three.little.boys
04-14-2008, 01:39 AM
Ok- I need some help fighting our insurance company. Has anyone had first hand experience with working at an ins. co, or fighting one? I recieved a letter from the neurosurgeon's office the other day saying that they are sending one more appeal, but it was not looking good, so they ask that I send an appeal as well. Here is what I cam up with...anyone that has the TIME...could you read it and give me your opinion??? THANKS!!! HONEST OPINIONS, please! I have not sent this yet...just spent 3 hrs on it, though!
April 13<SUP>th</SUP>, 2008
Blue Cross Blue Shield
Attn: Medical Director/ Appeals
PO Box 660044
Dallas, TX 75266-0044
Dear Sir/Madam:
My son, Quintin, was diagnosed on December 11, 2007 with Craniosynostosis of the Metopic suture resulting in Trigonocephaly. We then found out that Quintin would need a surgery called a CVR/FOA (Cranio Vault Reconstruction/Frontal Orbital Advancement) to correct this birth defect. If we did not have the surgery done then Quintin had over 15% chance that he would suffer brain damage. He was already having balancing issues as a result. This is a chance that NO parent would gamble on for their child!
I am writing this letter to appeal to you to please consider what you deem “reasonable and customary” for some of the charges incurred during my son’s corrective surgery. We are a family of 5 living on a single income. You will find in the paragraphs below our story of how we tried our best to first find a surgeon IN NETWORK for BCBS KC, but came up empty handed. Please review the following information and reconsider the amount BCBS is willing to pay.
Quintin’s diagnosis came from Dr. John Hiebert, MD, from the Hiebert Center at St. Luke’s Hospital in Kansas City on December 11<SUP>th</SUP>, 2007 . This diagnosis was made via a 3D CT scan performed the same day. Dr. Hiebert was in-network for our insurance policy with BCBS KC. We set a surgery date for mid-January.
After this stunning diagnosis my husband and I decided that I should research this condition more and make sure our son was receiving the best treatment. After further research, I realized that Dr. Hiebert was not a good candidate for our sons invasive surgery. Therefore, we were FORCED to look for other surgeons for our child’s safety! Here are the reasons why we decided Dr. Hiebert was not a good choice, and actually downright risky!:
Dr. Hiebert only performs ONE CVR surgery a month. The rest of his practice is other plastic surgery…mainly breast augmentations and face lifts.
Dr. Hiebert is the Medical Director for Fig, a Kansas City based plastic surgery clinic that performs the highly controversial LipoDissolve. This procedure has been banned in Kansas, but not yet Missouri. There are several class action lawsuits against Fig regarding this risky treatment…yet Dr. Hiebert endorses it?
Dr. Hiebert wanted to do an older type of surgery than the CVR. I believe the surgery he wanted to perform was called a Barrel Stave Osceotomy (sp??), which is known to cause more bleeding in the child and is not as effective in treating this condition as the more standard CVR surgery.
Dr. Hiebert wanted to install a peripherally inserted central catheter- (PICC or PIC line) into Quintin for 3 weeks to deliver a medicine called Procrit to him to boost his hematocrit levels. While the research I did does support the use of Procrit, everything I read said that Procrit could be given with a simple shot…not a PIC line that can expose the child to infection! (the surgeon I decided to use, Dr. Fearon, was able to collaborate with my local pediatrician to give Quintin his Procrit through a simple shot at her office once a week for 3 weeks) I would have to “FLUSH” this PIC line twice a day inflicting pain on my child and possibly introducing bacteria!
Dr. Hiebert also wanted my son to wear a molding helmet for 6 months after surgery. All research shows that this is NOT usual for a complete correction surgery for metopic craniosynostosis. Instead, the molding helmet is optimal for positional plagiochephaly or endoscopic craniosynostosis surgery, which Quintin was too old to be a candidate for. The helmet could actually cause Quintin’s skull more harm then good after surgery!After our decision NOT to use Dr. Hiebert was made, we realized we needed to find another craniofacial surgeon. We then looked into Dr. Singhal at Children’s Mercy Hospital in Kansas City. This surgeon is also in network for BCBS KC. Unfortunately, Dr. Singhal was booked solid and his first available consultation was not until May 2008...which was 5 months away from Quintin’s diagnosis. Quintin was already 8 months old at diagnosis, and the optimal age for craniosynostosis corrective surgery (CVR/FOA) is between 8-12 months old. Quintin would have been 15 months old before Dr. Singhal would have even had a consultation with him! So, Dr. Singhal was not a viable option for Quintin’s surgery, either.
