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Health insurance problems 1 year 4 months later

August 02, 2012
posted by  dxan29


So my blood pressure has gone up dramatically. As I received a bill from my son's ENT for $5637.27 and also a copy of a letter from Humana Military. Marek's surgery was performed April 2011. Tricare approved the surgery verbally over the phone, as it was pushed up and we had less than 48 hours notice. The surgery was performed, then tricare came back and denied it. Just lovely. Well, there was  over a year of fighting, it appears, between the doctor and my insurance and I thought everything was worked out. I went through the claims and insurance paid $21,000 of a $27,000 hospital bill. But it appears they only paid for the surgery. The BAHA sound processor was not paid for and was denied. So now I have a bill for $5637.27. Now on top of trying to pay to upkeep and/or maintain this processor and implant, money out of pocket for therapy's (which insurance doesn't pay but for a few times a year), a recession (lmao),now I'm suppose to magically come up with this kind of money, especially if I don't want to lose his doctor. I can't stop crying. I thought this was the right choice, but I just don't know how we can do this (oh wait it's already done).

 

Oh let me stop my pity party. I know I will find the money, sell the dog, whatever it takes. I just needed to vent or my eyes would get too puffy.

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Comments

 
2CI Ears--Connie J. Cochlear Volunteer Ambassador

August 03, 2012

Oh what a terrible thing to have to go through. I can understand why your blood pressure is sky high. First thing to do is make sure Humana Military understands that it is not a hearing aid--BAHA no longer stands for bone anchored hearing aid it is just a BAHA. Check your policy and see if BAHA is specifically listed as being excluded. Check to see if there is a difference in price in just the processor itself and the part that is implanted. The implanted part should be included as part of the surgery. When my husband was facing BAHA surgery we always knew that what you are explaining might happen and had to prepare to pay the out-of-pocket expense of the processor itself. Unfortunately many insurance companies don't understand the importance of this device. Lastly you might want to contact Cochlear Americas insurance support team and see if they can lend a hand. Hope things get better for you and anyone who served/serves our country should not have to go through this. Connie
 
cthor

August 11, 2012

Sorry for all the drama you are going through!! Currently trying to get daughter a new BAHA as the dog ate the other :( Thinking since the insurance company paid for the surgery...they would understand that he needs the prosthesis (BAHA) to work with implant. Make sure the claim is being filed as a "prosthesis" not medical equipment. Make sure the HCPCS code they are using is L8691 (audio osseointegrated device, external sound processor, replacement). You need to talk to a person at your insurance company...our claim was denied due to Audiologist ordering prosthesis. The computer automatically denies based on the thought that the prosthesis is an arm or a leg. It doesn't understand the prothesis is the BAHA. The doctors office may need to re-submit the claim just for the device only. They will need to show medical necessity and provide medical records. Just stay with it...good luck! We are still waiting to get our new BAHA...so I completely understand!
 
dxan29

August 11, 2012

Thank you for the comments and also those of you who emailed me. I talked with our doctor's office yesterday, and it appears they have had this problem with 2 cochlear recipients and tricare. They are passing it on to their lawyer. The office personel were very nice about it and told me to just hold off and let the lawyer fight tricare. I tried to find out how they made the claim or how it was filed (i.e. prothesis, medical equipment) and I'm still not sure. My EOB statement shows...BAHA. I also asked why it was billed separately from the whole hospital bill, and the office said that's how they did it. Who knows at this point. Very frustrating, but alas, if I end up having to pay it in the long run. $50 a month it is for the next 9 years. I did discover that the price was so high, because he received two full sets.
 
