Insurance company battles

hi everyone---

just wondering if any of you had to do any battle with your insurance companies. I have <admin. snip: name of insurance company removed for liability reasons> , but out of network benefits. the hospital and surgeon that I am using only participate with medicare, medicaid and blue cross, but the insurance company is already giving me problems with the old reasonable and customary stuff, and not even applying certain charges to my deductible. I am thinking that i need to be proactive. I had my internist write a letter of medical necessity, but am wondering what else I can do? anyone have any suggestions. i am having my hyst on april 6th so want to do battle now.
thanks as always nancie

My first thought was "Do you have a therapist?"

Then I checked your profile. You ARE one! So's my DH.

I have a therapist who used to work on a hospice team, so intimately understands the connection betweeen pain, depression and anxiety, not to mention the psychological effects of the surgery decision itself. She advocates like crazy with my HMO.

If you don't already have a therapist, and if pain is part of your motivation for the surgery, use your connection to find one who works with women in chronic pain. A letter from her about the reality of your need for surgery (or maybe her phone calls) to back up the one from your internest might help.

In my case, I made some headway because of my therapist's insistence that the psych treatment the insurance company was paying for was due, in large part, to problems resulting from years of chronic pain. If they'd pay for the surgery, they'd get to stop paying so much for other problems resultant from condition needing surgery, right?

I'm pretty sure your situation is different than mine, but just having a therapist familiar with the phychological/physiological effects of pain helped me through the total desperation in the year leading up to the decision to have, and then having, my hysto.

Also, check out www.brainplace.com and look at the brain scans of people in pain. And look at the ones on PMS. Hmmmm. The emperical proof is coming, but unless you're in California, you might have to wait a while. The rest of the website is good, too, and that doctor is brilliant.

Good Luck. I HATE battling for help.

Nancie:
As it happens, I work at <admin. snip: name of insurance company removed for liability reasons> . Are you on a PPO or Managed Choice Plan? Just curious why you are having your surgery out of network. Is the hospital "in network?"

Unfortunately, when utilizing out of network benefits, you are responsible for anything that is over the reasonable and customary charge. Would like to know what they are applying to your deductible that you think they shouldn't.

You can send me a private message if you don't want to discuss on the boards.

Just as an FYI, I am 3 days short of being 6 months post op. No matter what it will cost you, it's WELL WORTH IT!

hi jojo----

I had 3 complicated c sections. lots of bleeding, needed to be cauterized and drains inserted the last time. told that i could never have more abdominal surgery due to amount of scar tissue and adhesions. had the c sections at yale, which is an excellent hospital.

i am going to a gynecological surgeon to do the hyst-- he is an expert in very complicated surgeries. all my doctors want me to do so, and as i said my internist has written a letter expressing his concern that it would be dangerous for me not to do so.

i have talked to the non par unit--- trying to get this covered on par with participating. I think my plan is QPOS. I pay a fortune every month for insurance 1369 per month, obvously would not want to travel to hav ethis if didn't feel it was necessary etc.

so any suggestions for what to do to proceed?

Nancie:
Are you covered under the QPOS plan through an employer?

I think you should definitely pursue the getting it paid "in network" because of your situation. Do they have a case manager assigned to work with you? You can request this but have all your facts ready when you ask for one.

hi jojo--

i am self employed, so i get the insurance as someone who is self employed. i did get a case manager who is a nurse and she is trying to help me. she agrees with me about the complications possible due to the previous abdominal surgeries.

i am just wondering if i should also get letters from my allergist, gynecologist etc. or if i need to hire an outside advocate.

the other thing is that due to the mess from the previous surgeries, i may be having abdominal wall reconstruction done at the same time. they would not allow this at any of the local hospitals. thanks for trying to help me. nancie

Hi Nancie,

I hate insurance companies, they @#&! (sorry to offend anyone out there). I've have been very successful when I've taken a proactive role.