We then learned that there was only one other surgeon who performs this type of surgery in Kansas City…and he was trained by Dr. Hiebert, who was the first surgeon we saw! His practices were similar to Dr. Hiebert’s, and we had already deemed them unsafe.
So, as parents, where do we turn now? We turned to the world renowned pediatric craniofacial specialist, Dr. Jeffery Fearon of Pediatric Plastic Surgery, PLLC in Dallas, TX. Dr. Fearon performs over 80 CVR surgeries on pediatric patients annually. He has a lower blood transfusion rate of about 50%…compared to the national average of almost 100% for this type of surgery! Also, his patients spend on average 50% less time in the hospital. His patients average 2-3 nights ion the hospital after surgery vs. 5-6 nights as a national average. Dr. Fearon was and is still an angel in disguise for our family and son!
Dr. Fearon agreed to take on Quintin’s case, and surgery was set for February 19, 2008 when Quintin would be 10 months old. Dr. Fearon ONLY uses a select few handpicked surgeons and doctors to be on his surgical team. These doctors comprise of pediatric neurosurgeons and pediatric anesthesiologists that have had extensive experience with Dr. Fearon in doing this very surgery….thus minimizing the risk to the child. Therefore, we did not have the option to pick a neurosurgeon or anesthesiologist that was in-network for BCBS KC. But, we had already exhausted all of our in-network options in Kansas City…so we had no choice!
The surgery was performed as planned on Feb. 19<SUP>th</SUP> and went wonderfully! Quintin DID NOT need a blood transfusion and only needed to stay in the hospital for 2 nights. He has thrived ever since and I am 100% positive that we made the best decision when choosing our surgical team of Dr. Fearon and his colleges.
Then the bills came. I thought we would be paying our out-of-network maximum coinsurance of $3,750 plus a little extra, perhaps. Boy, was I wrong!
Our bill for Dr. Sacco, pediatric neurosurgeon, came in at $9,204.00, and BCBS agreed to cover only $4,532.92. This leaves us to pay the remaining $4,532.92 PLUS an additional 40% coinsurance of the amount BCBS has agreed to pay! This is absurd! I have been advised that this level of coverage is WAY below the standard of what is considered “reasonable and customary” for the Dallas area! I believe this is acting in bad faith, and I would hate to have to contact the Texas Department of Insurance!
Also, the charges for Dr. Fearon, craniofacial surgeon from Pediatric Plastic Surgery, totaled $13,080, and BCBS agreed to cover ONLY $2090.35 with a plan payment of only $926.95!! This is absurd that I am left with the balance of $12,153.05 when we hold a very good insurance policy that my family and my husband’s work pays approximately $1,000 a month for coverage! Our insurance policy is a contract, and we agree to pay our premium each month, and it is BCBS responsibility to hold up it’s end of the bargain and cover our son’s corrective surgery at an appropriate rate!!
The charges for the anesthesia was $2,560, and once again, BCBS has left almost HALF of this bill for me and my family to cover! BCBS agreed to cover $1,390.38 leaving us $1,169.62 to pay! This, also, is not acceptable and is also acting on bad faith on BCBS’s part!
Finally , a charge to Pediatric Acute Care Association for service on 2/19/2008 was filed for $496.00, and BCBS agreed to cover $114.20 Once again, this leaves us with a balance of $381.80! A second charge for the date of 2/20/2008 was $397 and BCBS covered only $95.50. WHY?? These were services rendered at an IN NETWORK hospital, Medical City Dallas, and were doctors working for this in-network hospital. We were not even aware of these doctors, nor were we given the choice to find an in-network doctor!
In closing, we did the responsible thing for our child by finding him a surgical team that was capable of safely performing this surgery and performing it in a timely fashion before his skull hardened too much to repair correctly. But, we are being punished by BCBS for seeking out quality medical care. Please take our situation to heart and see that we are a normal family just trying to survive in this financially unstable time. We were unaware that we would be left with SO MUCH of each bill as our responsibility and burden! Like I said before, I would hate to have to bring this matter up to the Texas Department of Insurance. But, I will if I have to. There is one thing I have a lot of…time! We may not have much money, but I do have the time to address this situation properly and fight for my rights as a policy holder!