cthor

August 11, 2012

Hey Again...I'm not sure if you have looked, but just in case you haven't. Humana Military website you can download the pdf Provider Handbook. Look at page 75...it talks about the prosthesis "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)/M_e_d_i_c_a_l_ _e_q_u_i_p_m_e_n_t_ _o_r_ _s_u_p_p_l_i_e_s_ _n_e_e_d_e_d_ _b_y_ _p_a_t_i_e_n_t_ _i_n_ _o_r_d_e_r_ _t_o_ _a_r_r_e_s_t_ _o_r_ _r_e_d_u_c_e_ _f_u_n_c_t_i_o_n_a_l_ _l_o_s_s_• _M_u_s_t_ _b_e_ _o_r_d_e_r_e_d_ _b_y_ _a_ _p_h_y_s_i_c_i_a_n_/A_ _p_r_e_s_c_r_i_p_t_i_o_n_ _r_e_q_u_e_s_t_i_n_g_ _D_M_E_P_O_S_ _a_n_d_ _s_i_g_n_e_d_ _b_y_ _t_h_e_ _b_e_n_e_f_i_c_i_a_r_y_’s_ _p_h_y_s_i_c_i_a_n_ _i_s_ _r_e_q_u_i_r_e_d_ _f_o_r_ _r_e_n_t_a_l_ _o_r_ _p_u_r_c_h_a_s_e_ _o_f_ _D_M_E_P_O_S_._ _P_r_e_s_c_r_i_p_t_i_o_n_s_ _m_u_s_t_ _s_p_e_c_i_f_y_ _t_h_e_ _b_e_n_e_f_i_c_i_a_r_y_’s_ _d_i_a_g_n_o_s_i_s_,_ _t_h_e_ _p_a_r_t_i_c_u_l_a_r_ _t_y_p_e_ _o_f_ _e_q_u_i_p_m_e_n_t_ _n_e_e_d_e_d_,_ _t_h_e_ _r_e_a_s_o_n_ _i_t_ _i_s_ _n_e_e_d_e_d_,_ _a_n_d_ _t_h_e_ _d_u_r_a_t_i_o_n_ _f_o_r_ _w_h_i_c_h_ _i_t_ _w_i_l_l_ _b_e_ _n_e_e_d_e_d_._ _A_ _c_e_r_t_i_f_i_c_a_t_e_ _o_f_ _m_e_d_i_c_a_l_
 
cthor

August 11, 2012

I copied and pasted...not sure why it looks like that. Also, if you look at the Feb "02 "Learning Library Document" you can see the Tricare Covered Benefits and Services. Looks like all is covered. Also, your healthcare plan uses cost & payments based on CMS Medicare. The CMS updated their coverage of just Cochlear to include the BAHA (its not called that of course)...that HCPCS code is L8614. I cannot log into benefits for you...but You can!! Go to www.humana-military.com Click "government"...then "explore" you can log on there and drill down more for your own benefits. Good luck..
 
anie96

September 06, 2012

Hi there. I'm new to the community here and saw you were working Tricare (Humana) to get a BAHA covered. I'm an active duty dependent and am considering a BAHA. I called Tricare today and asked about it and gave them the CPT code that was listed up in an earlier reply and they did say that as long as there was a referral in place for audiology that it would be a covered benefit. This is all a totally new adventure for me! I hope it all works out well for your son! I know how frustrating insurance (Tricare in particular) can be!
 
Robin White - BAHA Parent Volunteer

September 22, 2012

Trieste covered my son in 2011, surgery and processor. They would not cover a cros. It is all on the coding...
 
Heather

September 23, 2012

Hi. I hope they cover it for you. My insurance did not cover mine (I was a civilian working for the Army...my hearIng loss kept me from my dream of actIve duty mIlItary), so I used my flexible spending account so at least it was pre-tax dollars If that helps. Good luck! I hope they resolve this for you. And thanks for your service to our country.
 
LWyatt

November 03, 2012

My insurance is from Wal-Mart which doesnt pay for anything! We just assumed that we would be paying for it forever! I couldn't beleive when they approved it BUT it was because of the medical problems accomping the "sudden onset hearing loss". I have vertigo and tinitis. Someone at the insurance company actually told me to be sure the Dr included the medical diagnosis not just a "hearing aid". Maybe if there are any medical complications to go with your sons they might reconsider! Good Luck!

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