Here are a few of suggestions:

1) Prepare a brief summary of your situation (include how this only adds to the distress of an already difficult situation), get a copy of your PCP's letter and call your Senator in Washington and tell his/her assistant your situation. They'll probably ask you to fax the info, if they don't, offer to. The amount of persuading they can do in a very short time is nothing short of amazing!! An added bonus -- it's an election year, maybe not for them, but definitely for their party and they want votes!!

2) Call your state representative -- they should give you suggestions and there may be an appeal process.

3) Call Blue Cross and one other insurance company and see if you can get them to tell you how much your procedure "customarily" costs. If you can get a written/printed copy this would be even better. Use this as a bargaining chip.

4) Call your insurance company and (1) ask to speak to a supervisor OR (2) tell one of the people that answers the phone that you need them to provide a printed copy that states ALL of your benefits and supplemental statements (these usually detail the exceptions which is why the books are so big). Tell them, due to an emergency situation, you need it immediately! If they say your workplace has it, then call the HR dept. and get it from them (there are important details in there that you can use to write your insurance company a letter, if need be). (I'm pretty sure that legally someone has to provide you with that information in detail if requested -- where I live, they do have to). This process though takes a lot of time, reading info and writing letters and is usually not resolved quickly.

In each case, keep track of dates, times and names of people you speak with -- this is irreplacable when dealing with bureaucracy

Insurance companies count on people giving up and giving in, even when they are suppose to be paying the claim if you go through the long, winding process that they may not make intially available to you.

Hang in there -- take good care and go girl!!! I admire you tenacity!

All the best,
Hysterhelp

PS start with #1 -- I think it will be your quickest route.

Nancie:
Your best bet is to work closely with your Case Manager. It's great that you have been assigned one and that she understands your situation. She will be the best one to help you. I assume it wouldn't hurt to have letters from your providers (allergist, etc.) but I would confirm that with your Case Manager. There's no reason to run around and do unneccesary work. I would not, as someone else suggested, call your Senator and State Representative! You think Insurance Compaies are frustrating? Just trying getting politicians involved in your situation!

The fact that you are starting this early (I think you said your surgery is in April) is really good. Be sure you have your Summary of Coverage (SOC) or booklet that explains your benefits so that you understand what is and isn't covered under your plan. All insurance companies have to provide this to you.

I am curious abot one thing...you said you are covered as a self-employed person. Are you covered by this under an employer "pooled" policy (i.e., you are covered with a bunch of other self-employed people)? I ask this because <admin. snip: name of insurance company removed for liability reasons> doesn't write individual insurance policies - only through employer plans. Maybe there is something different in your state.

Also, insurance companies don't count on people giving up or giving in. It's important, from the beginning, not just when you need to use it, that you understand your insurance policy and how it works FOR YOU. Believe me, I know it can be frustrating - insurance companies are large corporation with lots of buracracy just like many other businesses.

Unfortunately I too have <admin. snip: name of insurance company removed for liability reasons> as well. I live in Alaska and we do have a PPO but very few Dr.'s are on the plan so we can use out of network Dr.'s as well. I really feel that <admin. snip: name of insurance company removed for liability reasons> denies everything and hopes you don't want to bother fighting. I am President of our local Union here and I cannot tell you how many complaints I have forwarded to our HR dept!!! On top of that I have had to personally threaten to go to the State Insurance Commisioner because they kept trying the old"reasonable and customery" line on me for my elbow surgery last year. They just cannot seem to understand that the charges for medical services are higher in Alaska than in Seattle where they do their comparisons. My advice is to keep all documentation and appeal everything. If that doesn't work take it to your State Insurance Commissioner. I too also do not mean to offend anyone but I have had more than my fair share of denial of claims by <admin. snip: name of insurance company removed for liability reasons>

wow---- you all are helping me so much.

i am self employed, but I joined the Ct bureau of industry and get my insurance through them. do you think I should contact them and explain what is happening? thanks as always, nancie