Saturday, August 13, 2011

Depuy, Broadspire and Surgical Claims

I saw a post on one of the law firms sites claiming  that Broadspire, the claims agent for Depuy, was asking that the insurance companies cover the second hip revisions.

This is what the law firm  claimed:

  "The out-of-pocket expenses that DePuy is covering through Broadspire are costs like co-pays, deductible expenses, lost wages and travel costs for the patient and his or her family. Broadspire, DePuy and Johnson and Johnson are trying to convince patients to leave the cost of the second surgery up to either the patient’s health insurance company or Medicare. DePuy and Broadspire are asking patients not only to rely on their insurance companies to pay these costs, but they are also insisting that Medicare and private health insurance cover the costs of blood tests and any other surgery-related expenses.While this may appear that DePuy is stepping up to the plate to try and remedy the severe injuries and pain that their recalled products caused, a more important question remains: Who is actually paying for the second surgery?"

 I am unclear as to what this law firm's issue is. If the insurace company covers the claim up front, the insurance company then  subrogates claims to Depuy once they get them.  THE PROCESS of where the claims is sent  IS NOT THE ISSUE.  THE ISSUE IS WHAT HAPPENS TO THE CLAIM ONCE THE INSURANCE COMPANY SUBROGATES THE CLAIM TO DEPUY.

Perhaps this law firm is claiming that the insurance company's right to subrogate the claim is not being honored for the actual revision??  Makes no sense to me.

The following is  both my understanding of this issue and my experience in dealing with Broadspire:
  • Depuy has a video on their site (or it was there a number of months ago) which explained the claims process.  The video was directed toward physicians not consumers.  I listened to it though.
  • The presenters in that video which was moderated by the former CEO of Depuy,  requested that the claims all be sent through the insurance company.  (This is not the same thing as asking the insurance company to become ultimately responsible for the claims.)

    • When providers send in claims for reimbursement, most of them are not reimbursed at the invoice rate but rather through a negotiated rate which is set by the insurer.
    • If all patients send in their invoices to Depuy directly without having been submitted to the insurance company first, Depuy would have to pay the invoice rate so I can understand why they would like all invoices to go first through the insurance company. They didn't say this in the video but I can surely see why they would take this path.

  • While I have not gone through my revision (now scheduled for the first Monday in Nov), I have had no issue with Depuy covering any invoices either those submitted directly  to them or those submitted to them once I have first submitted them to the insurance company.
  • 90% of my claims have been submitted directly to broadspire and paid by broadspire  immediately.  I only deal with one claims agent who is very familiar with my case. 
  • If Broadspire asked me to submit the surgery claim through the insurance company, I would use the same process I use when submitting a depuy claim to the insurance company, albeit, that is not my preference because it is time consuming: 
    • I call the insurance company and tell them a particular claim is to be subrogated.
    • They put a reimbursement rate on the claim, refuse the payment and then send it to Depuy.
    • Depuy pays the claim though Broadspire.
Honestly, I find this whole claims process confusing and I have spent many hours talking to people to try and find a solution that seems to work.  I surely would suggest that prior to any surgery, you should talk to the Broadspire agent and confirm the subrogation process so that your insurance company is not stuck with the bill.  If you have a surgery, your insurance company is going to pay the bill. They have no way of knowing the claim should be subrogated unless you tell them. Many insurance companies now require pre approval for surgery reimbursement anyway.

UNLESS you HAVE A CONVERSATION WITH YOUR INSURANCE COMPANY, THEY DO NOT KNOW WHAT CLAIMS SHOULD BE SUBROGATED AND WHICH ONES SHOULDN'T.  EVERY TIME I SUBMIT A CLAIM TO THEM, I HAVE TO CALL THEM AND TELL THEM WHICH CLAIMS REQUIRE SUBROGATION>

The process is very time consuming but it works.  I have had all of my claims reimbursed regardless of how they are submitted.  I have no issue having a claim run through the insurance company so long as the claim is subrogated to Broadspire and paid.  Again, who gets the claim is not the issue.  The issue is who ultimately pays the bill.

Insurance companies are quite accustom to dealing with subrogated claims.  It is not something new to them.

Your health insurer will usually pay for the costs of treating your injuries. However, after making payment (and sometimes even before they submit the payment) your insurer may contact you to discuss how the injuries occurred. The insurer is probably trying to determine if someone (other than the injured person) is fully or partially to blame for the injuries. The insurer may even try to determine if you are planning on suing another party for the injuries you have received. Ultimately, the reason the insurer is asking these questions is to determine whether some third party may be responsible for paying for your injuries, thereby relieving some of the insurer's financial responsibility. The above example embodies the concept and reasoning behind insurance "subrogation

 Each state differs in exactly how and when insurers are allowed to assert their subrogation interests, and how the existence of a subrogation interest affects the settlement of third party lawsuits.  My insurance company has not had a problem submitting any claims to Depuy/Broadspire for payment.

I can only comment on my experience.  Many of you likely have lawyers who deal with the Broadspire people on your behalf.  I can tell you, I have never had an issue with Broadspire paying for anything through either subrogation or through direct invoices sent to them.  Everything is paid promptly.

If anyone has had other experiences, let me know.




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