The Insurance Gauntlet

The ExoSym devices are sometimes covered, depending on your insurance and your location. I was completely unsure what to expect insurance-wise, but had never had insurance say no to any of the devices or procedures related to my clubfoot so far.

From the moment I contacted the Hanger Clinic, the specter of insurance hung over the whole experience. In the packet of information the clinic sent after I reached out they talk about how difficult it is to get insurance to approve the ExoSym and to be prepared to pay myself.

That said, they assured me they’d send in letters and support for the devices to the insurance company in an effort to receive pre-approval. However, without pre-approval, I needed to understand insurance may not cover it and I’d owe $18,000 at the time of delivery of the two devices.

My doctor sent in all the items the clinic requested, Ryan at the clinic wrote his own letter of support, and the Hanger Clinic sent it all in to my insurance, Premera Blue Cross, for pre-approval. Then, two weeks later I got an email from the clinic forwarding a letter from Premera stating they don’t pre-approve the devices and payment of a claim would be made based on “benefits and eligibility at the time of service.”

In the email to me the Hanger Clinic let me know I could be on the hook for the whole price now. What did I want to do?

Well, I called my insurance company in tears. Bless the customer care lady’s heart at Premera. She calmed me down and said she’d get to the bottom of it. She checked two things, 1) if the Hanger Clinic was in my service area (yes, it was), and 2) my benefits (orthotics and prosthetics are covered in full when a doctor deems them necessary).

“Honey, you’re fully covered, minus your deductible. The reason we didn’t pre-approve is because you’re already covered for these services. They don’t need pre approval.”

Cue the waterworks again. I even got the sweet customer care lady crying too, she was so happy she could help. She got me on the phone with a customer advocate who then called the clinic to let them know I was covered while I was on the line. Yay Premera and my husband’s employer for the incredible coverage!

However, before I called the insurance company, I’d called my mom who worked at a hospital as the go-between person between the hospital and insurance companies. She told me I had the right to appeal denied claims and could even have my doctor call the doctor on staff at the insurance company to work out claim payment. I’ve also seen several folks on the Adults/Teens with Clubfoot Facebook page share stories of being denied and then through appeal be able to get approval. I’m trusting my insurance company that it will be paid and hope I don’t have to go further down the appeal road when all is said and done. My family deductible is $6,000, which is already a hard pill to swallow in a year when other big ticket items with the house suddenly happened.

It is important to note, however, that the Hanger Clinic requires you to pay your remaining deductible to them upon delivery of your devices. They’ll call your insurance and determine that exact cost, but be ready to pay out some, especially if you have a high deductible plan. They did tell me they’ll accept the credit card for my HSA for the full amount on that card, then any other card for the rest. That helps!

Update on July 7: After my first visit, Ryan highly recommended I get it in writing that my insurance covers the devices. I called the insurance company back and they sent me (and faxed the clinic) a letter stating medical devices are covered. We shall see. I hope I’m not being naive, but I trust now four people at the insurance company telling me the ExoSym devices should be covered.