|“I was able to return to my pre-surgery climbing level after six months, and was quite active in the second half of 2005 with climbing and hiking.”|
|Friday, January 13, 2006Success with U.S. Insurance (LONG)|
Eleven months after surgery in Belgium, I finally obtained insurance reimbursement for 100% of my medical expenses. Here are details.
My health insurance is an ERISA plan. This means that my employer is self- insured, but hires a health insurance company (Aetna in this case) to administer the plan. My employer, along with a committee of health professionals, assembled a “Medical Plan” – a specific set of rules on what is and is not covered. Upon reading through the Medical Plan, I couldn’t find anything that specifically precluded coverage for out-of-country hip resurfacing. However, the relevant criteria for coverage were subjective (e.g. established as being effective for the condition to be treated), so coverage was clearly not guaranteed. The rules of my company’s Medical Plan differ in a number of ways from the coverage you would get with normal Aetna health insurance.
Two months after surgery, when the final hospital bill arrived, I submitted my initial claim letter. In this letter, I addressed each of the listed criteria in the Medical Plan, gave my argument why hip resurfacing qualified, and quoted text from the FDA’s position and from Aetna’s own health insurance (they cover it).
After a few months, Aetna notified me that they had denied my claim. When I asked for the reason, they gave me a very vague explanation – essentially saying that hip resurfacing didn’t meet all the relevant criteria. I pressed for a more specific explanation. They replied that there was a “lack of clinical evidence [for the effectiveness of the procedure]” and then told me to stop pestering them. They had given me an approach to take for an appeal.
My appeal had two main parts. The first was a list of five recent (since 2003) peer reviewed, published papers on the results of hip resurfacing. The references for these papers are given at the end of this post. I had been given a copy of the Amstutz et al. paper by Dr. Paul Beaule, whom I had seen pre- surgery for a consultation. The British Journal of Bone and Joint Surgery sent me free copies of the two papers from their journal after I sent an email request. For the two papers in Hip International, which is published in Italy, I was only able to obtain the abstracts (available free from the web site listed at the bottom of this post). There is an on-line system for purchasing access to the full text of a paper, but this system is in Italian and I was unsure how to navigate through it. Therefore, my appeal letter had the bibliographic information for all five papers, with copies of the full text of three of the papers and printouts of the abstracts for the other two. I think that this set of five papers was what won the appeal. The second part of my appeal was a description of why this surgery was the right choice for me. Here is a lightly edited version:
“In December, 2004, shortly before my surgery, my right hip pain was so bad that I could not stand up to give a 15 minute presentation at work, even with the use of a cane. My job requires that I give regular presentations to co- workers and to potential customers. Just a few months after the surgery, I was able to stand up comfortably for an hour, without a cane, and could give presentations again.
Hip resurfacing was the best choice for my health, since it allows a higher post-op activity level than a total hip replacement. This higher activity level will help me to maintain a lean body weight and to keep my blood pressure and cholesterol low.
Hip resurfacing was the best economic choice because it cost only 30% as much as a total hip replacement, and the available data suggests that the lifetime of my resurfaced hip will be at least as long as for a total hip replacement for someone of my age and activity level.”
My appeal letter contained eight attachments, each boldly labeled with a cover sheet. One attachment had the bibliographic information (the list at the end of this posting) for the five papers. A second attachment had copies of the three papers from The Journal of Bone and Joint Surgery (American and British), with the abstracts from the other two papers in a third attachment. A fourth attachment was a letter of support from an American hip-resurfacing surgeon (Dr. Beaule). A fifth was a copy of my initial claim letter. A sixth was a copy of Aetna’s denial of coverage notice. My point is that I included all relevant information in a way that was clearly labeled. Even so, additional clarification was needed (see the next paragraph).
After two months (and an email reminder to Aetna), they notified me that they would pay $13,900 out of my $14,800 claim. A week later, they decided to only pay $6700. An inquiry revealed that an Aetna auditor thought that $8000 of my expenses were for the Holiday Inn in Gent. I explained that my lodging was billed separately, but that visits to the Holiday Inn by a nurse and a physical therapist after surgery were part of my claim. Then Aetna decided to pay all of the $14,800. The complete hospital bill was part of my initial claim letter, but it had obviously confused some people at Aetna.
ADVICE The people who work in the claims department of an insurance company are accustomed to getting standard claims on standard forms from doctor’s offices and hospitals. If you submit a surgery claim yourself, especially if it’s for an overseas procedures, you need to do everything possible to help out the person processing your claim. Carefully label every piece of documentation, and clearly refer to it in the text of your letter. Include an itemized list of every expense. The person in your insurance company won’t necessarily be opposed to your claim, but he/she will certainly want to be sure that money is paid only for valid expenses. Thorough and even somewhat redundant documentation is helpful.Roger RBHR De Smet Jan. 11, 2005List of recent peer-reviewed publications on hip resurfacing (chronological order)“Is the Birmingham Hip Resurfacing Worthwhile?” T. C. B. Pollard, C. Basu, R. Ainsworth, W. Lai, and G. C. Bannister, Hip International, volume 13, pp. 25 – 28, 2003.“Development of Metal/Metal Hip Resurfacing” D. J. W. McMinn, Hip International, volume 13, pp. 41 – 53, 2003.“Metal-on-Metal Hybrid Surface Arthroplasty: Two to Six-Year Follow-up Study” Harlan C. Amstutz, Paul E. Beaule, Frederick J. Dorey, Michel J. Le Duff, Pat A. Campbell, and Thomas A. Gruen,, The Journal of Bone and Joint Surgery, volume 86-A, Number 1, pp. 28 – 39, January, 2004.“Metal-on-Metal Resurfacing of the Hip in Patients Under the Age of 55″ J. Danial, P. B. Pynsent, and D. J. W. McMinn, The Journal of Bone and Joint Surgery, volume 86-B, pp. 177 – 184, March, 2004.Early Results of Primary Birmingham Hip Resurfacings: An Independent Prospective Study of the First 230 Hips” D. L. Back, R. Dalziel, D. Young, and A. Shimmin, The Journal of Bone and Joint Surgery, volume 87-B, pp. 324 – 329, March, 2005.Note: for The Journal of Bone and Joint Surgery, the “A” in the volume number designates the American voume, and the “B” designates the British volume.The web sites for the Journal of Bone and Joint Surgery are: <http://www.ejbjs.org/> American volume <http://www.jbjs.org.uk/> British volumeThe web site for Hip International is: <http://www.hip-int.com/index.asp?a=> current