Thank you for your time and consideration.
Regards,
Sadie Decker
Member ID
Group Number
Policy holder name: Anthony R. Decker (my husband)
Policy offered by Burns and McDonnell Engineering
April 13<SUP>th</SUP>, 2008
Blue Cross Blue Shield
Attn: Medical Director/ Appeals
PO Box 660044
Dallas, TX 75266-0044
Dear Sir/Madam:
My son, Quintin, was diagnosed on December 11, 2007 with Craniosynostosis of the Metopic suture resulting in Trigonocephaly. We then found out that Quintin would need a surgery called a CVR/FOA (Cranio Vault Reconstruction/Frontal Orbital Advancement) to correct this birth defect. If we did not have the surgery done then Quintin had over 15% chance that he would suffer brain damage. He was already having balancing issues as a result. This is a chance that NO parent would gamble on for their child!
I am writing this letter to appeal to you to please consider what you deem “reasonable and customary” for some of the charges incurred during my son’s corrective surgery. We are a family of 5 living on a single income. You will find in the paragraphs below our story of how we tried our best to first find a surgeon IN NETWORK for BCBS KC, but came up empty handed. Please review the following information and reconsider the amount BCBS is willing to pay.
Quintin’s diagnosis came from Dr. John Hiebert, MD, from the Hiebert Center at St. Luke’s Hospital in Kansas City on December 11<SUP>th</SUP>, 2007 . This diagnosis was made via a 3D CT scan performed the same day. Dr. Hiebert was in-network for our insurance policy with BCBS KC. We set a surgery date for mid-January.
After this stunning diagnosis my husband and I decided that I should research this condition more and make sure our son was receiving the best treatment. After further research, I realized that Dr. Hiebert was not a good candidate for our sons invasive surgery. Therefore, we were FORCED to look for other surgeons for our child’s safety! Here are the reasons why we decided Dr. Hiebert was not a good choice, and actually downright risky!:
Dr. Hiebert only performs ONE CVR surgery a month. The rest of his practice is other plastic surgery…mainly breast augmentations and face lifts.
Dr. Hiebert is the Medical Director for Fig, a Kansas City based plastic surgery clinic that performs the highly controversial LipoDissolve. This procedure has been banned in Kansas, but not yet Missouri. There are several class action lawsuits against Fig regarding this risky treatment…yet Dr. Hiebert endorses it?
Dr. Hiebert wanted to do an older type of surgery than the CVR. I believe the surgery he wanted to perform was called a Barrel Stave Osceotomy (sp??), which is known to cause more bleeding in the child and is not as effective in treating this condition as the more standard CVR surgery.
Dr. Hiebert wanted to install a peripherally inserted central catheter- (PICC or PIC line) into Quintin for 3 weeks to deliver a medicine called Procrit to him to boost his hematocrit levels. While the research I did does support the use of Procrit, everything I read said that Procrit could be given with a simple shot…not a PIC line that can expose the child to infection! (the surgeon I decided to use, Dr. Fearon, was able to collaborate with my local pediatrician to give Quintin his Procrit through a simple shot at her office once a week for 3 weeks) I would have to “FLUSH” this PIC line twice a day inflicting pain on my child and possibly introducing bacteria!
Dr. Hiebert also wanted my son to wear a molding helmet for 6 months after surgery. All research shows that this is NOT usual for a complete correction surgery for metopic craniosynostosis. Instead, the molding helmet is optimal for positional plagiochephaly or endoscopic craniosynostosis surgery, which Quintin was too old to be a candidate for. The helmet could actually cause Quintin’s skull more harm then good after surgery!After our decision NOT to use Dr. Hiebert was made, we realized we needed to find another craniofacial surgeon. We then looked into Dr. Singhal at Children’s Mercy Hospital in Kansas City. This surgeon is also in network for BCBS KC. Unfortunately, Dr. Singhal was booked solid and his first available consultation was not until May 2008...which was 5 months away from Quintin’s diagnosis. Quintin was already 8 months old at diagnosis, and the optimal age for craniosynostosis corrective surgery (CVR/FOA) is between 8-12 months old. Quintin would have been 15 months old before Dr. Singhal would have even had a consultation with him! So, Dr. Singhal was not a viable option for Quintin’s surgery, either.
