Health insurance involving hospitalization

[Deleted]

My husband has an abdominal aortic aneurysm. It is an immediate danger because of size (5 centimeters) and shape. He has two forms of insurance--coverage through mine and coverage through Medicare.

Because he is on blood thinner (he also has a pacemaker/defibrillator), the surgeon's plan is to admit him on Monday, put him on blood thinners by IV which leave your system more quickly, take him off on Wednesday (still hospitalized), and operate on Thursday. They are shooting for the least invasive version because of bleeding, but there is always the chance that the surgeon may have to switch to open abdomen.

My insurance company (BCBS) requires preapproval for any hospital admission other than an immediate medical emergency (you get approval within 24 hours in that case). My husband did get a second opinion, mostly because the first guy only would do open abdomen.

It has been a week, and they still haven't approved it. Isn't it a lawsuit waiting to happen if they deny it, and then it bursts? Don't they have to at least suggest a medically acceptable alternative? This isn't experimental surgery. Five centimeters is the standard at which they operate.

If his doctor hears tomorrow, he will let us know. Otherwise, we have to wait another week.

Has anyone ever been in this situation before?

[The Walk of the Penguin Mich]

Have you contacted your insurance company to find out what the delay is?

When I had my last hip replacement, approval for surgery was requested mid Dec. for a Feb. 1 surgery date. I received an approval letter that was dated 2/7 on 2/14. Surgery went on as scheduled.

In my experience, the doctor's offices have dealt with pre approvals. Have they requested your intervention?

[Deleted]

The doctor's office hasn't requested our intervention, but they aren't moving forward until it is approved.

Ironically, last week the doctor's office tried to get my husband to get himself admitted that day. He wanted to tidy up some personal details first (adding me to his bank account for example), and I was going, "Uh, we have to get pre-approval." Then they thought it wasn't going to be a problem.

This is driving us nuts. Thanks for answering, Feeb.

[moxie]

"It has been a week, and they still haven't approved it. Isn't it a lawsuit waiting to happen if they deny it, and then it bursts?"

*You would think.


"Don't they have to at least suggest a medically acceptable alternative? This isn't experimental surgery. Five centimeters is the standard at which they operate."

*If that is the standard, I would think it would be approved. I have had very good luck with BCBS in the past.


All my best to your husband and you, ss.

[973beachbum]

When I was a claim approver we had to get our determinations out in two weeks. I have never heard of taking months to approve something like that. What were they waiting for the person just o give up?

SS are you sure your insurance is primary? If he is over 65 I would say that medicare would be the primary payer. If he is under 65 and on medicare because of a disability I would say your health insurance is. When I was in health insurance we only did the pre approval if we were the primary insurance. If we were secondary we wouldn't.

I am not sure it is helpful but I HTH.

ETA We were not allowed to make any suggestions about care. All we could say is what the plan would pay for or not if asked. Anything else was considered practicing medicine without a license.

[Deleted]

I will say that we have been totally confused about which health care plan (BCBS or Medicare) is primary. When I entrolled him at age 66, BCBS answered an email saying they were primary. My retired friends say that isn't so, but I am still working so maybe that is why they would be primary. They have been paying that way with Medicare picking up some of the not-paid portions.

The plan should pay for his surgery if it isn't experimental. I am guessing that the problems are maybe stuff like open abdominal vs. less invasive, going off blood thinner at home vs. hospitalization (a real danger) and stuff like that. But maybe they have simply taken a week to figure out who is responsible as primary Beachbum.

That actually makes me feel a little better. I can't figure out how they can refuse him surgery that falls with the "standard." If he goes off the blood thinner at home, there is the risk of death. Again, it seems like another lawsuit waiting to happen if the doctor's recommendation was otherwise.

The idea that they had to provide suggestions for alternative care comes from my dental plan. It is also BCBS, and when they reduce, etc., they tell us what the "standard" procedure would be and pay for that.

[marvholly]

Medicare is ALWAYS primary. Your BCBS is DH's medigap. If Medicare approves (pays) and it sounds like they will then BCBS MUST pay the remaining 20% of approved Medicare charges.

NOTE: The hospital, Dr, lab ...........must take the approved amount between Medicare & BCBS as FULL payment. They cannot come after you for overages.

[alabamagal]

Good luck trying to sort this out.

Re the potential lawsuit - I knowlots of people are "sue happy" and I am not saying that you are. Just remember that the insurance companies are not saying that you can't go to the hospital, they are just getting the paperwork regarding payment of the claim.

