services to be paid at the INN (In-Network) level of benefit."

I had the operation July 15, according to my Explanation of Benefits, Carefirst has settled on 1 of 5 claims for this South Carolina surgery.

I am so glad I didn't have to wait until open enrollment in December to pay up $600 more a month $7200/yr for a PPO policy in Maryland or move to South Carolina and get an ACA plan mid year there because of a life changing event.

I'll give a thumbs up for Dr Gross for completing the application with compelling reasons of why I had to go out of state to get a hip resurfacing and that his practice was accomplished in the operation and he had data for better outcomes and lower prices. 


Danny Hahn

[dannythebeerman]

5 of 6 claims paid:  Surgery Center, Anesthesiologist, Surgeon, Assistant. Each had a co-pay to me of $100 for the facility and $40 for each individual provider $220 total.  Over $24.5k paid by my Maryland ACA HMO insurance.

of the other 2 claims.  The day before surgery was an office visit which was denied, but the DXA scan at that office visit was paid at ~$170, no co-pay. The DXA was submitted 3 weeks later as the Midlands claims department didn't think it would usually be covered.  I asked them to submit anyway, I think I got lucky on the DXA claim, but the lesson is don't assume anything.  The office visit for for $455 is under appeal, it included pre-surgery office visit to Dr Gross and xrays.

Keep in mind that Midlands Orthopaedics had not had a successful request granted by an out of state HMO in many years, thus coverage expectations by the insurer was not known, but indicated by words written on the "Notice of Authorization", which act as a contract. ie who, what, when, how much.

In speaking with Carefirst Member Services and the Utilization Management Department, they speculate that the office visit claim the day before surgery was denied because of 2 reasons.  First, the "Date Span of Authorization" line on the "Notice of Authorization" did not include the date of my office visit, it was off by one day.  Second, it was speculated that the authorization was for an Ambulatory Surgery setting.  The Authorization was addressed to "Surgery Center at Midlands Orthopaedics" which is a different provider and location than "Midlands Orthopaedics", customer service rep said a second Authorization should have been produced for office visits now and in the years to come.  This is speculation because we have no contact with Carefirst Claims.

[dannythebeerman]

My other cost were travel, lodging and food.  I stayed 10 nights at the Marriott Residence Inn, about $1000.  it's located less than a quarter mile from a hospital Dr. Gross has Emergency Room privileges.  I wanted to stay long enough until I felt the risk for post surgery complications had passed, once you leave the area you have to have an emergency plan to get back to Columbia, SC.  Staying by Lake Murray or in town was not a safe choice because you can't depend on an ambulance to take you to the right hospital.

I drove because of covid.  I should have taken more breaks and elevated feet 18" over my heart for a half hour every 2 hours on the 8 hour drive home, turning it into a 10-11 hour drive.  From the drive and blood thinners Xeralto, I had a bruise on my heal that took a week to get under control from whence I got home.  The swelling went down when I came off xeralto and finally aggressively raised my feet 18" above my bed overnight.  6 inches wasn't cutting it and I like icing.

[Pat Walter]

Danny, Thanks for adding to your original post. Glad you are able to post OK. I think everyone is at this time.

[dannythebeerman]

6 of 6 claims processed and paid.  Looks like my Blue Cross HMO Obamacare plan in Maryland covered my out of state surgery, God bless America!

This process was relatively painless with Carefirst of Maryland and Blue Cross Member Services.  However with the claim handling, it took a month to convince Dr Gross' billing and claims staff person to directly re contact the Carefirst of Maryland employee to amend the "Notice of Authorization" as 2 Carefirst employees advised me to tell her to do so, and not go through the appeals process, go back to the person that said "yes".  I was in Insurance for 10 years and knew that most employees like to correct their work so it doesn't get scrutinized by supervisors or another department. 

I am convinced what got me approval was that Dr Gross wrote I had tried to find a surgeon to do the procedure in my home network and was denied the resurfacing, and to the best of his knowledge he didn't know of any surgeons in my network proficient in the procedure.  Be sure to review your Doctor's application before they send it to the Insurer to be sure a statement like this is present in the submission.

[imgetinold]

This is fantastic information for others who might be in your situation.  Thanks, Danny.


I am now day 3 post-op with Dr. Gross.......my 2nd.  He did my right side 8 years ago, and he is the BEST.


Hope your recovery is going well.


Andy

[dannythebeerman]

Each week is better than the last, mostly because I don't tweek it.  Just doing allowed activity, and waiting for the 6 month mark to do piriformis stretches and inward rotation.  I'm happy with walking and stretching quads and psoas, have taken on chores around the yard and house, just not ready to carry anything heavy, but walking is good.

Hope yours is going well, I don't know if peaches are in or out of season but I enjoyed them and riding by Lake Murray when I needed a break from icing and elevating.