The Quirky Quad, Ali Ingersoll share her personal story of her long battle and victories with insurance giant Blue Cross and Blue Shield.
When I think of Moving Mountains Paralyzed Insurance Companies the analogy of a Goat herder comes to mind. The Goatherder will watch out for its flock as long as it produces enough fur for the season for the goat herder to line his financial pockets. The moment the goat gets out of line or stops growing fur, the herder will slaughter the goat, and eat it for dinner.
Similarly to insurance companies … As long as you pay your premium and don’t step out of line an insurance company will offer you basic protection. However, if you start creating a commotion, appealing everything, and asking for more — insurance companies will find some way to slap you with financial bills that seem unimaginable.
Since my accident 7 ½ years ago I’ve been a goat that has been slaughtered by insurance companies and I have also been a goat that has managed to break free. Navigating the waters of insurance companies to get what you need, especially when you are paralyzed, requires voracious tenacity, extreme dedication, a lot of hard work, patience, and knowledge of how to work within grey areas.
Generally, when you have a claim that is denied you have the right to appeal the insurance company’s decision. There can be anywhere from 2 to 3 denials from the insurance company where you have to stay on top of them, call them on a weekly basis (if not more), write letters of medical necessity with your doctors, and keep recorded phone calls. The insurance company can give you a final denial where they make you think you have no other choices. This is where it can get tricky. You do have more choices … You can go above an insurance companies head to your states Department of Insurance and appeal the insurance companies final decision. This can be a lengthy process, but if you have patience and are diligent about being “pleasantly persistent,” you can move mountains.
Two major examples come to mind of experiences I’ve had to deal with, one of which I majorly messed up, and another which probably took a little piece of my soul, but resulted in victory for the patient!
1.) My Major Mistakes
In 2015 I developed a major pressure sore over my tailbone resulting in a giant hole in my behind. To make a long story short I needed a surgery that would remove my tailbone called a coccygectomy. I scheduled surgery for January 2016, but was aware that health insurance plans were changing. In December 2015 I relentlessly called my insurance company and the hospital where I was having surgery to make sure that the surgery was in-network for the coming year. I was assured verbally over and over by both the insurance company and the hospital this would be no problem. This was my first egregious mistake… I did not get this in writing. A huge NO NO!
In January 2016 I went in for surgery confident that my maximum out-of-pocket would be about $2,000 after my deductible was met with co-insurance. I spent countless hours trying to figure this out. To my utter surprise, I was sent a $15,000 bill at the end of January 2016. I did not know what I did wrong.
After about 25 phone calls I learned that this particular hospital was no longer in-network for 2016 despite all of the effort I put in to make sure this did not happen. So, I downloaded the appeals form from my insurance website and wrote a very detailed letter of explanation with dates, and times of phone calls I made with the insurance company. I patiently waited for 30- 60 days to go by as this is the typical time for an appeal to be processed. In the meantime, I had a $15,000 bill the hospital was trying to collect on, and I tried to work with their financial department to tell them I was appealing Blue Cross’s decision.
Naturally, the hospital did not care about my appeal process and kept threatening to send my bill to the collections department, and ruin my credit. They really had a knack for scaring the hell out of a patient who was laid up in bed, healing from a major surgery, and in complete distress. It was atrocious and disappointing.
I did not give into their threats and I waited patiently for the appeals to go through. I was trying to appeal this claim to move from out-of-network to in-network. I had to appeal three more times, with doctor’s letters of medical necessity, conversations I’ve had with insurance companies over the last few months, and I reached a point of near insanity.
Several months later I received a $3,000 check in the mail from Blue Cross and Blue Shield. I was completely ecstatic as I thought I had won. Here’s where I made a second terrible mistake. I cashed the check and I sent it to the hospital. I thought that was it … end of story. I was wrong on so many accounts.
What Blue Cross and Blue Shield did to me was send me their “allowed amount” for the bill, which was still actually processed out-of-network. I was still left holding a $10,000 bill owed the hospital. The hospital could do nothing for me as they said the insurance companies decision was final, and because I cashed the check I was now responsible for the $10,000. I was completely sick to my stomach and started to panic.
I quickly sent in another appeal, which you can keep sending in appeal upon appeal, which will push back what you owe for many months unless the insurance company gives you a letter of final denial. You can further appeal this with more complication. I went back and forth with Blue Cross and Blue Shield for 8 straight months all the while this $10,000 bill from the hospital was now headed towards collections.
