Since winning the approval of my seat elevator for my power wheelchair through navigating the labyrinth of Blue Cross and Blue Shield’s appeal’s process by taking my story to the local news – I have since been busy making quick work of trying to get further “medically necessary” equipment approved by insurance.
A challenge many of us face within the world of health insurance and disabilities is trying to prove, and convince insurance companies that many pieces of equipment we need in our home such as specialized shower chairs, seat elevators for power wheelchairs, specialized manual wheelchairs, adaptive exercise equipment, etc. are not “accessories” as defined by health insurance companies; rather they are “medically necessary” to not only survive in our daily lives, but to thrive.
In this light, my advocacy mission to help folks learn how to be their own advocates has really taken off. I thought of no better way to teach folks how to be their own best advocate than by working towards getting equipment in my own home that is “medically necessary” approved for myself first. This way I can better help folks navigate within the private health insurance world first, then later on to Medicare & Medicaid, with respect to best practices & strategies for winning health insurance denials.
About a month ago I embarked on my next mission to see if health insurance, specifically Blue Cross and Blue Shield, would pay for a highly specialized shower chair. There are hundreds of different shower benches available, but only a handful that tilt, recline, have foot rests, headrests, etc. I have a specialized power wheelchair that performs all of these functions because I am paralyzed from the chest down and am unable to hold myself up right without the assistance of a caregiver. I do not understand the rationalization of why Blue Cross and Blue Shield does not consider specialized shower chairs any different than a power wheelchair in particular situations for folks with severe disabilities, but they do.
I spoke with dozens of other wheelchair users and they, most often than not, have not been able to convince their insurance companies that these several thousand dollar specialized shower chairs are essential for their medical condition with respect to safety, and quality of life. There are a few exceptions, however, such as the VA or vocational rehab.
Do I not deserve to be able to take a shower with dignity and safety?
Why should my disability prevent me from properly bathing myself just because an insurance company thinks a piece of equipment I need is not “medically necessary” in their policy?
The insurance process is a winding road of denials, appeals, and negotiations.
Whenever an insurance company tells me “NO” I look at this as a starting negotiation point and an opportunity to perfect a battle strategy for success.
I’m working with SPINALpedia to outline a very detailed, yet simplified, process for folks on how they can better understand the approval, denial, and appeals process within their own health insurance company. I’m hoping this will serve as a template to make navigating your own health insurance battles more streamlined. We’re hoping to have this out in the next several months, but in the meantime, here are the general steps for insurance authorization, approvals, denials, and appeals:
The most important thing to remember is organization and making sure you build strong relationships with your medical professionals. So, when you send in a mountain of paperwork to your insurance company you have all your ducks in a row to justify why a piece of medical equipment is “medically necessary,” and not just an accessory.
My Shower Chair Battle
In July of 2020 I made quick work of meeting with my physical therapist, so we could justify every single function of the specialized shower chair I was looking to have approved. The shower chair I was after is called the Lopital Nemo Chair. Armed with every angle of justification my physical therapist and I could come up with, I then reach out to my general practitioner, and helped him to write a letter of medical necessity for Blue Cross and Blue Shield.
The first step is for your durable medical supplier to submit all paperwork for said piece of equipment to the insurance company, which includes your physical therapists & physicians Letter of Medical Necessity, a price quote from your durable medical supplier, and the proper medical code attached to said piece of equipment. The first step is called Prior-Authorization. This is where your insurance company looks to see if you are even eligible under your plan benefits for said piece of equipment.
This is an interesting little caveat because in order to get equipment approved, the company selling the equipment needs to have a specific medical code attached to it. If there’s no medical code you are usually denied right on the spot.
It’s also important to make sure that your durable medical supplier, who will be purchasing equipment on your behalf, is “in-network.” Each insurance company contracts certain vendors and they have a negotiated allowable amount on certain pieces of equipment you purchase. If your durable medical supplier is “out-of-network,” then you are likely going to be left holding the financial bag at the end of the day because there’s not a negotiated rate between the two companies. Basically, this means you end up paying out-of-pocket for your equipment even if your insurance company approves your claim.
I created a strategic battle plan for myself with the expectation I was going to be denied during the Prior-Authorization step of the process. I’m always prepared for this because the next step, after Prior-Authorization denial, is the appeals process where you further justify the “medical necessity” of the piece of equipment you are trying to purchase.
