Blue Cross Blue Shield paid 100% for the procedure. You will be told that the procedure is not covered. We went to a medical appeal and proved using research that the procedure was cost effective and the best treatment option in the long term treatment of scleroderma. Other insurance companies like United Health Care are very supportive of this treatment. I have put together a letter on how we fought for the procedure and it has helped others who have been through the medical appeal process. Read below.
Letter to Aid others Fighting Insurance Companies
After dealing with Blue Cross Blue Shield and knowing how traumatic it can be particularly for people who are already suffering with major symptoms of scleroderma. We would like to share with others advice that we found useful with dealing with this most difficult experience.
When dealing with people outside the medical field always talk in terms of bone marrow transplantation instead of stem cell transplant. Bone marrow transplantation makes a regular person think of cancer which has been around for along time. They may know people who have had this treatment, so they are usually more sympathetic. Stem cells, to people who do not know better, may have negative connotations. Always mention itâ€™s your own stem cells that are harvested and returned.
You need to be very proactive in dealing with the insurance. Educate yourself in the various trials Astis, Assist and Scot trials. Knowledge about the research will help you get the insurance people to get over the â€œexperimentalâ€ blinkers they all wear. Send all the positive research you can attain - scleroderma is a rare condition and trial data is expanding but is limited. Use the data for stem cell transplantation for all autoimmune diseases as well as the sclero trials. Laarâ€™s and Tyndallsâ€™s articles talks of 10 years worth of data with over 700 people being treated this was published in 2006. Tell the insurance well over a 1000 worldwide have been treated now. Tyndal and Furstâ€™s article mentionâ€™s 170 people for scleroderma being treated. Quote Dr. Burtâ€™s research at every opportunity. His latest research mentions 926 treated people for autoimmune diseases and stem cell transplantation.
There is a video from Austin 8 news, which explains the procedure very well and should be sent to lay people and your case manager before you arrive to explain the procedure and give added credibility to your request for help.
Here is their news site: http://www.sclerodermatrial.org/announce/
This is a link off of that site: mms://vidsrv1.duhs.duke.edu/dcms/scot/scot_tv_release.wmv
It is imperative to express Dr Burtâ€™s credibility and biography. Send his old and new bio to the insurance, as he is the worldâ€™s pioneer in stem cell transplantation and has treated the most people for autoimmune disease. Insurance will constantly express their doubts about the treatment. Emphasize that they are mistaken and Dr. Burt is the expert with the relevant knowledge, skills and experience. I printed every article off of his from the links on the northwestern site and sent it to the insurance.
It is important to have the backing of your personal physicians: pulmonologist, rheumatologist, renal doctors and/or whoever is seeing you. Ask your doctors for their help. Explain what you are doing with regard to stem cell transplantation, educate them on the merits of the procedure, and get letters from all of them to send to the insurance. When the medical appeal occurs, your doctors need to speak with the medical director of your health insurance. Ask your doctors to emphasize the symptoms you have, that they are worsening, and major medical complications await. Ensure this happens by passing on their pager numbers to your case manager. Follow up with both parties to ensure the conversation has happened.
The present management philosophy of scleroderma is to treat the symptoms rather than treating the disease. Emphasize that stem cell transplantation is a potential treatment for scleroderma and complications from scleroderma can be prevented if the disease is treated early on. Tell them you are on the precipice and that an avalanche of complications will arise unless they act quickly to help you. This also has a cost implication that is beneficial to the insurance company. Emphasize this point. Insurance companies fear expensive complications down the way. Pulmonary Fibrosis can lead to lung transplantation that costs a minimum of $300,000. Pulmonary hypertension and flolan treatment costs a minimum of $100,000 per year; dialysis for kidney failure costs $50,000 per year, and disability costs equipment and care. Comparatively, a stem cell transplant is cheap, half the price of a lifetime of treating symptoms.
Emphasize other insurance companies, such as United Health Care, Etna, Medicare, and now Blue Cross Blue Shield are saving lives by paying for stem cell transplants. Your health insurance should too. Have a go at them but communicate appropriately, talk calmly, be tenacious, but donâ€™t lose your cool. They want you to lose your cool and start shouting this way they will call into question your sanity and being irrational. Keep telling them their logic is wrong. You pay your premiums and when needed they are cheap compared to others. Talk about Michael Moore and his film Sicko. Quote the world health organization statistics for America spending the most but languishing way down the polls and how insurance is dragging this country down. Tell them you will not rest until they do the decent thing. You will go public and never go away. Call your case manager daily ensure they return your calls; they like to delay and hide behind answering machines. Speak with a congressman tell them at the insurance what you are doing. There are many patient testimonies on the Internet of people who have gone before us, heroes one and all; this is important evidence. I can forward you their website and blogs. We all can share our acceptance letters fax them to your health insurance.
Have your employer on your side by contacting your manager or supervisor; let them know what you are doing, then go to the top to the Directors not their assistants. Send them the Austin News 8 video I referred to earlier. Make an appointment and see everyone personally.
Find the head of Human Resources (HR) and make the appointment with the senior people not the junior HR representatives. They will ask you to see junior. Tell them it is of the utmost importance that you see the head HR person. I was told by one junior HR rep to come back post appeal. No way would I do this! The vice president of HR was one of our crucial advocates as he negotiated the contracts with the Insurance Company; after all they are his clients.
We got our physicians and medical people on board prior to our meeting with the HR director. 10 doctors total called and emailed the HR director and senior managers to let him know we were coming. The director will have their arms in the air waving the white flag of surrender when you arrive. Share the research and make sure they watch the video so they understand the procedure and treatment, and ensure they know their role in all of this. Ask that they become one of your advocates, a liason with whoever they negotiate with at the health insurance company. They must insist you are to be helped and are an important member of the company. Remember reputation and retention of staff is everything for a HR in recruitment.
I hope this helps people going through this most traumatic experience of appeal, insurance and transplant. Remember what you are fighting for is your future so tenacity and hope is the key. We are willing to help anyone who needs it 24/7.