Cold Pad Pump vs TriCare

[Beans]

I just had knee surgery yesterday, and am chilling on my couch with the snazzy cold water pad pump my doc's office had sent to me for recovery. I'm currently serving in an area that is not around any big Navy hospital, just a small AF base for my MTF, so I've been working through all the hoops of referrals to outside providers, etc.

One hiccup I've recently encountered is the authorization my orthopedist put in for my cold pad with circulating pump (code E0218) was denied by TriCare last Wednesday. Problem is, the item arrived last Thursday and I had no idea it was denied until yesterday (I guess I could've done my HW and checked). Being a "medical anything" device, and not a rental, it's not returnable.

I chatted with United Healthcare about it and they said my provider has to do a "Peer to Peer Review" with them about it. After some more searching, these devices are apparently addressed in the TriCare policy manual, and I attached the page from it here. Apparently Tricare thinks the machine's a waste of money ($150-200), and I should hobble over to the fridge every half hour to change my ice out.

Anyone have any experience with this and with getting this covered, say through this peer to peer review thing or with the authorization appeals process? Are the rental types of machines covered? In that case, I could've probably told my orthopedist that and they'd have hooked me up with that.

Either way - watch out for this if you have any orthopedic surgery coming up outside an MTF.

 

[jcj]

I just had knee surgery yesterday, and am chilling on my couch with the snazzy cold water pad pump my doc's office had sent to me for recovery. I'm currently serving in an area that is not around any big Navy hospital, just a small AF base for my MTF, so I've been working through all the hoops of referrals to outside providers, etc.

One hiccup I've recently encountered is the authorization my orthopedist put in for my cold pad with circulating pump (code E0218) was denied by TriCare last Wednesday. Problem is, the item arrived last Thursday and I had no idea it was denied until yesterday (I guess I could've done my HW and checked). Being a "medical anything" device, and not a rental, it's not returnable.

I chatted with United Healthcare about it and they said my provider has to do a "Peer to Peer Review" with them about it. After some more searching, these devices are apparently addressed in the TriCare policy manual, and I attached the page from it here. Apparently Tricare thinks the machine's a waste of money ($150-200), and I should hobble over to the fridge every half hour to change my ice out.

Anyone have any experience with this and with getting this covered, say through this peer to peer review thing or with the authorization appeals process? Are the rental types of machines covered? In that case, I could've probably told my orthopedist that and they'd have hooked me up with that.

Either way - watch out for this if you have any orthopedic surgery coming up outside an MTF.

Peer-to-peer review means that they want your orthopedic surgeon to call & talk to a physician reviewer who works for the insurance company to explain why you need the device. I'm a general surgeon, and the couple of times I've had to do this have both been United - they cave as soon as I call them & tell them "yes, my patient needs this". The insurance company physician, who is usually not a surgeon, is working of a checklist and the question they ask me about it usually makes no sense. The business model for this is they bank on is your orthopedic surgeon being too busy or annoyed to call them back, so they get away with denying payment for the device.

With that said, most contracts you won't personally be on the hook for paying for the thing - it's the responsibility of whoever gave it to you to be sure all the paperwork is done to support billing the insurance company, and if there's a dispute and they can't get the insurance company to pay then whoever provided the device to you has to eat the charge. Your only liability should be whatever your deductible and co-pay was with or without this device.

Whoever gave you the device may be twisting your orthopedic surgeon's arm to do the peer-to-peer call, or if it's really only a couple hundred bucks (with the actual cost to whoever gave it to you probably much lower) they may agree it's not worth the hassle. And then United makes a couple hundred bucks windfall by avoiding an expense by throwing administrative hassles up in the way of your providers getting paid.

Welcome to health care finance.

 

[Beans]

Peer-to-peer review means that they want your orthopedic surgeon to call & talk to a physician reviewer who works for the insurance company to explain why you need the device. I'm a general surgeon, and the couple of times I've had to do this have both been United - they cave as soon as I call them & tell them "yes, my patient needs this". The insurance company physician, who is usually not a surgeon, is working of a checklist and the question they ask me about it usually makes no sense. The business model for this is they bank on is your orthopedic surgeon being too busy or annoyed to call them back, so they get away with denying payment for the device.

With that said, most contracts you won't personally be on the hook for paying for the thing - it's the responsibility of whoever gave it to you to be sure all the paperwork is done to support billing the insurance company, and if there's a dispute and they can't get the insurance company to pay then whoever provided the device to you has to eat the charge. Your only liability should be whatever your deductible and co-pay was with or without this device.

Whoever gave you the device may be twisting your orthopedic surgeon's arm to do the peer-to-peer call, or if it's really only a couple hundred bucks (with the actual cost to whoever gave it to you probably much lower) they may agree it's not worth the hassle. And then United makes a couple hundred bucks windfall by avoiding an expense by throwing administrative hassles up in the way of your providers getting paid.

Welcome to health care finance.

Thanks Doc. I'll let you (& all our readers out there) know how it turns out.

 

[BusyBee604]

Welcome to health care finance.

Now that's what I'd call one hell of a fine, informative reply. It would have taken me two hours to type that out. Thanks Doc, for taking the time to share your expertise!
BzB