If you’re buying new cochlear implant processors to replace old ones, and need to figure out how to get insurance to pay for it, this post is for you.
I’ll answer four questions: What did the processors cost? (By “processors” I mean the external devices that sit on the ear, not the surgically implanted devices.) How much did insurance cover? How long did the process take? What hoops did I have to jump through?
In my case, I needed new processors because my old Harmony processors were eight years old and declining. The two new Naída processors plus accessories cost $19,210.00 before insurance and $6,036.63 afterward. In other words, I got 68.58% back. Overall, it took almost six months and a number of calls, letters, and forms.
It’s possible to get even more back outside of the insurance process, and I’ll discuss that at the end.
First, some backstory: I have bilateral cochlear implants made by Advanced Bionics, and I’m covered under my wife’s plan through CareFirst (also known as Blue Cross Blue Shield) of Washington, D.C. It’s a PPO plan. These specifics are important because insurance outcomes vary by manufacturer, insurer, plan, and state.
In outline, the process went like this.
1) I bought the new processors upfront.
2) Advanced Bionics filed a claim on my behalf with CareFirst.
3) CareFirst reimbursed me, but at my plan’s out-of-network rate, which is (theoretically) 80% of the cost.
4) Advanced Bionics asked CareFirst to reimburse me at the in-network rate, which is (theoretically) 100%. CareFirst turned down this request.
5) I wrote to D.C.’s state government asking them to appeal on my behalf for in-network coverage.
6) CareFirst sent me reimbursement at the in-network rate.
Here is the detailed story.
December 6, 2013: I purchased two Naída cochlear implant processors directly from Advanced Bionics, with various accessories. The cost was $19,210. (CareFirst wouldn’t approve the purchase ahead of time.) I paid for them with an airline credit card to get the miles. Advanced Bionics sent CareFirst a claim on my behalf.
February 6, 2014: CareFirst sent me a check for $10,568.41, which was 55% of the cost. I appreciated that, but given how much money I’d spent, I was hoping for the in-network rate of 100%. So the next step was to appeal to be covered at the in-network rate.
February 18, 2014: Advanced Bionics sent CareFirst a letter asking for the purchase to be re-categorized as an in-network purchase. In insurance jargon, they asked for a “network waiver.” Their letter pointed out that since Advanced Bionics was the sole supplier, and it was out-of-network, there was no in-network provider I could have bought them from. Therefore, I was reasonably entitled to in-network rates.
February 18, 2014: CareFirst declined to grant a network waiver. In the refusal letter, they noted that I could request an external appeal from the Office of Health Care Ombudsman and Bill of Rights in Washington D.C. This is a state-by-state thing; to get an external appeal in, say, Nevada, you have to write to the appropriate office in Nevada.
April 14, 2014: I wrote to the Office of Health Care Ombudsman and Bill of Rights in Washington D.C. asking the state to file an external appeal. I sent CareFirst a copy to let them know what I was doing.
April 20, 2014: The Office of Health Care Ombudsman and Bill of Rights in D.C. sent me paperwork to fill out. It gave them the right to request from CareFirst the records associated with the claim and the denial.
May 6, 2014: They sent CareFirst a letter asking for everything: emails, the policy, medical records, minutes of meetings, etc. They gave CareFirst just five business days to hand it all over. They sent me a copy of the letter. I was impressed. D.C. was on the ball.
May 30, 2014: CareFirst sent me a check for an additional $2,604.96, having granted the network waiver. I don’t know what transpired behind the scenes. Maybe CareFirst decided to grant the network waiver to avoid digging up the records, or maybe they did send the records and the state told them to pay up. I’ll never know.
So, to add it up –
Out-of-network reimbursement: $10,568.41
In-network reimbursement: $2,604.96
Total amount CareFirst reimbursed me: $13,173.37 (68%)
My cost after reimbursement: $6,036.63
Cost per ear: $3,018.32
Time from purchase to reimbursement: 5 months and 25 days.
I’m not counting non-insurance reimbursement in this. Your manufacturer may offer a buyback program. For example, Advanced Bionics will buy back used Harmony processors for $1,900 apiece (up to two processors.) If you can do this, it brings the cost down even further. And I did a little financial engineering. Buying the processors with a credit card yielded an airline ticket worth about $500. One has to balance this against the interest paid on the debt, of course.
Why didn’t I get back exactly $19,210, since I’m covered at 100%? For inscrutability, insurance mathematics is right up there with quantum physics. For one thing, our out-of-pocket maximum for durable medical equipment is $3,000 and CareFirst’s website says we’ve used $703.37 of it. Things like that mean that 100% is almost never actually 100%.
One lesson I’ve learned is that insurers frequently deny the first appeal, so it pays to be persistent and go to that second level of appeal.
Please note again that this story is specific to Advanced Bionics’s Naída processor and to my wife’s CareFirst PPO policy, and to the laws and bureaucracy of Washington, D.C. Insurance in the USA is highly decentralized. Just because it happened this way to me doesn’t mean you will have an identical outcome.
I hope this is of help to people. I’d be happy to give out copies of the letters requesting the internal and external appeals. Getting the jargon right (e.g. “network waiver”, “durable medical equipment”) is important. I also aimed to be concise and clear, and to explain the relevant facts about cochlear implant processors to insurance employees who probably knew nothing about the technology. You can contact me through my website.
My thanks to Advanced Bionics, whose employees spent quite a bit of time with me on the phone explaining what to do, and to the Office of Health Care Ombudsman and Bill of Rights in Washington, D.C.