I had a Xiaflex treatment on my right hand this past December. The results have been terrific. I had thought going into the procedure that it would be covered by Anthem BC/BS of NH. I had waited about 6 mos. for the approval process to get the serum. Once approved, the serum was shipped from the pharmacy to my hand doc and I had the injections one day and the manipulation/straightening the next. Two months later I get notification from BC/BS that they would not cover the manipulation portion of the bill stating that the procedure was "experimental/investigational" and they did not provide benefits for that. Thus, a month later I received a bill for $1300+ for the "manipulation, finger Joint Under Antheshesia" Insurance covered the cost of the drug, the injection, and the splint, but was denied because the manipulation portion of the therapy is considered in their manual to be investigational and/or experimental. They wrote "We have determined that: No demonstrated evidence exists to determine that the service is not experimental."
I appealed and was denied a second time. I talked to an agent of the insurance company again yesterday and she pointed out that the cost of the drug was covered because the prescription portion of my insurance is different from BC/BS and that they covered the actual injection because they cover all injections and it had nothing to do with it being a treatment for DP. They also covered the cost of the splint.
She said I could appeal a second time but before I do, I would like to know the experience others have had in getting insurance companies to recognize and provide benefits for this procedure and what arguments or evidence I can provide to show that this is an FDA approved procedure that works, is less invasive and cheaper than surgery, and is not still in its testing or experimental phase.
I'm happy to report that 4 months out, I have full extension of my right hand, no sign of recurrence, and it feels as good as new. My left hand has some nodules but little contraction yet. When and if the time comes for my left hand to be treated, I will opt for surgery because insurance will pay for that unless I can get some satisfaction in my present case.
Does anyone have any ideas on how to fight for insurance coverage?
I hope my memory serves me right but I think it was Blue Cross in NH that out sourced it's approval process to another company. That company recieved significat bonuses if it saved over 20% in insurance payments. It was denying things like stress test to men with cardiac symptoms.
I would ask for a physician specialty specific review and if denied again I would contact your state insurance regulatory agency. This is FDA approved.
Also consider contacting the maker of Xiaflex. They are under the impression that it is covered by all insurance now. They have deep pockets and their own lawyers.
I think if a big drug company was making money off of Radiation medicare would be paying for it.
Was the doctor who administered the Xiaflex a BCBS provider? If so, then it is up to the doctors office to verify your insurance and coverage. Also, the doctor who gave you the injection is your best shot at getting the manipulation covered. I realize that the drug was covered by your prescription plan, but, and this may sound like a stupid question, is Xiaflex used in any form of treatment where manipulation does not occur? I would also document the research and FDA approval information, give this information to the insurance company and as suggested get a doctor review as another form of your appeal.
Thanks to all for the suggestions and support. My doctor was Dr. Horangic @ the Dartmouth Hitchcock Clinic in Manchester NH, and yes he is a BC/BS provider and I had all necessary approvals from my primary care doc. The office told me they submitted the claim twice to the insurance and both times it was refused and thus, they sent me the bill. Talking to the billing dept, I was told there was nothing else they could do and asked if I wanted to set up a payment plan, put it on a credit card or send them a check. I told them I was going to pursue the insurance payment further and would pay them if and only after all the avenues of recourse were exhausted.
I also recall that the denial was from an outfit in Conn. that was hired by NH BC/BS and it was signed by a doctor that worked for this out of state "third party" insurance reviewing Co. Interesting that this might be a case as you described where they benefit by denying claims as part of their contract.
Go to XIAFLEX.COM and go to the physician site and look up reimbursement help. The doctor's office /billing people should be more helpful!!! If the insurance company is denying them, I don't think they can go after you for the remainder. They likely verified your insurance benefits and should help you.
Photobill:I also recall that the denial was from an outfit in Conn. that was hired by NH BC/BS and it was signed by a doctor that worked for this out of state "third party" insurance reviewing Co. Interesting that this might be a case as you described where they benefit by denying claims as part of their contract.
Just curious....if they had approved it before your treatment, did you sign any papers saying that part/all would not be covered and you would be responsible for the balance....if you didn't sign anything prior to treatment, how can they bill you now?
Is the doctor who gave you the injection the same as your primary care doctor? If not then you would have probably needed approval with/through the doctor who gave you the injection. Also, if approval was received or even requested it will be in your records at BCBS. All conversations are documented. Not only will it be in your records at BCBS but a copy of that approval should be in your records at your primary care doctors office. Your primary care doctor should have documented the day, time, name of person, etc...who gave the approval or if they looked online I would have thought they would have printed your insurance information stating that it was approved. I would suggest you go to your primary care doctor and ask for that verification and then contact BCBS. If approval was through the doctor that gave you the treatment then that doctor has a contract with BCBS to provide your treatment at a fixed price and if they messed up the approval then it is their fault and it is up to them to collect from BCBS. I know there is a disclaimer when I call BCBS that even though I am checking benefits there is no guarantee as to payment of claims, but I would think that if treatment had been questionable as to whether it was experimental it would have been disclosed at the pre-approval conversation with BCBS at your primary care doctors office.
Good luck, with your claim issue. I work in the mental health field and deal with getting approvals all week long. If approval was received there is a paperwork trail.