I figured I had a better shot at negotiating $.50 on the dollar or so with a collections department than I did with paying the entire bill. Of course there was the threat of my credit being ruined, but I did not have these funds at the time to pay the bill.
Eight months later, at least 45 calls to Blue Cross and Blue Shield, tens upon tens of hours of being put on hold, ‘I finally won the battle’. Blue Cross and Blue Shield moved my case from being out-of-network to in-network, but did not even tell me. They ended up paying the hospital, but it wasn’t until I investigated further that I learned I no longer had a bill to pay with this particular hospital.
It was a completely maddening situation and the advice I can give with respect to when your insurance company sends you a check is double check exactly what they are paying for.
2.) The Big Kahuna
“This story is probably one of my most trying and heartfelt victories I have achieved so far in my Moving Mountains Paralyzed Spinal Cord Injury career with respect to
When you are paralyzed many of your muscles don’t work, become atrophied, which can lead to pressure sores, loss of blood circulation, etc.
There is one company in particular, who is a leader in their field, called Restorative Therapies located in Baltimore, Maryland. This company has a functional electrical stimulation bike called the RT300. In my opinion, electrical stimulation for anyone who has paralyzed muscles is such a crucial part of an exercise regimen in order to keep the muscle mass in your legs. The medical benefits are countless and too lengthy to get into for this particular article. Suffice to say, I find it a key piece of my exercise regime to stay healthy.
The problem is insurance companies do not find electrical stimulation to be medically necessary. There is so much research out there, but it takes insurance companies quite a long time to deem anything medically necessary. The challenge is these bikes range from $20,000-$30,000 brand-new from the company. I worked with these bikes over the last 7 ½ years and I can’t speak highly enough about them. When I was first injured I managed to get my hands on one, but over the years I needed an upgrade and insurance would not cover it. You should see my legs… They don’t even look like they are paralyzed — I mean other than the fact that I can’t move them 😉
So, I set out to work with the Restorative Therapies team to see if we couldn’t get a brand-new electrical stimulation. I knew this battle would not be an easy one and before I even started down the long road of trying to get this bike approved I had to prepare for war. I knew it may take over a year, we would run into all kinds of roadblocks, but we needed to create a tactical plan of attack!
In September 2016 I worked with the company to start getting this bike approved. To no one’s surprise the bike was denied several times in a row. We kept appealing all the way up to December 2016. Unfortunately, I had a major setback as Blue Cross and Blue Shield was switching insurance plans for 2017. This meant all the hard work we had put in so far was wiped clean. We had to start all over in January 2017. I worked with Restorative Therapies and we started the process all over again on January 2 of 2017. I was in an insurance race of a lifetime!
After about four months, several appeals, and all denials from Blue Cross and Blue Shield it seemed like we are out of options. Blue Cross and Blue Shield gave a final decision to permanently deny this case as this bike was deemed medically unnecessary through a panel of Blue Cross and Blue Shield supposed “Medical Experts.” Most people would’ve given up at this point, but I did not, nor did Restorative Therapies.
We decided to go above Blue Cross and Blue Shield heads to the North Carolina Department of Insurance. Every state has their own Department of Insurance. Restorative Therapies filed a copious amount of paperwork with cited cases of the medical benefits of electrical stimulation + my past history with this particular bike as well. I know Restorative Therapies worked a lot on their end with the Department of Insurance, but I, too, spent hours on the phone with them justifying the needs of this bike.
I framed the conversation in such a way where I made the argument that atrophied muscles lead to loss of blood flow, skin degradation, gastrointestinal issues, bone frailty, etc. I made the case that the long-term benefits of this bike far outweigh the short-term denial because the long-term issues created with lack of working out paralyzed muscles would result in me spending much more time in the hospital, having surgeries for pressure sores, spending time in nursing homes recovering, etc. I tried to make them see it from a patient perspective, not from a financial standpoint.
In August 2017 I received the most welcome phone call of the year. The North Carolina Department of Insurance called me to say they overturned Blue Cross and Blue Shield’s final denial. This meant Blue Cross and Blue Shield would be forced to allow me to have the bike. This seemed so simple, but it gets much much more complicated. Before I learned how much more convoluted this process could get I received a call from a lady at the Department of Insurance to congratulate me personally on such a victory. She told me that they had denied other folks requests in the past, but approved me because of the argument I presented about the long-term costs the state would have to pay with potential hospitalizations because of lack of preventative care. I was very heartened by this.
