KarenK
Well-known member
Yesterday I got a copy of a poorly prepared partially completed appeal that’s certain to be denied.
1st - No required Appointment of Representation form.
2nd - Where it asks for the specific medical service for this appeal it only states “aortic valve replacement”. There’s no mention of TAVR or SAVR and the aortic graft was completely omitted. I was to have SAVR and an aortic graft (David procedure).
3rd - The form asks, “What should we know? Please be as specific as possible.”
CC’s only statement was, “Aortic stenosis – severe, EF 64%” CC entered only one test value that’s in the normal range.
“Normal coronary arteries per cath” That does nothing to support AVR.
“Ascending aorta 4.1 cm” That’s just an unrelated of fact.
This appeal is like some high school kid with an after school job wrote it! If the pre-authorization request was prepared by the same person in the surgeon’s office… that would be why the ins. co. denied it.
I question if this appeal was purposeful. Were they looking to keep the ins. co. out of the picture? Was self-pay their motive? Certainly the CC of all places would know how to file a proper appeal.
I actually don’t know if the ins. co. received this “appeal”. I requested docs from the CC and the appeal was included in an email. I’ve received many conflicting answers on if and when an appeal was done and on financial matters too. A couple days before I was to fly out, the CC said that they filed a late appeal and is was approved! I checked, that was false and the CC retracted their statement. On another earlier occasion they said they filed an urgent appeal, then contacted me when a response from the ins. co. was due to respond and said it was denied. They never filed an urgent appeal!
Then they said they submitted my case to the powers that be and they would go ahead with the surgery and deal with the ins. co. on the backend. They would accept only what they were able to get from the ins. co. If the ins. co. paid nothing, I would pay nothing. I was told that they are doing this because they are a non-profit and give back when needed, etc. A couple people read a document to me about this but when I asked for a copy they both said no. Red Flag! Another red flag, the CC had no clue about my financial situation and whether I could self-pay or not. It didn’t make sense that they would do that.
Later it changed with no explanation. It became all you have to pay is your maximum out of pocket as they’ll deal with the ins. co. on the backend. When questioned about what happens if the ins. co. continues to deny and there is no max. out of pocket? That question everyone avoided like the plague.
Just before I was to fly out I had a number of calls from various people all saying the same thing and trying to persuade me to accept this verbal arrangement and downplaying the written contract that states I am fully obligated to pay for any and all amounts the ins. co. doesn’t pay.
I lost my trust in the CC. If they can’t deal with the ins. co. on the frontend I don’t believe they would start on the backend. I was not about to end up owing hundreds of thousands on their extreme pricing ($450+K minus 30% for self pay per website = $315,000) and battling with the CC for years to come. Not all good surgeons are at the CC.
1st - No required Appointment of Representation form.
2nd - Where it asks for the specific medical service for this appeal it only states “aortic valve replacement”. There’s no mention of TAVR or SAVR and the aortic graft was completely omitted. I was to have SAVR and an aortic graft (David procedure).
3rd - The form asks, “What should we know? Please be as specific as possible.”
CC’s only statement was, “Aortic stenosis – severe, EF 64%” CC entered only one test value that’s in the normal range.
“Normal coronary arteries per cath” That does nothing to support AVR.
“Ascending aorta 4.1 cm” That’s just an unrelated of fact.
This appeal is like some high school kid with an after school job wrote it! If the pre-authorization request was prepared by the same person in the surgeon’s office… that would be why the ins. co. denied it.
I question if this appeal was purposeful. Were they looking to keep the ins. co. out of the picture? Was self-pay their motive? Certainly the CC of all places would know how to file a proper appeal.
I actually don’t know if the ins. co. received this “appeal”. I requested docs from the CC and the appeal was included in an email. I’ve received many conflicting answers on if and when an appeal was done and on financial matters too. A couple days before I was to fly out, the CC said that they filed a late appeal and is was approved! I checked, that was false and the CC retracted their statement. On another earlier occasion they said they filed an urgent appeal, then contacted me when a response from the ins. co. was due to respond and said it was denied. They never filed an urgent appeal!
Then they said they submitted my case to the powers that be and they would go ahead with the surgery and deal with the ins. co. on the backend. They would accept only what they were able to get from the ins. co. If the ins. co. paid nothing, I would pay nothing. I was told that they are doing this because they are a non-profit and give back when needed, etc. A couple people read a document to me about this but when I asked for a copy they both said no. Red Flag! Another red flag, the CC had no clue about my financial situation and whether I could self-pay or not. It didn’t make sense that they would do that.
Later it changed with no explanation. It became all you have to pay is your maximum out of pocket as they’ll deal with the ins. co. on the backend. When questioned about what happens if the ins. co. continues to deny and there is no max. out of pocket? That question everyone avoided like the plague.
Just before I was to fly out I had a number of calls from various people all saying the same thing and trying to persuade me to accept this verbal arrangement and downplaying the written contract that states I am fully obligated to pay for any and all amounts the ins. co. doesn’t pay.
I lost my trust in the CC. If they can’t deal with the ins. co. on the frontend I don’t believe they would start on the backend. I was not about to end up owing hundreds of thousands on their extreme pricing ($450+K minus 30% for self pay per website = $315,000) and battling with the CC for years to come. Not all good surgeons are at the CC.
