Anthem BC reimbursement rates

[cbo111]

We are battling Anthem BC to authorize a heart-monitor loop for my DW. For the past couple months, her pulse goes from 50 to 200 when she is just sitting around, walking, or riding a bike. It leaves her with a headache and feeling nauseous. She wore a monitoring harness for a week and now the cardiologist wants to place a loop to find out what is going on and hopefully treat this. Yesterday, Anthem denied this loop procedure. My question is how to determine what dollar amount Anthem would pay the cardiologist if they did authorize this loop? I could then use this number to negotiate an out-of-pocket payment to the physician. I've never done this type of negotiation before with a physician and need some guidance. Thanks for any inputs.

 

[MBAustin]

It probably depends on what kind of Anthem BC you have - is it through a Megacorp pre-Medicare (probably self-funded), a small business or individual policy, or Medicare supplement? And I have no idea how to find out without asking the doctor.

Has the doctor appealed the denial? That to me would be the first step to take. Good luck!

 

[cbo111]

Yes, the doctor appealed yesterday which was denied (medically unnecessary) and the next step is filing our own appeal. Meanwhile we feel the loop needs to be installed to assess why her heart rate shoots up and down. I have seen cost estimates from $3K to $20K for this device and will find out what the doctor expects for compensation with no insurance involved. It would be nice to get a ballpark insurance rate prior to speaking to the doctors office.

 

[youbet]

Is this an implanted device? Is it more than just a heart rate monitor? What is the advantage over just wearing a Holter monitor for several weeks?

Edit: Nevermind the questions. I got curious and asked my buddy Google. The folks at Johns Hopkins have a nice explanation on line.

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/loop-recorder-implantation

I have long term, persistent AFIB so naturally am interested in your thread and associated discussion. In my case, diagnosis was easy since my significant arrhythmia exists constantly. What to do about it seems to be the issue. Right now I'm just taking an expensive blood thinner, trying to lead a healthy life style and hoping for the best.

Good luck to you and DW. Keep us posted.

 

[Charlotte]

Just wanted to extend my sympathies to your wife. I have paroxysmal atrial tachycardia and it really is quite uncomfortable when it goes off. The tachycardia starts suddenly and goes back into proper rhythm suddenly. It’s definitely disconcerting.

I hope you all are able to get the help and care she needs.

 

[Teacher Terry]

Is this a Medicare advantage plan? I have tachycardia controlled with a beta blocker but have never heard of this. I wish you guys the best of luck resolving this issue.

 

[cbo111]

Is this a Medicare advantage plan? I have tachycardia controlled with a beta blocker but have never heard of this. I wish you guys the best of luck resolving this issue.

No, she actually has a Anthem/BC plan, Tricare secondary that has been excellent in the past. Yesterday, we the cardiologist billing office and were told the procedure was $4,900 if we paid with no insurance help. Push come to shove, we will just pay it ourselves.