[AMP-L] Insurance Issues

[Jimmy DW]

I thought I would send this email out to everyone, trying to get some 
information and some thoughts from other amputees, prosthetists, friends, 
families, other health care providers, etc. on the issues of insurance 
coverage and problems.

Recently I had revision surgery done on my leg (I am a bk amputee, 
frotstbite injury 9 years ago, etc).  During the past 9 years (I am now 42, 
still very active, participate in various sports, etc), I have had about 5 
periods of time where I could not wear my leg for a week or so.  For 
example, I  had an ingrown hair, which required surgery to remove the hair 
and the infected/inflamed tissue around the hair, which put me off my leg 
for 10-14 days while it healed up.  Another time, I had a bad reaction to 
some soap, my skin broke out in some horrible rash, which took about 2 weeks 
to heal up and go away.  These are just the basic issues and problems that 
pop up at times, and are an inconvenience to say the least.  During these 
episodes, I have dealt with crutches and got by ok, but a total pain.

This time, I am off my leg for 6 weeks (unless I just totally get tired of 
it here and cheat and start wearing it before that 6 weeks is up...but I am 
really trying to obey the doctor, and am doing pretty good with it), and 
here in Indiana, we have had a lot of snow, ice, then rain, more snow, ice, 
etc.  It just seems like it is not going to end for a while.  On crutches, 
it is totally dangerous to get around, especially like going to the grocery 
store, getting inside, and then hitting the wet tile floors....they are 
deadly.  I decided it is time to break down and get a wheelchair.  That was 
not a big issue, I have insurance, they approved me getting a manual, 
lightweight, wheelchair.  I am NOT interested in a power chair, I don't want 
to mess with that at all.  I just need something that I can throw in the 
back seat of the car, or whatever, and go to the mall or the grocery, pull 
it out and take off in it.  Getting the approval for it was not an issue at 
all.  BUT, when I went to the local DME store, I was told that because I 
have Anthem Blue Cross, they will not provide it to me.  The reason is that 
Anthem only allows $1400 for that chair, and the COST of the chair to them 
is over $1500, and so they will lose money by providing me with that service 
and equipment.  I totally understand that, and do not fault them with that 
decision.  They are a business and need to make money in order to stay in 
business.  If they lost $100 or even just $1 on every person that went into 
that store, it won't take long to be out of business.  So, I went to 
Indianapolis to a couple other bigger DME stores, and found the same thing.  
Nobody will provide a wheelchair (a light weight chair at least...I don't 
know about other categories of chairs) to me because me insurance pays so 
poorly for that chair.  To compare it to other insurances, the allowable 
from Medicare (for people over 65 years old) for an ultralight wheelchair is 
about $2500.  Medicaid (for low income, disabled, etc) allows and pays about 
$2000 for that same chair or a little more than that.  BUT, for Anthem, they 
only allow $1400 for that same item.   If I was classified as 'disabled', 
and qualified for Medicare (based on disability, which some people have 
managed to get approved by the social security administration office...they 
are able to qualify for medicare disability based on an amputation...but 
that is NOT an 'across the board' kind of approval...it depends on the 
counselor, case worker, the office, etc), then I could easily get a chair 
from any DME vendor.  Or, if I qualified for Medicaid, I could get a chair.  
But, because I am a working person, and have an income, and have to pay for 
my own private insurance (which is NOT cheap), I cannot get a chair because 
they pay so poorly.

Here in my city, the local hospital has just told Anthem to take a hike, and 
terminated their contract with Anthem and was not going to provide services 
to any Anthem subscriber.  Indiana University is the biggest employer in 
this area, and they use Anthem as their insurance.  Anthem was NOT budging 
at all to negotiate with the hospital.  In fact, Anthem had sent their new 
contract to the hospital at the end of 2006, which was lowering its 
allowables, dropping something like 15% more than before.  We all know that 
the cost of living is going up, gas costs more, electricity costs more, 
insurance costs more, etc.  Now, anthem has gone and raised everyone's 
premiums 10-20% (mine went up 12% this year), but yet anthem still finds it 
in their best interst to lower the fee schedules for the providers.

To end the story on the wheelchair, I was directed by one of the DME vendors 
to go to Ebay and check there for a wheelchair.  I did that, and found a 
demo chair in San Diego, and purchased that chair for about $900 with 
shipping and all.  That was the best deal I could find on a lightweight 
chair.  The chair I bought was not actually on Ebay, but I got the contact 
information from ebay about the company in San Diego, I called them, and the 
salesman looked around all their facilities and offices to see if they had 
any model of chair that was my size (16" x 16", a pretty normal size chair). 
  He found one, and made a great deal for me, since he knew and understood 
what my dilema is.

