A Win is a Win……..

Insurance Issues

A win is a win even on a technicality. My insurance company has paid everything I believed they should have paid. However, they only paid this “just” amount because of a technicality according to their letter. As I have previously written, I was blindsided by two insurance company policies that I was unaware of and which resulted in my insurance company underpaying my surgeon’s medical billing by $12,000.

These two insurance company coverage policies are:

“Multiple and bilateral surgical procedures" which means if they perform more than one procedure or surgery at the same time then one will be billed as the primary and will be covered at 100%. All other procedures will be billed as secondary and will be covered at 50%. In my MMA surgery that means that the upper jaw surgery was covered at 100%; the lower jaw surgery was covered at 50%; the Septoplasty was covered at 50%; and the arch bar placement was covered at 50%.

"Primary billed procedure and secondary (minor) billed procedure" which means the insurance company can determine that certain procedures performed during surgery that are billed separately, such as the Septoplasty and arch bar placement can be placed into the primary billed procedure such as one of the jaw surgeries. Once they do this they then only pay for the primary procedure and in effect disallow all of the secondary charges.

My approach to these two issues: I recommend fighting these coverage policies separately. I was successful on getting my insurance company to keep each of the four billed procedures as separate procedures and pay on them accordingly; thus abandoning this "Primary billed procedure and secondary (minor) billed procedure" policy. This is when they brought up the “multiple and bilateral surgical procedures" policy to only pay 50% for the second, third and fourth procedures. To make a long story short, I then wrote a letter directly to the President of my insurance company in which I argued against this “Multiple and bilateral surgical procedures."

I only won this battle and got them to ignore this policy because they failed to advise me of this policy in my pre-surgery authorization letter. Therefore they covered each of the four procedures as separate procedures. Their letter specifically said that this policy still exists and the only reason they were covering everything at 100% was because in my preauthorization letter they failed to advise me of this procedure.



Sleep Issues

Now on to my sleep….. My sleep is improving. Just last night I sleep all night from 10:30 pm to 5:00 am with just one awakening (and just for a few minutes). Prior to that I had been waking up about one to three times per night (after 2:00 am), but I then would fall back to sleep. I am certainly more refreshed when I wake up and have much more energy during the day. I still get pretty tired by 6-7 pm, but I still think and act like I am only a 30 years old during the day so I should expect to be tired at age 60. Everyone states that your body systems will take up to a year to learn normal sleep patterns. After all, I was not sleeping normally for over 30 years.



More Good News

Some further good news, I had some general blood tests taken two weeks ago and the results were very impressive. My cholesterol and testosterone levels have greatly improved and that is without any medications. For 20 plus years my testosterone levels have been very low and have not responded to various medications. Now they are in the normal range without any medications. My cholesterol levels are in the high normal range and again without medications. Prior to surgery I was able to keep them in the normal range only by medications. My antibodies still need major improvement. Let’s see how they look after 9-12 months of deep sleep. I will keep you posted.


Post Op Sleep Study

I go for a post operation diagnostic sleep study at Stanford on April 29. It will be exciting to see how my obstructive apneas have decreased and what the other numbers show. I will let you all know. Thanks for being interested in my progress.