Insurance Denying Payment for BAHA

[leapyrtwins]

Catflower -

yes, definitely get it in writing.  I have heard of some insurance companies covering the surgery, but not the processor.  Doesn't make sense to me    I mean, the surgery without the processor doesn't do anyone any good.

Hang in there,

Jan

[sgerrard]

I mean, the surgery without the processor doesn't do anyone any good.

Except maybe me...

Catflower - good going! It sounds like you have turned the corner, now you just need to get the details ironed out. Must have been the CPT codes. You have avoided the "tough sailing" while "stuck on a log".

Steve

[OMG16]

Catflower make sure they are using AN as the diagnosis code and not a generic reduction in hearing code.  This could make all the difference.  You have to make sure the procedure and diagnosis are the right codes and the people they hire to do the billing usually use generic codes if they do not know the specific circumstances of your case.  Maybe Tamara can get that code for you.  Good luck and keep us all posted. 16

[Nancy T]

I just talked to Blue Cross (in Oregon) and they told me that they will pay for the BAHA surgery under major medical, but they won't pay for ANY of the BAHA device except with their hearing aid benefit ($450, for something that I think costs around $10,000!).

I also heard that Blue Cross reneged on a patient after he'd already had the surgery, and he was stuck for the whole bill. I am suspicious, because Blue Cross also told me that there is NO preauthorization for this--they do a review AFTER the procedure to decide whether they'll pay or not. How backward is that? You consider whether to jump off a $20,000 cliff and they say, "We'll decide for sure whether to catch you AFTER you've already jumped."

I'm waiting to hear the verdict from my other insurer, Kaiser. I'm not too hopeful about that either.

The CPT code that my doctor's office told me would be used is 69714, which is supposed to include the surgery and device.

[leapyrtwins]

Nancy T -

I think the cost of the BAHA processor is around $4,000 but I'm not sure - haven't seen that bill yet.  $10,000 seems kind of high.

The hospital where I had my surgery - approximately 2 weeks ago - billed my insurance company roughly $25,500 and my neurotologist billed them $6,095.  I had local anesthesia, so there is no anesthesiologist bill.

The review post surgery does seem very strange.  My insurance company told me verbally that they would cover both the surgery and the processor and sent me a letter stating the same thing, but with the added clause that "this isn't a guarantee of payment".  The typical insurance company equivalent of CYA 


They have had my claims for at least 10 days now and I can see on their website that they are discounting both the hospital and doc's charges but they are still holding onto the payments.  They are saying that the claims are "pending further review".
 
I'm anxious to see if they give me a hassle about issuing the payments.  I'm going to give them about a week and then call to see what the problem is.

Jan
 

[Nancy T]

Jan--yes, I think that's what Blue Cross meant--that they will say they'll cover it, but not guarantee payment until the claim is reviewed. I guess insurance companies can find reasons not to pay (hopefully they wouldn't do that!).

I have been confused about the cost of the device, but I think I've finally figured it out--I think the EXTERNAL processor, the snap-on part, is what costs around $4,000, while the total cost for whole device--the implant, abutment, and processor, in other words all the hardware--is around $10,000. This is what the insurance person at the doctor's office told me and what I saw on the BAHA users' forum.

I'm having a hard time thinking about how I could come up with that kind of money, short of taking out a second mortgage! If I'd known in 1999 (when I lost my hearing) that eventually there would be this expensive, non-covered device approved four years down the road that might help me, I might have started saving some money for it--or I might have thought about suing the doctor(s) who missed my sudden hearing loss and thus my best chance of saving hearing! (Although I seriously doubt I would have sued them, as I'm not litigious and it probably wouldn't have made any difference anyway.)

And even when I found out about the BAHA three years ago, I was told by an audiologist that my insurance would probably cover it within a year or two. If I'd known they wouldn't, I might have started saving THEN. Plus, I wouldn't have made the large contributions to a free medical clinic that I have been making for the past 3-4 years--I would have put that toward a BAHA fund!

Now, I don't know... plus we have taken out big loans for college tuition for two kids and paid more out of pocket for tuition and living expenses--paying $10,000 or $20,000 for the BAHA would be very difficult. At our stage of life particularly, with my husband nearing retirement and with my own health somewhat uncertain, I am really hesitant to take out another big loan.

Well, we'll see what happens with the other insurance and/or possibly appeals. Sorry to ramble...

Jan, I sure hope your insurance company pays as expected, without any nasty surprises for you! Best of luck with your healing and BAHA, too!

Nancy

[Soundy]

I am still fighting ...gave them the code and they said they would get back to me ... that
was a week ago and when I called yesterday they say they are researching further options... 

they are stalling and wasting my time and hoping I will go past my insurance roll over date and they
won't have to pay as much... right now I am covered 100% with just $30 co-pays for specialist visits,
$15 for regular doctor visits and $100 co-pay for any surgery... after June 30 the surgery co-pay
jumps to $2000 plus a $300 co-pay on surgeon which right now there is none... and stuff would be
covered at 80% instead of 100%

they did tell me again that the surgery it's self was covered just not the hardware
and I could go ahead with that part of it as they researched ... which I read as code for
you can have surgery and be stuck with a big bill for implant and processor and have to
sell your first born to pay for the thing...
My first born is 29 , in good health and is a hard worker ... wonder if he will bring enough?

and yes I am in a bright cheerful mood this morning 

[Catflower]

The latest news from the hospital is that the insurance will cover the entire BAHA process.  The lady in finance is saving all emails and correspondence for back-up if necessary.  Now that this is resolved I'm getting nervous.  April 8 will be here soon.

[leapyrtwins]

Catflower -

that's excellent news!  Congratulations!

Don't be nervous, you'll do great!

Jan

[leapyrtwins]

Yesterday I received a copy of the doc's bill from my BAHA surgery and thought I'd share the billing codes he used.

The first code is 69714 (mentioned previously in this post) "Implant, Osseointegrated w/o Ma" - I have no idea what Ma refers to.
The second code is 15120 "Skin Split Graft, Face/Neck/Ear.

Hopefully this will be helpful to those of you still dealing with your insurance companies.

Jan 

[lori67]

Good news, Catflower!

Don't be nervous - dealing with the insurance company is the worst part of the whole BAHA surgery!  Once you've tackled that, the rest should be smooth sailing!

Lori

[leapyrtwins]

Good news, Catflower!

Don't be nervous - dealing with the insurance company is the worst part of the whole BAHA surgery!  Once you've tackled that, the rest should be smooth sailing!

Lori

True, so true