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I am a below knee amputee. More importantly, I am also Mommy to two boys, a very active 10 year old (Robby) and an mischievous toddler (Timmy). I have learned that being a parent with a disability can create some unusual and sometimes humorous situations. This blogger is available for hire! Let's talk and learn how a blog can expand your business.

Wednesday, October 19, 2011

Insurance Overload

During the past few weeks I have been eating, drinking, and dreaming all things related to prosthetic insurance. To say that I feel overwhelmed is an understatement. I'm doing my best to absorb as much information as possible.

Every night, when I feel discouraged I congratulate myself for knowing more about the topic than I did when I woke up. I remember feeling this lost when I first began to learn Braille. With practice and time, the code made sense and is now second nature for me. I'm hoping that I can experience the same success deciphering the insurance red tape obstacle course!

Many times my head feels like it is spinning with all of the new information I am trying to process. At the same time, I find myself feeling sad. I never realized how much of an amputee's prosthetic care was dictated by the insurance policy!

While many policies now provide provisions for bionic technology (C-leg, Rheo knee and Proprio foot, etc.), the inclusion does not necessarily mean that the amputee will receive the device. The pesky "when medically necessary" rider in all policies often precludes amputees from gaining access to these life changing devices. Because of this stipulation, amputees need to know that their initial insurance claim for a bionic device will almost certainly be denied, prompting an appeal.

During the appeal the patient and the practitioner must prove why the desired prosthetic device is required. Proving medical necessity is a time consuming task, and many practitioners are not willing to invest their staffing resources towards this effort. Therefore, many amputees are forced to settle for an "almost-as-good" prosthetic.

A willingness to fight the appeal is not the only variable to secure success. I learned that appeals can go to one of two places, depending upon the type of insurance. The optimum route is having the final appeal decided by the state insurance board of appeals. This options provides for the most unbiased ruling and affords the amputee the best chances for having the claim approved.

Unfortunately a majority of insurance plans in this country are employer based plans, referred to as an ERISA policy. These plans are most commonly offered by companies with more than 100 employees. My husband works for a school system in Virginia. Our insurance is Blue Cross and Blue Shield, but it is an ERISA based plan.

Why is this information important? Because in an ERISA based plan, the final insurance appeal goes directly to the employer, not to the state insurance board. The employer decides what is covered and what is not going to be covered because they are the direct payer. The insurance company is merely acting as the middle man during the claim process.

With an ERISA based plan, the amputee's prosthetic decisions are relegated to nothing more than a simple popularity contest. If the individual, or somebody in their family, has clout within the organization, there is a good chance of having the appeal granted. If they are simply another employee without political ties within the company, the chances of having their claim approved may be greatly diminished--regardless of how hardworking the individual or how necessary the device.

There is no greater time in history to be an amputee. Prosthetic technology stands to change the quality of life for scores of individuals who have been struggling with limb loss. Unfortunately, the reality remains that this technology remains elusive for so many. It is heartbreaking to realize how many amputees are denied access to these life changing prosthetics because of riders in insurance policies and a popularity contest at their place of employment.

1 comment:

  1. Not that I want to make things even more complicated regarding a post that tackles an already-complicated issue, but it's not just the "not medically necessary" determination that's an obstacle. In particular, for newer technologies, that basis for denial is often combined with an "experimental/investigational device" denial. And proving that a device isn't experimental/investigational can be a real challenge, especially in the absence of prolific research and studies to back it up.

    Kudos for tackling an important subject!