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Friday, January 13, 2006
Success 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, 2005
List 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 volume
The web site for Hip International is:
<http://www.hip-int.com/index.asp?a=> current
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