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Author Topic: How do you talk with INSURANCE people?  (Read 982 times)

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Offline Scout

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How do you talk with INSURANCE people?
« on: June 08, 2007, 05:45:39 AM »
I had waited long enough to hear back about my next Synvisc appt and I finally called my doctor back.  The insurance company won't cover it.  Anyone ever run into this problem?  They say that Synvisc is experimental and they won't pay for it.  I am guessing they mean experimental in my case, (chondromalcia patella).

If anyone has run into this problem and knows how to speak to insurance people, to get them to see things differently, please let me know!

Offline TwoBadKneesUSA

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Re: How do you talk with INSURANCE people?
« Reply #1 on: June 08, 2007, 03:04:59 PM »
I have a thought.  Since some coworkers and I were discussing what insurance pays for dental items I'll use an anology with it.  For example many dental insurances will not pay for a tooth colored filling in a back tooth, but will pay up to the cost of a silver filling.  Maybe you could call the customer service number and see if they will do something like that.  I am not sure what Synvisc is comparable to procedure wise, unless may a cortisone shot?  It is frusterating when insurance companies determine medical treatment.  I know they have docs and whatnot on staff, but they don't know your personal case like your own doc.

If you don't get a good answer to your question from the CS rep, ask for their supervisor.  Keep going up the chain until you get things explained to your satisfaction.  You do need to be persistant.

Good luck.
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Offline DeborahinNC

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Re: How do you talk with INSURANCE people?
« Reply #2 on: June 08, 2007, 03:45:27 PM »
Hi Scout

My insurance company tried the same thing except they said they would not pay because it was self injected!!! Go figure.  Anyway, I was able to get my broker to call them and after the same run-around that I got he finally got them to understand that this is a normal and long used procedure, it was not self admininstered and being ordered by a surgeon.  See if you can get someone from the doctors office to call or if you have a broker or who ever you purchased through they may be able to help.  In my case it was a stupid misunderstanding when they looked up the drug.  I guess there was a listing for cosmetic use and they thought I was going to inject to look better.  What do they know - a bunch of admin people with not much medical background making decisions.

Good luck - I did get them covered and although they were not bad to sit through I did not get the relief I was hoping for.  Many have though so keep fighting for it.  I was so desperate that I was going to pay for them out of pocket if I needed to.  I'm glad it didn't come to that since it is very expensive.

Deborah

Offline jathib

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Re: How do you talk with INSURANCE people?
« Reply #3 on: June 08, 2007, 04:05:13 PM »
Synvisc is very expensive and a lot of insurance companies don't pay for it because it doesn't work most of the time. I've never heard of it being used for chondromalacia so it may very well be experimental for that. My OS doesn't use it for anything because of poor results. Just not worth it. I had the injections several years ago and they did absolutely nothing for me. It's not worth the fight with insurance if you ask me.

Offline Scout

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Re: How do you talk with INSURANCE people?
« Reply #4 on: June 09, 2007, 08:34:32 AM »
Synvisc is very expensive and a lot of insurance companies don't pay for it because it doesn't work most of the time. I've never heard of it being used for chondromalacia so it may very well be experimental for that. My OS doesn't use it for anything because of poor results. Just not worth it. I had the injections several years ago and they did absolutely nothing for me. It's not worth the fight with insurance if you ask me.

I did find some relief with that first shot.  I was hoping to get the full round.

Offline Plumb

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Re: How do you talk with INSURANCE people?
« Reply #5 on: June 09, 2007, 02:12:02 PM »
I believe it depends on what is going on with each person.  My OA and your OA  can be at totally different stages.
 Each knee for each person can be at a different stage. I had the shots in my right knee last year and than my left knee this year.

I had my right knee replaced last year.  My left knee is holding it's own pain wise. I still have odd ball pains with it.

I think a good standard of success is .  How many blocks can you walk and how long can you walk?

If we say:
****A healthy knee is able to withstand a hours of walking
****The unhealthy knee the standard maybe you could pray that the earth would open up and swallow you whole so you wouldn't have to walk a half a block. Thats the point I feel that the shots do not have a hope in hell of working.

Offline Scout

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Re: How do you talk with INSURANCE people?
« Reply #6 on: June 10, 2007, 07:34:11 AM »
I believe it depends on what is going on with each person.  My OA and your OA  can be at totally different stages.
 Each knee for each person can be at a different stage. I had the shots in my right knee last year and than my left knee this year.

I had my right knee replaced last year.  My left knee is holding it's own pain wise. I still have odd ball pains with it.

I think a good standard of success is .  How many blocks can you walk and how long can you walk?

If we say:
****A healthy knee is able to withstand a hours of walking
****The unhealthy knee the standard maybe you could pray that the earth would open up and swallow you whole so you wouldn't have to walk a half a block. Thats the point I feel that the shots do not have a hope in hell of working.


The reason insurance won't cover me is because I have "Chondromalcia Patella", not OA.  I can't even walk for 30 minutes if it's on uneven ground without pain reaching 6 or 7 out of 10, thus no backpacking until the maltracking is resolved I guess, the doctor says I am likely stage 2.  I absolutely had to go back to work today, first time in 5 weeks.  After 2 hours, I had some pain; by 5 hours, the level was 5 out of 10; at 6 hours it reached 6.  I kept sneaking places to sit down; I am a cashier and they won't let me sit.  The pain seemed to level off there.  I am at home now and sitting and stretching out my legs, it's mostly better, but tight feeling.

Offline bungleg

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Re: How do you talk with INSURANCE people?
« Reply #7 on: June 10, 2007, 12:25:36 PM »
send them your solicitors  business card, boy do I hate insurance companies, they like to take your money but try getting them to pay out. ::)
30/08/05 tpf, plate 8 screws and bone graft, pivot brace 5degs movment, 12weeks nwb, pt, leg stuck at 45deg
30/11/05 got leg straight phone books came in handy,rom 60degs,hydro,pt, start wb increase 10kg per week
01/03/06 full wb rom 95
may 06 rom 110
nov 06 screws + plate removed arthroscopy