If your doctor says your husband should go to the hospital on Monday to prepare for surgery for a life threatening situation, then you should follow what the doctor says and sort out everything later.

[Martivir]

I had a doc turn me down because I have Medicare even though I also have coverage through DH's work. Medicare is primary no matter what. It's a pain in the rear because I can have a balance at the doc's office for months before everything is straightened out between the two insurances.

[Deleted]

SS - when MIL was diagnosed with brain cancer and wanted surgery the insurance company initially turned her down. FIL had his HR rep call the insurance company and also paid a lawyer to send a letter (cost about $200). She was approved within days.

Does his dr. take medicare? I believe that when medicare is primary and approves a bill the secondary picks up with no fight. Have you spoken to BCBS yourself?

[Deleted]

I found this out on the web:

If you are not 65+ years old, completely disabled, or both, and your spouse is employed by a company with 100+ employees, then your spouses insurance is primary. However, if you are disabled, 65+ yrs old, or the company your spouse works for has less than 100 employees, then your medicare would be primary.

[shanendoah]

I haven't read all the responses on this, so forgive me if someone said this already, but you or the MD's office need to be calling the insurance company and requesting an urgent or expedited review. At expedited levels, they usually have a max of 72 hours to get a response back to you. However, if you dont' request an urgent or expedited review, then insurance companies usually have around 10 working days to review and authorize or deny any pre-approval request. (It will depend on your state laws.)

[Deleted]

No, Marvholly, Medicare isn't always primary if the Medicare recipient's spouse works for a large employer ( over a certain number of employees - I don't remember how many ), and the Medicare recip is carried on the working spouse's employer-sponsored medical insurance. In that case, the other insurance is primary.

This is what we were told at the hospital today. My insurance is primary because I am still working. I just checked this on the Medicare website. It is in their policy handbook.

We got the approval this morning, and he was admitted. The problem with simply following the doctor's advice no matter what the insurance company says is that this surgery will be extremely expensive. He is spending a minimum of five days in CU (maybe one of those in ICU) assuming he gets to home the day after the surgery. He has three heart specialists seeing him daily.

[Deleted]

Like anything, you just have to jump through the hoops. Some insurances companies are easier to navigate than others. The best thing for everyone is to really understand what is required of them before they get into a situation to help ease them through the process. Sounds like you are on the right track.

[Deleted]

Hope everything goes great for your DH!

[Gardening Grandma]

Jul 8, 2012 19:10:41 GMT -5 @chef241 said:

I would think Medicare should be primary and BC secondary.

That was my thought as well. Are you positive that Medicare is not primary? Have you asked your insurance company whether they are primary or secondary? If Medicare is his primary, then there is no need to wait....

Oops, just read the rest of the posts.. Glad to hear he got admitted and hope all goes well....

[973beachbum]

Jul 10, 2012 13:02:21 GMT -5 Gardening Grandma said:

Jul 8, 2012 19:10:41 GMT -5 @chef241 said:

I would think Medicare should be primary and BC secondary.

That was my thought as well. Are you positive that Medicare is not primary? Have you asked your insurance company whether they are primary or secondary? If Medicare is his primary, then there is no need to wait....

Oops, just read the rest of the posts.. Glad to hear he got admitted and hope all goes well....

I was looking it up and it seems they changed this a few years ago. Everytime the fed gov wants to say money with medicare they do a change that makes any other insurance primary over them. They are right about that though it will save Medicare money. ;D

I hope all goes well with your DH SS.

[muttleynfelix]

I hope the procedure goes well.

[busymom]

Best wishes for your DH! You can't even prepare yourself (or DH) emotionally for surgery because of all this stupidity from the insurance company....


Sending prayers your way!

[Deleted]

The procedure is tomorrow (Thursday). It's been a bad three days because he has been so incredibly bored. What I learned about the CCU is that everyone else there is so sick they don't care about stuff the rest of us care about. The rest of the hospital has large flat screens with good reception; he has a 1990s style tv with snow and no closed captioning. That matters because you can't turn the volume up because everyone else is so sick. There is no bathroom and no shower because the typical CCU patient can't get out of bed, much less shower. Oh, and there is no phone! I guess the typical CCU patient is too sick to talk.

