An el Dean Lo ez May 18, 2017 To the Claims Depanment I am writing to appeal the low reimbursement rate my family has experienced for treatment my son and 1 received following separate surgeries on our hands Sometimes life Ihrovts up an odd coincidence ihai can point out an imbalance or Injuslice which may go unnoticed olhemlse Such an eveni took piace when my son Theo and 1 both severely iniured our righi hands in separate incidenis ihai took piace wilhtn 10 days of each other inst October In this case, the Injustice ofthe low reimbursement rate for our treatment is compounded because the same thing is happening to both ofus at once, creating a double hardship for my family 1 mang1ed my right hand in a power tool accident at home on October 21, 2017 1 had reconstnictive plastic surgery on three fingers and spent tvto nights in the hospital Then, on October 30, Theo, age 9, severed a tendon in his right hand whlle carving a 1-1a11oween pumpkin He also required reconstructive plastic surgery to reattach his tendon Here we both are following our surgeries in ear1y November Following our surgeries, both Theo and 1 required 1ong and invoived occupniionni therapy regimens to recover the use of our hands Theo's plastic surgeon recommended a novel "early movement” protocol that he designed while working closely with Theo’s occupational therapist at Children’s Hospital Los Angeles. Theo’s therapist shared a building facility with his plastic surgeon and was an integral part of his recovery team. As part of his treatment plan, she attended and documented every follow-up visit with the surgeon. As part of this appeal, I am enclosing a letter signed by her and the surgeon. My injury was more severe; I required a second surgery to remove a pin which was stabilizing my fourth finger. After that surgery, I was able to proceed with my own complicated recovery therapy. When my cast finally came off after two months, all four of the fingers on my right hand were swollen and immobilized. It took many weeks of work to regain movement – even on my uninjured fingers. Things were moving slowly until I transferred to the Cedars Sinai Hand Therapy Clinic, where I received individual attention and was able to make more progress. The therapies we received included the fabrication of several custom splints for both Theo and myself. Over the course of the therapy, these devices needed constant maintenance and revision. Here is a photo of a few of these splints: I am writing to appeal the low reimbursement rate our insurance plan is offering for these highly necessary treatments. For some reason, the very specialized post-surgical treatments my son and I have received are being typed in a category that offers a low per-visit reimbursement limit. There is simply no way that the care we received can be reimbursed at a rate of $60 per visit. So therefore, by definition, this reimbursement rate leaves either myself or the hospital facility that performed the treatments with a steep loss. This artificially low reimbursement rate is flawed, because it has left my family with a financial hardship as detailed below: Theo Lopez Occupational Therapy Treatment Dates and Coverage Children’s Hospital Los Angeles Occupational Therapy Date Billed Discount Not Covered WGA Benefit 11.4.2016 11.10 11.18. 11.29 12.06 12.13 12.16 12.28 12.30 01.03.2017 01.10 01.17 01.24 01.31 2.14 2.28 3.28 $515 528 560 560 560 560 315 560 560 560 560 560 560 560 560 560 560 172 185 217 217 217 217 0 217 217 217 217 217 217 217 217 217 217 283 0 (Exam) 283 283 283 283 255 283 283 283 283 283 283 283 283 283 283 $51 343 60 60 60 60 60 60 60 0 0 0 0 0 51 51 51 Totals 7840 3395 4245 967 As you can see, my family is left with quite a large balance for these very necessary medical services. Theo’s surgeon specified a very detailed regimen which needed to be followed in order to make sure that the surgery was effective in helping him regain the use of his hand. Without this treatment, there was a real risk that the surgery would not help him – and therefore the resources that covered the surgery would be wasted. This follow-up treatment should be covered in the same manner as his original surgical treatment. I am requesting to have the category of our postsurgical care changed to reflect its true medical necessity. The care we received was integral to the healing process and should be covered that way by insurance. My experience following surgery exactly parallels that of my son. I needed the same robust intervention to regain the use of my hand. On the next page are the totals for my own occupational therapy. Angel Lopez Occupational Therapy Treatment Dates and Coverage Cedars Sinai Hand Therapy Clinic Date Billed 01.05 01.10 01.12 01.17 01.24 01.26 4.03 EOB amounts from 3.27 EOB subtotaled below 2.02 2.7 2.9 2.16 2.21 2.27 3.27 EOB 4695 Discount 2816 Not Covered 1286 WGA Benefit 248 amounts from 4.03 EOB subtotaled below 4449 2668 1420 306 3.14 3.30 3.27 EOB amounts from 4.11 EOB subtotaled below 1803 1081 601 102 Totals $10,947 6565 3307 656 So, after treatment for myself and my son, my family is left with bills totaling some $7500, as our insurance covers barely $1600 of the costs of treatment. This is simply not right. I have been a WGA member for over 20 years. I have been covered by our Health Plan for over 15 of those years. We have birthed three children under our insurance… And I have never experienced such a lack of coverage for our basic medical needs. The reimbursement rate of below 25% is completely upside down – my family should not have to pay for these services at a rate approaching 80% of the cost. I implore the Appeals Committee, as fellow writers and members, to help rectify this situation for me and my family – and for other members who may find themselves with the same problem. Thank you, Angel Dean Lopez CthrenS Hospnal ANGELES. DIVISION OF AND SURGERY April 4, 2017 Blue Cross of California -- PPO Writers Guild Industry Health Re: Theo Lopez -- To whom it may concern: Theo Lopez is a 9 year old male with sustained a right little finger zone 2 flexor tendon complete laceration Injury on 10/30/16. On 11/07/2016, Theo underwent a complex surgery to address the injury with Dr. Seruya: 1. Right small finger, radial and ulnardigital nerve neurolysis 2. Right small finger flexor digitorum superficialis tenotomy 3. Right small fingerllexor digitorum profundus repair with an epitend'lnous suture and a a strand Adelaide locking cruciate repalr 4. Right small finger A4 pulley partial release Post-operative occupational therapy treatments at Hospital, Los Angeles were ordered preoperatively by Dr. Seruya. Starting at post-operative day 4 then once per week thereafter, the occupational therapist fabricated series oi protective and corrective orthoses/splints, treated Theo using an early motion protocol to prevent unwanted scar adhesions while promoting movement through the joints of his right littleiinger, and provided education and updated home program torthe famlly. Occupational therapist was also present for each of Theo's visits with Dr. Seruya to inlorm the surgeon of Theo's progress as well as to safely update the therapy plan. Occupational therapy was and is an essential part of the rehabilitative process to promote safety and best surgical outcomes after Theo's complex injury and delicate repair. Without occupational therapy, the risk of rupture of the repaired tendon and poor functional outcome increase significantly, Each of Theo's 15 occupational therapy treatments to date was integral to his rehabilitative progress. Sincerely, 7 5 2v? Mitch Seruya, MD Date (7 Gina Kim, Date 2mm GUILDVIND USTRY HEALTH FUND :2 Bax m6 22.2222. CA 9.527 <<2na7227.7265 ammo--Inns Plnicipanl ANGEL LOPEZ Number Dale 03/27/2017 ANGEL LOPEZ by WGIHF Anthem Cm" Lu. 22.1 Hzalm prundncaum admnuumum mum 22.1 am 22. 2mm. any financial nor cums EXPLANATION or nur .r 2 ms Explanation of Benefits (EOE) .s no|ify you |ha| we have processed your clan-n. Ir clarifies your paymem responsibimy. reimbursemem and/or .r {unher informaflon is requned process your claim. Remin ror your records along with any pmwder bil Quesuon 7 Come. us. 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