I took this story to the local newspaper, and they put in in the 
paper...front page, with a big photo of me standing on crutches in the snow, 
pant leg tied up, with my wheelchair sitting there behind me.  The title of 
the article was:  Jim DeWees feels that his premiums are just a DONATION TO 
A MILLIONARE CEO, in big BOLD letters.  It went on to explain the story, and 
then researched Anthem and their CEO, Larry Glasscock, and printed that in 
2003, he got a bonus of $43.5 MILLION.  In the Indianapolis paper a few 
weeks ago, they listed the top 5 paid people in Indiana, and Larry Glasscock 
was number 3 in the state.  He was outranked by the owner of the 
Indianapolis Colts, and another ceo of some other huge company here.  But, 
in that article he was reported as having some $112 million salary, and an 
additional $58 million bonus on top of that.... a whopping total of some 
$170 million or someting obscene like that.  NOBODY in this world is worth 
that much money.  When the Anthem spokesman was questioned about that on my 
account last week, he said that Anthem is proud of their profit margins, and 
that the bonuses are based on the profit of the company.  He was proud of 
that.  Anyone that has a basic understanding of businesses would agree that 
the ultimate goal is to make money, unless you are a service based company 
that prides itself in giving good service to the consumers (like health care 
should....but still any company needs to be profitable just to stay in 
business).  But, basic business sense is simple:  to increase profit levels, 
you need to increase the amount of money coming into the company, and also 
you need to limit the amount of money going out of the business.  So, Anthem 
has raised the premiums, and are bringing in more money than ever before.  
AND, they are also cutting back on what they allow, and what they will pay 
for the services.  In my opinion, the most respectable and honorable 
insurance company would be one that only made $1 in profit for any given 
year.  That means that they are ONLY charging the customers the bare minimum 
to give them coverage, and/or are paying the doctors, hospitals, 
prosthetists, etc. just the right amount of money to cover the costs and to 
provide good quality service to the patients.

Anyway, the article here locally opened the eyes of many people here.  Part 
of the article was about how I was being treated as a patient or consumer of 
these services, and how horrible it is out here.  Then, it trashed Anthem 
for their obscene bonuses and what the CEO is making, and what the cost of 
that means to all of us needing the services that we pay for.  ALSO, I am a 
certified prosthetist, have my own business here as well.  I shared some 
scenarios of how much some of the devices or components cost me to buy, and 
what Anthem allows for them, which is sometimes BELOW the cost of the 
components.  I pointed out that even Medicaid, which is coverage for the 
people that cannot work, or are low income, disabled, or whatever, pays a 
lot more than Anthem does.  It is a sad day when a working class person 
cannot get decent services or sometimes cannot even get any service at all.  
A person, like myself, would be better off NOT working and relying in the 
government to pay for my health care that I need.  And, what makes this 
worse, is that some CEO is making millions every year and being rewarded for 
this kind of management and treatment.

Well, the article caused an outrage here in my town, and it also made Anthem 
not too happy, to say the least.  It was the last week of negotiations (the 
deadline for Anthem patients to go to the hospital here was March 1), and 
this is the kind of publicity that Anthem did not want out there in the 
public.  Well, finally last Friday afternoon, Anthem caved in and signed a 
contract with the Hospital.  I know that the hospital would not budge on 
there demands and would NOT accept any pay cuts from anthem.  Neither of the 
parties are at liberty to discuss the terms of the contract, what was gained 
or lost, etc.  I am sure that Anthem does not want other hospitals to see 
that if they stand up to them that they might gain anything.

EVERY amputee out here needs to share their stories and frustrations with 
the local news media, whether it is the newspapers, tv, radio, or whatever.  
We need to be careful to not look like some pathetic angry person, but we 
need to come across as rational, level headed, positive attitude, etc. but 
just having difficulties with getting the appropriate services.  It is 
amazing what impact this story had in my community, and it did make a 
difference in some ways to some people.  It will not help me in getting paid 
any better from anthem at this point, but maybe it will in the future.

On another topic, the ACA is pushing all across the country for Parity 
legislation, which means that EVERY insurance company would have to allow 
the same kinds of services that Medicare allows.  For example, some 
insurance companies and contracts have an annual cap on them, like $1500 a 
year, or $5000 a year.  Others do not include any electronic devices, like a 
C-leg or myoelectric hands, elbows, etc.  This parity law would make it 
mandatory that every insurance company would allow these devices and not 
have any caps on coverage.  BUT, the big downfall of this legislation is 
that the insurance companies are not required to pay any set fees for these 
services or devices.

Basically, Anthem or any insurance company can set their own fee schedules 
as they wish.  The way it works, from my business standpoint, the insurance 
company every year sends an updated contract packet to me.  In that packet 
is a list of the codes and their allowable amounts.  It is a "take it or 
leave it" kind of deal.  They say that they have enough providers that have 
agreed to these fee schedules, and so if I do not like it, then I shouldn't 
sign it, and they don't care.  Well, we all know that Hanger will sign 
anything, and is the nationwide provider for every insurance network, and so 
as long as there is at least ONE provider in the region, that is all that 
the insurance companies have to provide to the patients.  But, I have never 
had any opportunity to actually "negotiate" any fees with any insurance 
company.  It is very one-sided to benefit the insurance company, of course.

