Notice to Blue Cross Federal and Medicare Patients
Notice to Blue Cross Federal and Medicare Patients (Last Updated 4/15/07)
These two insurers will not preauthorize any treatment whatsoever, including
BAHA or cochlear implant surgery (either unilateral or bilateral)
A refusal to preauthorize is not the same as a denial. Basically what they
are telling you by doing this is "if we find it is medically necessary,
we'll pay for it, but we won't make that determination until after you
receive the service"
Medicare has its own appeals process, and you may not use the insurance
commissioner of your state to intervene, which makes the appeals far more
difficult and take a much longer time to resolve. Blue Cross Federal
covered members who are federal employees may (but more likely won't) have
access to their state isurance commissioners. These rules differ on a state
by state basis.
Additionally, refusal to pre-authorize means that all Blue Cross Federal and
Medicare appeals are post-service. This is an extremely important fact for
two reasons:
Post service appeals take an average of one year from the date of the
initial denial to resolve, with the range running from nine to sixteen
months, depending on your region. During this period of time, your provider,
facility, anesthesiologist, etc. will want to be paid.
Post-service appeals on a nationwide basis have a much lower chance of
success than pre-service appeals. Across all insurance denials in the US, 80
% of pre-service denials are eventually overturned, while only 36 % of
post-service appeals are overturned. The reason for this is purely
psychological. The argument is no longer about whether your medical
condition is going to be treated, the argument is only about who is on the
hook for paying for it. While LTHF's average is much higher than this for
both pre-service and post-service appeals, there is a substantial chance
that you may end up paying for the treatment yourself.
Blue Cross Federal Specifics
Blue Cross Association changed their policy on February 15th, 2007, to
recommend coverage for bilateral cochlear implants as medically necessary.
The Let Them Hear Foundation Advocacy Program is aware of at least
one client whose claim for a simultaneous bilateral implant subsequent to
this policy was paid without requiring an appeal. While it may still be
possible for Blue Cross Federal to claim that the second implant was not
medically necessary for other reasons, they can no longer claim that they
are not obligated to cover it due to its experimental or investigational
nature.
Let Them Hear Foundation has been successful in getting Blue Cross Federal
to pay for sequential bilateral cochlear implants on appeal prior to this
policy change on multiple occasions.
To have the best opportunity to have a sequential bilateral cochlear implant
covered by Blue Cross Federal, we strongly recommend that you have a letter
of medical necessity from your physician and an audiogram done within the
previous 12 months before the surgery demonstrating that the patient
receives no meaningful increase in speech perception even with the most
powerful hearing aids in the unimplanted side. To demonstrate this, you
need to have tests with the CI alone and the CI+HA. If the patient does not
wear an HA, they will have to borrow one from the clinic, a letter stating
the loss is too profound to benefit from an HA may not be accepted by the
insurer. If there is significant benefit from the HA, another approach is
to show deterioration of speech perception in the presence of noise, for
example, doing HINT testing with CI+HA at no more than 60 dB speech
presentation level with a 10, 5, and 0 S/N ratio.
Medicare specifics
Medicare has enabled the -50 bilateral modifier to the 69930 code for
cochlear implantation surgery. So, in principal, they are agreeing that they
will pay for bilateral cochlear implantation. However, they have not
established a separate set of criteria for who is eligible to receive the
second implant. This is especially important for individuals who have
already received one implant and may have good results with it. We have a
couple of appeals in progress, but it may be April of 2007 before we have
results
What do you do?
First and foremost, unless you can write a check for $60,000 without
flinching, you need to find a flexible provider and facility. Chances are it
will be at least nine months from the time you have the surgery until they
get paid. Keep in mind that the insurer may not be obligated to cover
complications caused by a surgical procedure that they refuse to provide
approval for.
Negotiate a cash rate and payment plan IN ADVANCE of the surgery should you
not win your appeal.
The Let Them Hear Foundation Advocacy Program cannot assist
patients with pre-authorizations. We can assist you with your appeal if you
chose to proceed with the surgery and receive a denial after the surgery.
There is a statute of limitations that applies to all denials. If you miss
any of the appeal deadlines, you lose your rights to continue your appeal.
Therefore, please fill out the online application as soon as possible after
you receive your initial denial of payment.
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