We then received another letter from Blue Cross and Blue Shield saying I was approved for the bike, but only out-of-network because Restorative Therapies is not contracted with Blue Cross and Blue Shield. This was quite a disaster because in 2017 my out-of-network maximum out-of-pocket cost was still $29,000 as opposed to several thousand dollars in-network. Clearly this did not help me very much. We then went to work on trying to get Blue Cross and Blue Shield to consider Restorative Therapies an in-network provider. This is a very complicated process, but we got it done.
In November 2017 I thought we are free and clear. However, we ran into another major snafu. When Blue Cross and Blue Shield works with an in-network provider and is sent a bill, generally Blue Cross and Blue Shield evaluates the cost of anything, whether that be durable medical equipment, catheters, etc., based on invoice amount. However, Blue Cross decided to become very fresh and sneaky with us. They said my allowable amount was only $6,000 and we could not figure out how they were getting this number. It turns out they were using some obscure miscellaneous medical code for some electrical stimulation unit, of which this particular electrical stimulation unit bike by Restorative Therapies called the RT300, does not have a specific code. This is actually where most of my time was devoted to – the 11th hour to get this bike approved.
What was sneakier was that I think Blue Cross was expecting me to cash the $6,000 check. I absolutely did not! Had I done this I would’ve been left holding the bag for the remaining $24,000 invoice to Restorative Therapies.
Fool me once, shame on you, fool me twice… You get the idea.
I kept it in my lockbox because had I had cash this check it would have been game over!
I spent dozens of hours with Restorative Therapies claims specialist on the phone with Blue Cross and Blue Shield. We kept speaking with supervisors, managers, etc., and nobody could tell us what this miscellaneous code they were using for the bike. It was a complete mystery, extremely maddening, and was starting to make me pull my hair out.
We kept talking to higher up managers at Blue Cross and Blue Shield and they kept giving us the run around, and telling us that the $6,000 was the final decision, but nobody could figure out why or who came up with it. Fortunately, Restorative Therapies reached out to a guy who also got his bike approved over the last year, and we learned that we had to file yet another appeal to appeal the fact that Blue Cross and Blue Shield was basing this piece of equipment off a random medical code, and not the actual invoice amount of $30,000. I know it sounds utterly confusing, and it is!
I kept calling Restorative Therapies and Blue Cross and Blue Shield several times a week in the month of December 2017. We were coming to the end of an insurance cycle and I was afraid I was going to have to start all over again. Excuse my French, but I almost lost my shit!
Fortunately, I did learn that my new plan for 2018 would remain the same, so whatever claims I have to process in 2017 would continue to be processed in
2018 from the old plan.
Anyway, when we finally submit the last appeal, I lost count at that point how many appeals we had filed, last week I received a $27,000 check in the mail from Blue Cross and Blue Shield. When I opened the envelope I was expecting another bill as usual, but I was in complete another shock. I was happy, I was excited, I was completely and utterly exhausted, and I felt like I had just run three marathons in a row.
I was having trouble comprehending what had just happened… Dammit, I WON! I just couldn’t believe it. I called up Restorative Therapies five minutes later and I think we were all pretty much in tears that over 16 months later we finally had won this battle. There then was a matter of the co-insurance, which I owed for the remainder of the several thousand dollars to Restorative therapies. They have such a fantastic team there that they have allowed me to trade in my old bike.
What does this mean? — NET NET = After 16 months of hard work I’m getting a $30,000 bike free of charge minus a small piece of my soul I traded to the insurance company 🙂
While this was a huge success story for me I will tell you that I have lost many battles, but I have learned over the years that you absolutely have to keep appealing, keep calling, and then calling some more to be absolutely tenacious with these insurance companies. Honestly, I hate to say it, but they do not care about you, they will try to save a buck wherever they can, and if you are not going to be your own advocate then you’ve got to color within the lines. Personally, I love to color outside the lines.
Many of us with spinal cord injury spend a lot of time at home, and therefore, I believe, have the time to be tenaciously persistent because who else is going to be for us?
With respect to this particular RT 300 functional electrical stimulation bike, I hope I am just one more case in the arsenal that one day forces Blue Cross and Blue Shield to make these electrical stimulation bikes much easier for patients to get. Perhaps it was a baby step in the insurance world, but it was a giant leap for me!
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