Posts Tagged blue shield
Breast reduction is defined as the reduction and lifting of naturally enlarged breasts. Medical insurance can cover this surgery but the insurance requirements vary from insurer to insurer. The insurers pay variably as well for surgeons who are Provider doctors and those who are not. Some pay so poorly that I can’t afford to take their rates. You will find few MediCal plastic surgeons in Orange County. There will be very few good ones.
The process for obtaining health insurance coverage generally involves your plastic surgeon writing a Letter of Medical Necessity to the insurer requesting coverage. This should be done before surgery and does not absolutely guarantee coverage, but at least makes it almost certain.
The letter generally needs to have a picture of the woman’s breasts and a description of her problems. Her height and weight and a prediction of the mass of breast tissue to be removed (in grams) are traditionally also indicated.
There are certain ICD-9 diagnostic codes that are pertinent in a letter of medical necessity. They indicate problems for which breast reduction might be helpful. A few that we indicate in our letter when appropriate are:
611.1 Hypermastia – Excessively enlarged breasts
611.7 Mastodynia – breast pain
719.41 Pain in joint; shoulder region, Scapula
724.5 Back pain unspecified
If this letter is successful, a return letter from the insurer indicates a conditional pre-approval. They are always vague on this item. Sometimes the insurer will require physical therapy for a period of time or a weight loss program prior to approval or ask that another pre-approval be sought after non-surgical therapy is tried.
There is no general rule. Each insurer has its own process and they are not forthcoming on exactly what they require. Blue Cross, Blue Shield and United Healthcare are the same only in that they will not tell you how they come to a decision. Some patients are approved and others denied. There is an appeal process in most cases.
Your surgeon should know if you are a reasonable candidate to try for insurance coverage. The worst they can do is say no.
John Di Saia MD
We have discussed health insurance games before. They commonly entrap doctors and patients in red tape and denials of care and payment. The public only occasionally becomes involved in the situation when they are affected directly. This time 20,000 Orange County Blue Shield HMO patients are involved, so there is interest:
Nearly 20,000 Orange County HMO patients are caught in the middle of contract dispute between Blue Shield of California and Monarch Healthcare, an Irvine-based medical group with more than 2,000 doctors. Starting May 1, Blue Shield will no longer have a contract for its HMO patients to see Monarch’s network of doctors across the county. Yet the insurer alleges that patients are being falsely told they are losing their doctors this month, and in a few cases, have been denied care.
Health care contracting is a complex maze. HMO patients generally buy their insurance from one of the large health care insurers such as Blue Shield. Few if any doctors can bill an HMO directly though. The usual arrangement is for the large health care insurer to sell (yeah, sell) the responsibility of the care of the patients in groups to an IPA (Independent Practice Association.) The kicker is that the large HMO insurer gets to keep up to 30% of the premium payments in this sale. That amounts to less money available for the care of the patients! Physicians must join an IPA to get paid on HMO business. The IPAs pay poorly for specialty services, so many sub-specialists (like Dr D ) do not deal with them.
The bottom line here is that for HMO patients to get regular care they need to maintain a relationship with a doctor who is a member of an IPA that is contracted to their HMO. They essentially enroll in that IPA to set up the linkage. When the chain is broken, the patient finds him or herself without a doctor. In this case that happened due to a contracting dispute between Blue Shield and Monarch IPA.
John Di Saia MD
California insurance regulators cleared the way Wednesday for Anthem Blue Cross to implement scaled-back rate hikes after a previous increase was canceled amid an uproar over its size. Anthem said it intends to put the new rates — averaging 14% and as high as 20% — into effect Oct. 1 for nearly 800,000 individual California policyholders. Regulators also allowed one of Anthem’s nonprofit competitors, Blue Shield of California, to move ahead with rate increases — averaging 19% and as high as 29% — for 250,000 individual policyholders.
Insurance regulation is pretty much a joke in the sense that it really doesn’t protect the consumer from the highway robbery that is health insurance. This is the same kind of regulation that allows insurance company CEOs to take huge bonuses while they cut payments to doctors and deny patient treatments. It seems that these hikes only apply to individual policy holders. It is really becoming imperative that patients put together insurance groups. I guarantee you that these increased rates will not be seen as increased payments to my practice from these same insurers. This, like the federal Wall Street bail out, will line the pockets of the insurers and not help the consumer one bit.
John Di Saia MD
Originally posted 2010-08-27 07:30:44.