So the real story is going to be that the insurance companies are not going 
to just roll over and take it.  We might get this legislation passed, and 
win that little battle, but I guarantee that the insurance companies will 
find a way to NOT pay for these items.  The easiest way is going to be to 
lower the fee schedules to a point where nobody can afford to provide the 
services.

Medicare allows 2 new silicone liners per year for a lower limb prosthesis, 
that is there standard.  So, Anthem or Aetna or anyone could say that's 
fine, and even better than that, they will allow a new liner every month 
(that's stretching it, but it is totally feasible), which means an amputee 
can get 12 new liners a year, which is a lot BETTER than medicare even.  
BUT, they can drop the reimbursment rate down to like $50 per liner.  The 
COST of these liners (for me to buy them from the manufactures) are as much 
as about $450 or even more depending on the brand of liner, and the quality. 
  There are some cheap ones out there that cost about $200 a piece, but 
still a lot more than the $50 that the insurance might decide to pay for 
them.  The end result is that NO amputee can get the liners, because NO 
prosthetist is going to just eat it every time and lose money on these.

The insurance companies will be forced to pay for a C-leg, and so they might 
decide to drop the reimbursment on these items to $2000, which is WAY below 
the cost of getting that knee joint into my office.

So, you see the dilema here, we can force them to provide for the services, 
and allow them, but they can pay so poorly for these items that no 
prosthetist can afford to do the work.  Just like my situation with the 
wheelchair.

My solution is to have a national push to get any amputee to automatically 
qualify for Medicare Disability benefits.  I am NOT talking about disability 
income, but just getting the insurance benefits through Medicare.  That is 
the only REAL solution that I can think of.  Several of my patients that are 
not even close to 65 years old have managed to qualify for medicare based on 
their amputation.  It makes it a lot easier for me, as a prosthetist, to 
provide the services to these patients, because there is no fighting with 
some insurance (which is almost always the case with EVERY prosthesis I make 
for private insurance companies), and then I don't have to worry about what 
I am going to get paid, and try to figure out if it is even worth doing the 
job in the first place.

I hate having to turn away patients and tell them that I cannot help them or 
provide the services to them.  I have a not-for-profit organization where I 
make limbs for people in the Dominican Republic because the people there do 
not have ANY access to getting a limb, and they have no money to get one 
even if they had the access to that service.  I want to help people, that is 
my ultimate goal and the reason I am working in this field.  But, I cannot 
afford to work myself to death, and work so hard that I put myself out of 
business, while some CEO's are walking away with millions of dollars every 
year and laughing about how stupid we all must be to work ourselves into 
bankrupcy.

I am open to anyone's ideas about fighting to get EVERY amputee qualified 
for Medicare, and also interested in information from people that live in 
states where parity has already been passed, and seeing it it has actually 
made any difference in the REAL world.

I know this email is long (as are most of my emails that I post here), and 
there is a lot of information here.

If anyone wants a copy of the newspaper article that was circulated last 
week, email me and I will email it back to you, I have it saved as an 
electronic file.

Thanks for reading this, and we all need to stand up for our services and 
protect our future to have prosthetic services available to us.  To me, that 
is not a real issue, I will always be able to make my own legs, I will be 
able to take care of myself.  But, it is not certain that any prosthetist 
will be able to stay profitable and continue to maintain a business with all 
these cuts.

My other email that is better to contact me is 
jdewees at prostheticsindiana.com, which I check more regularly (like all day, 
every day).

Thanks,

Jim DeWees


>From: "Wayne Renardson" <wayne at renardson.org>
>Reply-To: wayne at renardson.org,        Amputee Information Network 
><amp-l at u.washington.edu>
>To: amputee Information Network <amp-l at u.washington.edu>
>Subject: [AMP-L] Seeking College Age Amputee Athlete (s) Date: Mon, 12 Feb 
>2007 16:53:36 -0600
>
> >From Ms. Corrine Frayer: Please respond directly to her via e-mail
>below.
>
>From: Cori Frayer <cori at ecollegetimes.com>
>Sent: Monday, February 12, 2007 4:00 PM
>Subject: College Times seeking amputee athlete
>
>Hello:
>
>My name is Corinne Frayer and I am a health and fitness writer for
>the College Times, a local newspaper in Tempe, AZ.  We are an
>independent newspaper serving college campuses around the Valley,
>including Arizona State University.
>
>I have been searching for a college-age amputee athlete to feature in
>our publication for a few weeks and have been having a difficult
>time. I am wondering if you know of any college-age amputee athletes
>in Arizona?
>
>If you know of anyone that you could put me in contact with, please
>let m know. It would be greatly appreciated!
>
>I hope to hear from you soon.
>
>Thank you,
>
>Corinne Frayer, College Times
>2211 S 48th St, Suite G
>Tempe, AZ 85282
><cori at ecollegetimes.com>
>
>(847) 421-0711
>
>
>
>
>
>amp-l mailing list
>amp-l at u.washington.edu
>http://mailman1.u.washington.edu/mailman/listinfo/amp-l
>

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