Over my last several insurance battles and local media coverage, I was connected with someone in the customer care department of Blue Cross and Blue Shield. I suppose I must be on their radar now because I ruffled quite a lot of feathers. Every time I send in Prior-Authorization paperwork I first send it to the customer care department in Blue Cross and Blue Shield, and send a certified letter to the President of Blue Cross and Blue Shield North Carolina informing them of the piece of equipment I am trying to have approved, and why it is “medically necessary” my life.
I also offer them the opportunity to comment because if I am denied I will reach out to local news outlets to highlight my story. I present this email in a very diplomatic fashion so as not to not embarrass them if they would like to work with me first.
This is key!
Always try to work with your insurance companies first before embarrassing them in the news 🙂 Now, I did do this with my seat elevator, and it worked, but the path of least resistance is always the best route in my mind before going nuclear.
My Big Surprise
The Prior-Authorization phase of the process usually takes about a week or two. I was waiting on the edge of my proverbial wheelchair seat for an answer. I was ready to take the next steps, but I received a personal phone call from Blue Cross and Blue Shield informing me that they approved my specialized shower chair.
WHAT?
I was completely flabbergasted. From my experience and many of the experiences I had heard from other wheelchair users, this is definitely not the “norm.” I must have a little sticker in my file that says “pain in the butt.”
In any event I graciously said thank you, but they informed me that while my durable medical supplier was in-network, the manufacturer of this specific specialized shower chair was out-of-network. Oh boy!
I explained to them that I would not be able to accept the shower chair because I could not pay $3,000 for it. I asked them if they could provide me a list of manufacturers for shower chairs that were in-network. The challenge lies in that many manufacturers who provide medical equipment don’t bother to jump through the hoops of trying to get in-network with an insurance provider because the product is constantly denied, so it is not worth their time, headache, or financial burden.
The Blue Cross and Blue Shield representative told me that she will try and work with the department to see if they can’t make an exception to put my shower chair in-network this time. I know Blue Cross and Blue Shield has the power to do this because they did it for me in 2016 when they moved a specialized electrical stimulation bike costing $30,000 from out-of-network to in-network for me.
Another week passed and I didn’t hear any news. Finally, I received an email in the middle of August informing me that they had made an exception for me.
I would like to say I was speechless, but I think because of my organization skills, working with my medical professionals on writing a kick ass letter of medical necessity, and my tenacity in following up that this is what yielded my successful results. Anyway, I like to think so 🙂
SUCCESS
My specialized shower chair just arrived this week at my durable medical supplier’s office, which I plan to pick up shortly, and I’m absolutely elated as well as frustrated.
We should not have to jump through this many hoops to get the “medically necessary” equipment we need in our homes, but this is the system we live in, and we have to learn how to navigate within it.
I know it’s a lot, but while I’m presently working with individuals on their own private battles, I am also currently creating a roadmap for the masses on how folks can take control of their own health insurance battles.
WHAT’S NEXT?
Home Exercise Equipment
In my opinion, the medical justification for a specialized shower chair for physical safety is a lot easier to get approved than trying to justify adapted home exercise equipment.
Don’t get me wrong, I think insurance companies ponying up several thousand dollars for the small minority of wheelchair folks around the country to stay healthy for long-term preventative maintenance is far less than the costly hospital stays that will likely result with poor health, and secondary complications.
Able-bodied people can just take a walk and get exercise, but if you are in a wheelchair you need special adapted equipment – especially if you are a quadriplegic. Most gyms are closed due to the pandemic, and even if they were not, it costs nearly $100 an hour to go to a specialized gym to exercise. I mean it’s ridiculous!
So this battle will be a hard-fought one for sure, but what’s going to make it epic is the fact that many companies who sell adapted exercise equipment do not have medical codes attached to their pieces of equipment.
What does this mean?
If you are trying to apply for insurance to pay for a piece of equipment without a medical code, they don’t have any basis to justify why it’s “medically necessary.” It’s very costly and time-consuming for a small company who makes several pieces of adapted equipment to jump through all the insurance hoops to apply for a medical code.
I will be trying to get an adaptive rowing machine called the VitaGlide (www.vitaglide.com). It is an excellent piece of exercise equipment and it specifically addresses certain needs with my level of paralysis. I’ve been working with the owner and they stopped manufacturing these beauties for about 10 years and started up several years ago again. The challenge they face, as a small company, is that they just don’t have the sales yetto justify applying for a medical code with insurance as of right now.
This is current next battle that I am presently engaged in as of August 27, 2020. I will keep everyone updated as I progress along in this journey.
Bottom Line Folks – Even if it is borderline criminal, you have to fight for your right to survive! It pains me even put those words on paper, but throughout history minorities have had to fight for their place in society, and so do we with respect to our place in being recognized within insurance companies.