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BCBSTX Health Select

Discussion in 'Insurance Issues' started by lauriesings, Oct 19, 2008.

  1. lauriesings

    lauriesings New Member

    Joined:
    Oct 19, 2008
    Messages:
    1
    Hi -
    This is specific and I know it doesn't impact everyone reading this,
    but if it does, please read:

    I talked to Medtronic Friday and they told me they have sent
    multiple requests to BCBSTX for pre-determination for CGMS (Real Time)
    for people on BCBSTX Health Select (group #38000). Every request has
    been denied.

    If you/your child is on this plan, or if you know someone who is, can you please do the following:

    The Assistant Director of Benefits for the Employees Retirement System
    of TX (the "employer" for this huge plan) is Kenneth Hobbs. His email
    is Kenneth.Hobbs@ers.state.tx.us. Email Kenneth and demand that ERS
    cover real-time CGMS. You can note that BCBSTX is covering CGMS on
    other BCBSTX plans (thus ask, why is ERS not covering it?). Give
    reasons (ie benefits of CGMS, reasons why it is needed, you can cite
    the recent JDRF study) as well.

    It took a lot of work to get Ken's contact information. I've talked to him
    myself and he simply doesn't understand why CGMS should be covered. He
    says "it's covered for 3 days" and doesn't understand the difference
    between the physician model and patient one.
    He clearly needs to keep hearing that this must be covered, from
    more than one person. Gotta keep at it...I know there are tons of
    people on this plan.

    This plan impacts state employees (higher education,
    parks/maintenance, city/county workers, highway department etc.). If
    you know anyone in any of those categories that might be on this plan,
    perhaps you could forward this to them?

    If you're otherwise motivated (simply out of advocacy) and want
    to write him, go for it!

    thanks!
     
  2. Paige's Dad

    Paige's Dad Approved members

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    what is there reason for denial though. If it is for medtronic, and they say it is experimental, then that would be pretty easy to defeat. That is what Rick and I were working on before and still have my appeal letter that I will send to anyone that it will help.
     
  3. rickst29

    rickst29 Approved members

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    Messages:
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    Hello (I haven't visited in quite a while)

    BCBSTX Health Select" may have written right in the contract, "no coverage for continuous glucose monitor devices". But, because they will admit some use for 3-day sessions, it seems very unlikely to be banned by contract-- instead, it's just a mere "medical policy", based on very weak arguments which try to deny "proven effectiveness" or "cost-effectiveness" or "medically necesary" for just about everyone, and usually backed up by "relevant studies" which were written years before modern, semi-invasive 24x7 CGMS had even been invented.

    Kenneth Hobbs is probably irrelevant, and these cases probably are winnable (even within Texas, one of the worst States for consumer protection law.) Can you give me a URL for the current plan contract specifications? (The 70+ page one, not the 2 page "summary".) Kenneth Hobb's real job is not to help covered persons "enjoy" their benefits, rather his job is to keep the plan costs as low as possible, while not creating an absolute riot among "cheated" policy holders. But, he's utterly unqualified to make a medical decision which over-rules the expertise of your (or your child's) LICENSED Endo. It's called "practicing medicine without a license", and even in Texas, the penalties are probably quite severe.

    If your policy covers treatments which are Medically necessary" AND "proven medically effective" AND are "not investigational" AND are "cost effective", and a few other possible requirements which they choose to proclaim, then a good attack can be undertaken-- with high probability of success. But pleading with a non-medical flunkey about "proven effective", "cost effective", and etc. will not succeed. Instead, it is necessary to get these PARs appealed, by the actual covered person, to a level at which an actual MD claims to be "qualified" to review your physician's judgement.

    THAT'S where these things are won against insurance companies who try to deny coverage for medically necessary treatment. necessary 's with horrid policies. The letter which you send to initiate the medically-qualified review process should threaten action against the actual license of any physician who dares (a) claim to be qualified to make this determination; and yet (b) confirms DENIAL of the PAR.

    The phrase that pays in that letter is, "obviously practicing outside the scope of his/her competence". That phrase converts the fight, from one where you merely plead for coverage (with good reasons and evidence), into one where you actually threaten the career(s) of MD's high up in the BCBSTX food change who dare to confirm such nonsense. Every time I've ghost-written THAT letter, it's won. But each such letter must be tailored to one specific case, backed one one person's PMI and their own MD's professional judgements. I sometimes help individuals with strategy and by draft letters, but a lot of "boilerplate" without specific PMI to back it up isn't likely to work very well.

    I think that every time a PAR is lost, it's bad for all of us actual PWDs. Minimed, IMO, is not doing a good thing by dropping all these PARs right upon the first denial. But Minimed has no need to pursue these cases further-- they're selling R/T and Guardian like hotcakes, they'll just drop you and move on to the next prospect when your case turns out to be kinda hard to win. Dexcom simply can't afford to help much, they're still not profitable at all. And Abbott, like Minimed, enjoys a long waiting list, doesn't need to fight the challenging cases. So, if you really want it, you really need to do the work to overturn a CGMS denial YOURSELF. Nearly all of those insurance companies which are now "routine, easy" for CGMS didn't get that way because they wanted to be nice-- rather, tenacious bulldogs like me have beaten them up enough times that they've put up the white flag and changed their ways.

    Less pleading, more teeth. (just my opinion. IANAL, IANAMD )
     
  4. moco89

    moco89 Approved members

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    Because these are benefits provided through the state of Texas to their employees, different rules apply.

    If it is a non-govt BCBSTX plan, they are already covering cgms.

    But if it is a govt plan, you're screwed. This thread is about a govt provided plan.

    Kenneth Hobbs has control of what gets covered. Nobody else. Not even through appeals.
     
  5. Amy C.

    Amy C. Approved members

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    My son is covered under BCBS of Tx under ERS. He has not wanted to pursue getting a CGMS, so I haven't pushed it.

    That is interesting to know that there would be an uphill battle (apparently losing at this point) to have the CGMS covered.
     
  6. Paige's Dad

    Paige's Dad Approved members

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    That is part of the appeal process, to take it to a "higher power". With an appeal process it would go over his head to the next level. Then if denied, would proceed to the level above that, so on and so on.
     
  7. moco89

    moco89 Approved members

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    No, the administrator has the final say.

    Trust me. Their appeal system is quite limited in comparison to typical "non-governmental" health plans.

    This is basically one of the reasons why people for example that are on medicare have limited ability in obtaining cgms coverage.
     

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