We then learned that there was only one other surgeon who performs this type of surgery in Kansas City…and he was trained by Dr. Hiebert, who was the first surgeon we saw! His practices were similar to Dr. Hiebert’s, and we had already deemed them unsafe.
So, as parents, where do we turn now? We turned to the world renowned pediatric craniofacial specialist, Dr. Jeffery Fearon of Pediatric Plastic Surgery, PLLC in Dallas, TX. Dr. Fearon performs over 80 CVR surgeries on pediatric patients annually. He has a lower blood transfusion rate of about 50%…compared to the national average of almost 100% for this type of surgery! Also, his patients spend on average 50% less time in the hospital. His patients average 2-3 nights ion the hospital after surgery vs. 5-6 nights as a national average. Dr. Fearon was and is still an angel in disguise for our family and son!
Dr. Fearon agreed to take on Quintin’s case, and surgery was set for February 19, 2008 when Quintin would be 10 months old. Dr. Fearon ONLY uses a select few handpicked surgeons and doctors to be on his surgical team. These doctors comprise of pediatric neurosurgeons and pediatric anesthesiologists that have had extensive experience with Dr. Fearon in doing this very surgery….thus minimizing the risk to the child. Therefore, we did not have the option to pick a neurosurgeon or anesthesiologist that was in-network for BCBS KC. But, we had already exhausted all of our in-network options in Kansas City…so we had no choice!
The surgery was performed as planned on Feb. 19<SUP>th</SUP> and went wonderfully! Quintin DID NOT need a blood transfusion and only needed to stay in the hospital for 2 nights. He has thrived ever since and I am 100% positive that we made the best decision when choosing our surgical team of Dr. Fearon and his colleges.
Then the bills came. I thought we would be paying our out-of-network maximum coinsurance of $3,750 plus a little extra, perhaps. Boy, was I wrong!
Our bill for Dr. Sacco, pediatric neurosurgeon, came in at $9,204.00, and BCBS agreed to cover only $4,532.92. This leaves us to pay the remaining $4,532.92 PLUS an additional 40% coinsurance of the amount BCBS has agreed to pay! This is absurd! I have been advised that this level of coverage is WAY below the standard of what is considered “reasonable and customary” for the Dallas area! I believe this is acting in bad faith, and I would hate to have to contact the Texas Department of Insurance!
Also, the charges for Dr. Fearon, craniofacial surgeon from Pediatric Plastic Surgery, totaled $13,080, and BCBS agreed to cover ONLY $2090.35 with a plan payment of only $926.95!! This is absurd that I am left with the balance of $12,153.05 when we hold a very good insurance policy that my family and my husband’s work pays approximately $1,000 a month for coverage! Our insurance policy is a contract, and we agree to pay our premium each month, and it is BCBS responsibility to hold up it’s end of the bargain and cover our son’s corrective surgery at an appropriate rate!!
The charges for the anesthesia was $2,560, and once again, BCBS has left almost HALF of this bill for me and my family to cover! BCBS agreed to cover $1,390.38 leaving us $1,169.62 to pay! This, also, is not acceptable and is also acting on bad faith on BCBS’s part!
Finally , a charge to Pediatric Acute Care Association for service on 2/19/2008 was filed for $496.00, and BCBS agreed to cover $114.20 Once again, this leaves us with a balance of $381.80! A second charge for the date of 2/20/2008 was $397 and BCBS covered only $95.50. WHY?? These were services rendered at an IN NETWORK hospital, Medical City Dallas, and were doctors working for this in-network hospital. We were not even aware of these doctors, nor were we given the choice to find an in-network doctor!
In closing, we did the responsible thing for our child by finding him a surgical team that was capable of safely performing this surgery and performing it in a timely fashion before his skull hardened too much to repair correctly. But, we are being punished by BCBS for seeking out quality medical care. Please take our situation to heart and see that we are a normal family just trying to survive in this financially unstable time. We were unaware that we would be left with SO MUCH of each bill as our responsibility and burden! Like I said before, I would hate to have to bring this matter up to the Texas Department of Insurance. But, I will if I have to. There is one thing I have a lot of…time! We may not have much money, but I do have the time to address this situation properly and fight for my rights as a policy holder!
Thank you for your time and consideration.
Regards,
Sadie Decker
Member ID
Group Number
Policy holder name: Anthony R. Decker (my husband)
Policy offered by Burns and McDonnell Engineering