Insurance
We are often asked by US Patients, "Will Prof. Dr. Bertagnoli take my medical insurance?" The better questions are "Will my insurance company pay?", "Who will the insurance company pay?" and "When will my insurance company pay?" These are questions often asked by doctors in the US of the patient's insurance company and it is no surprise that Prof. Dr. Bertagnoli asks them also.
Because insurance companies normally pay hospitals and practices, it is important that a patient understands that he/she comes as a private patient of Prof. Dr. Bertagnoli and not as a patient of the hospital or his German practice. Payment is made to him, not to the hospital or practice. In insurance-speak Prof. Dr. Bertagnoli is the provider. From the payments made to him by the patients, in turn he must pay the hospital and his staff and other providers. These providers will not tolerate the long wait periods, which doctors are forced to endure by insurance companies. As most everyone knows, insurance companies are notorious among doctors for not paying the entire amount due and also paying very late. There have been cases of waiting two years for payment.
Prepayment by the patient and reimbursement to the patient by the insurance is the common method of payment. Prepayment by the patient or insurance is required by the professor for all the reasons mentioned above.(More and more insurance companies are reimbursing the patients as they become aware of the lower cost in Germany and of the skill of Prof. Dr. Bertagnoli.) Pre-approval by insurance companies is also becoming more common. However, pre-approval is not prepayment. Prepayment by the insurance company is rare, but does occur. So the patient normally pays upfront and then files a claim with the insurance company after returning home. (We realize this can be a burden for some patients, but it is unavoidable, because the financial integrity of Dr. Bertagnoli's work must be protected for him to continue.) Patients involved in lawsuits can usually have these medical expenses financed by their law firms or other law firms, who specialize in this type of financing. Expected reimbursement by the insurance company is six weeks, if the patient has a pre-approval letter or "Guarantee of Payment" letter. (We do not warrant the behavior of any insurance company. These statements are a reflection of the feedback we receive from patients.) Prof. Dr. Bertagnoli's office will assist in normal documentation, however further expenses and delays can be experienced if the insurance company insists on translated and itemized hospital charts.
For patients without the letter of Guarantee of Payment, the process can be longer. Usually there is one or two appeal process(es) conducted by the insurance company. Do not expect a reversal. Your real next opportunity comes when you appeal to your state board of insurance.
International workers and their dependents often get coverage/reimbursement for all our procedures. Such examples are oil workers, US State Department workers, US military members, and their families. Aetna Insurance, Blue Card Worldwide, Tricare Insurance for military personnel and dependents (Prof. Dr. Bertagnoli is ranked as the No. 1 provider for spine surgery for the US soldiers and families in Germany), and the US State department has already paid for surgery with Prof. Dr. Bertagnoli. Moreover, we see some success with patients getting reimbursement for medical expenses before state insurance boards. We have yet to see success in the courts because the only patient, who did sue their insurance company to recover cost of the procedure, settled with the insurance company just prior to the case being heard.
How to proceed to take your case before your insurance company or your state insurance board:
1. Document everything.
2. Get a letter of medical necessity, which will include the doctor’s findings and recommendations.
3. Get the ICD-9 (diagnostic) codes and the CPT (treatment) codes for your case.
4. Call the Synthes patient hotline at 1-800-895-7754 or 1-866-223-0508, if you receive a Prodisc implant.
5. Use the research papers available under Prof. Dr. Bertagnoli's publications to show your insurance companies the efficacy and research behind the ADR surgery.
Denial of Coverage
We strongly recommend the use of the Synthes Appeal Letter, if you are denied reimbursement. It provides an excellent outline of the steps to take for your appeal. Appeals are seldom won. The next step is the state board of insurance.
For assistance with insurance claims beyond our support, we recommend:
Patients should know that many insurance policies require pre-authorization for claims
MISSY CONLEY
Direct Line 540.627.6248
Fax 540.302.6108
David Suddendorf, Attorney-at-Law
415.806.6599
www.davidsuddendorf.com
| POTENTIAL CLASS ACTION SUIT FOR “FORCED” FUSION PATIENTS If you feel you were forced to accept a spinal fusion you didn’t want due lack of insurance coverage for ADR, or are you are now facing that dilemma, you may be a good candidate for a class action lawsuit against insurers forming now. To learn more, contact Dave Suddendorf, Attorney at Law at (415) 806-6599 or There is no expense to you. |