If all goes well, he goes home on Sunday. I will post the thousands of dollars this surgery cost and how much Blue Cross "negotiated" to pay. I appreciate our insurance with all my heart, but I feel sorry for those who have to pay the sticker cost.

This is my particular soapbox some days, but medical care shouldn't have a two-tier system with such a wide discrepancy. The uninsured are charged 100%. My BCBS policy usually pays about 10% and the hospital accepts it.

[The Walk of the Penguin Mich]

This is my particular soapbox some days, but medical care shouldn't have a two-tier system with such a wide discrepancy. The uninsured are charged 100%. My BCBS policy usually pays about 10% and the hospital accepts it.

I think you'll find that the insurance company will pay a negotiated rate of around 70% for hospitalization. That has been my experience for the 5 surgeries I have had since Feb. 2011.

Other services negotiated lower rates. For instance, my home health service billed $2800/week for supplies, IV antibiotics, picc line care and blood work. My insurance company paid just over $700, so about 25%.

The rest of my bills over the last year are paid at rates between those 2 examples and at this point, they're approaching $500k.

[taz157]

Jul 10, 2012 14:50:41 GMT -5 muttleynfelix said:

I hope the procedure goes well.

[Deleted]

I hope today goes well.

[Gardening Grandma]

Jul 12, 2012 18:37:04 GMT -5 @debthaven2 said:

I hope today goes well.

[Deleted]

*BUMP*

Any news SS?!

[Deleted]

Thank you all for the good wishes. Here is the update.

When the doc got him in the operating room, he discovered that the arteries were too narrow and had too much plaque to do the stent graft procedure. So he did the open abdomen. It was five-and-a-half hours of surgery.

My husband is "fine." His heart numbers are "up," whatever that means, but they have him back on Plavis. He actually took four today to elevate his levels. He is very disoriented, somewhat caused by the anesthesia and somewhat caused by the morphine drip. He was too out of it to handle the pain medication button. He isn't coherent enough to understand the button although he was very interested in the color. Lol.

He is now apparently going to bankrupt the state of Alabama with his care because he will be in SICU a few more days and in the hospital several more days. The doctor says we are looking a recovery period in terms of 2-3 months. Fortunately, the "worst" of it should be over before I return to work.

I can't wait to post the total cost of this procedure. I am guessing $250,000. I'll start a separate thread where we can guess.

The nicest part was that my sister had scheduled a visit this week and has taken care of our dog. The days prior to surgery were easy. She and I went out to lunch. Yesterday and today she was sole carekeeper, and that will probably be true until he gets out of SICU. She offered to stay another week, and I offered to pay the difference ($100) to change her ticket.

I am so grateful. Oh, and to turn this into a coupon thread, I discovered an unadvertsed special on the hospital's website. No one tells you this, but they sell discounted parking tickets. Normally, parking is $3-$5, which gets expensive if you come and return a couple of times a day. You can buy a book of tickets for 10/$15.00. I bought my second book of tickets today.

Couponers should be proud of me.

[busymom]

Great news, Susana!!

Your DH will probably be foggy (and funny) until they wean him off the morphine. Right now it'll help him with the pain, and help him rest, which is what he needs.

I'm glad you've got your sister to help hold down the fort at home. Nice work with the parking discount, too!

[Works4me]

My father had this procedure done back in 2001 at age 71 and did great. He was confused in ICU and then step down unit for a few days and then re-oriented as the morphine was reduced. He recovered very quickly and lived independently until 2010 at age 80. His mother died of a ruptured abdominal aortic aneurysm so it was such a blessing that his was caught, monitored and then treated effectively.

Glad to hear your DH came through the surgery and is recovering. Also happy that your sister is here. Don't forget to take care of yourself.

[The Walk of the Penguin Mich]

My husband is "fine." His heart numbers are "up," whatever that means, but they have him back on Plavis. He actually took four today to elevate his levels. He is very disoriented, somewhat caused by the anesthesia and somewhat caused by the morphine drip. He was too out of it to handle the pain medication button. He isn't coherent enough to understand the button although he was very interested in the color. Lol.

This becomes an interesting conundrum. Hospital staff do not want visitors pushing the button for the PCA, but when the patient is too out of it, how do they get pain meds to cover things?

IMO, after general anesthesia, there is an incredible amount of disorientation the first day, even if you can handle it well, without nausea. Things should be better tomorrow.

Best wishes for an uneventful recovery....

[suesinfl]

So glad to hear that everything is going well. You DH will feel sooooo much better as he recovers.