Is It Ok If I Vent? - Insurance Frustration!!!!!
Lounge By Jenna217 Updated 17 May 2007 , 9:25am by StarbucksAddict
I know I'm a newbie here but I love this place and I feel like I've known some of you from lurking for so long! 
I hope I can vent....here goes my novel...
I am so irate about my insurance! It all started Thursday... Over one year ago in April, I consulted my regular physician who referred me out to have an abdominal corrective procedure due to drastic weight loss. It took forever to get it approved through my HMO which only had one in-network surgeon, who we'll call 'Dr. X'.
I finally got a consult approved with Dr. X. That was scheduled in June '06 for my consult appointment to be in October '06. I got a call from Dr. X's office in September saying that Dr. X is no longer taking any new patients and he is possibly leaving. Ok, great...so now I have no surgeon appointment and we have no in-network surgeon now. Well that's ok, because if there is no in-network provider we can be referred out to another surgeon and it would be covered 100% just the same as in-network.
So I find another surgeon and get referred out and approved to 'Dr. Y'. I saw him for a consult in November and they submit to my HMO for my surgery to be covered. I got sick with a severe iron deficiency in January where I was hospitalized for 2 weeks and battling with it up until recently. I literally got a phone call while I was laying in my hospital bed from the surgeon's office asking me to schedule as it had been approved 100% paid for. Told them now is not a good time, am battling with illness - will call to schedule as soon as I am cleared by my physician to be medically healthy to proceed.
I also get a letter in January from the HMO office saying everything is approved with 100% coverage but if I want an additional elective procedure done on top of approved prcedure, that will be the only expense not covered which I will have to pay out of pocket. No problem, I'm not having that done anyways. Letter also says that because my inital referral is outdated (over 6 months old) to have my regular physician submit a new one for renewal after I've scheduled my surgery.
I've finally gotten clearance to schedule, so I called the week before last and scheduled my surgery for July 26. Yay!! I was so excited! And I worked it out with my job to where I can work from home 2 weeks!!!! I was over the moon!
I contacted my regular doc's office and had them resubmit my referral as per instructed. I got it back on Thursday and it was approved but I will owe 20%....WHAT?!?!?!? EXCUSE ME?!??!?! I am irate and think this must be a mistake. I march my heiney over to the HMO office in town and the director is gone for lunch. GRR!!! I wait until the exact time she's to be back call. She says that because Dr. X has now decided as of April to stay with his practice, my surgeon, Dr. Y, who I've already established care with is now considered truly out of network therefore they will only cover 80% of his services now. WHAT?!?!
UGH!!! If I can get in with stupid Dr. X's office...FINE! So I call that office and I find out I can't get a consult until the end of July and it will take one month after that to get a surgery date. Right now they are booking out until the end of November so I will have to wait until NEXT YEAR to have my surgery. I DON'T THINK SO!!! I've already waited a year longer than I should have!!!
I am going to appeal this decision. I should not be punished because Dr. X cannot get his poop in a group and decide what he's going to do with his life or where he's going to practice. I've already been established with my current surgeon, it was 100% approved before. I could not have had my surgery before April because I was sick (are they punishing me for that too?!). I have been waiting for the HMO medical director to be in tomorrow. She will be getting an earful from me. If need be, I will take it to the board of directors for sure!! If that happens, it's an appeals process that can take 6 weeks! And if it gets denied then, I'm going to have to come up with loads of $ for the 20% which is scarce these days, or cancel my surgery and be absolutely miserable for another whole year. Another kicker is that with m job, everyone's position is currently touch and go. Our business is not doing so well so our jobs are basically month to month. Who knows if I will be employed or have insurance by the time next year rolls around??
Fast Forward to Monday...
I got a call from the insurance medical director just seconds after one of the chairmen dropped off the complaint form I requested to take it to the board.
I expalined the whole story to her and she was apalled. She just kept saying 'Oh my gosh! I didn't know about this!' She said she will talk with the department about it on Wednesday, not to loose any more sleep and be assured that it will be taken care of and I'll hear from her Wednesday(which would now be today...and still waiting).
Today....
Well today the chairman who brought me the appeal form I requested on Monday came over today into my office (since we're on the same block as the HMO office), closed my door, sat down and asked what my appeal was for. I told him that they approved a procedure at 100% and then now will only cover it 80%.
He threatened me and said that if appeal it and I take it to the board there's a 'strong' possibility that they will retract everything and not cover it at all. Mind you, he's the chairman of the commitee. 
I'm still waiting for the medical director to get back to me and when she does, I will tell her what happened. This is ridiculous. I don't need idle threats and scare tactics on top of the crap pile they already left me. 
Stay tuned for more drama in my corner of the world...
Sorry to hear that. It's not enough to have the medical problems without the shenanigans of an HMO?! I can totally relate. When my son was born w/ Cerebral Palsey, I had an HMO for myself and him. After two months of therapy, he was going to be dropped as he was a chronic case! Evil-Bastards! Now he's twelve, and I have all of his insurance problems solved, thank goodness. But the HMO's have no heart, I know. Hopefully, everything works out for you. I'll keep thinking good thoughts for you 
Document every conversation you have with everyone involved in your case. You will probably need to give names and dates and promises, etc. It doesn't hurt to cover all the bases. They are there to get by with as little payment as possible. Just write everything down and file it away until you need it.
I was born with Spina Bifida... so been there, done that, can write the book on health insurance! I've been very lucky to have a spectacular health plan, I have no idea what I'd do without it.
I had a scar revision and liposuction on my low back (if you goole for pictures, you'll see a grapefruit-sized lesion on the low back of an infant--that's what I had, and unfortunately even after the neurological damage is repaired the area for some reason become filled with fat tissue... which can cause back problems as its hard to sit and causes posture problems). My plastic surgeon warned me it would quite possibly take many months after submitting for insurance approval, in addition to an appeal or 2, before I'd be able to get approval. Suprisingly, I had approval in less than a month, and was able to get a surgery date within a week (someone else had to cancel, this guy is usually book 9 months out and the only reason I was able to get a consult appointment in less than 2 months was because he golfs with one of my other doctors who called in a favor for me).
Unfortunately, I highly doubt you'll win this appeal. It really stinks that Dr. X wasn't sure what his plans were, but since he is staying there is an in-network option, so technically you're making the choice to go out of network. At 80% coverage, you're really lucky--I know my going out of network, they'll pay the amount they would had it been in-network, which you know is a low negotiated amount. Technically, you were only approved at 100% for a certain period of time, and with a certain doctor. That timeframe is up, and the doctor is no longer going to be a "participant" in plan coverage. It stinks, but even though you may get a lot of sympathy within the insurance company, the people who can actually do something tend to be the ones who don't want to! I can't even begin to go into how many times I've dealt with low-level customer service people who want to help me and feel so bad about a situation, only to be passed onto the "higher ups" who can do something that are hard-hearted enough to not want to do anything! I've usually gotten satistfaction by going above their heads--you may or may not have something above the committee.
And to the jerk who may pull the 80% authorization... ugh! Pull out your benefits guide/book. If it has already been deemed medically neccessary by a physician and the insurance company, and the situation hasn't changed (or changed for the worse), they will have a hard time backpedaling. Most of the time when you need authorization for such, it is because they want to make sure that it is really medically neccessary, not deemed neccessary by a doctor who is just looking to have a full/money-making OR schedule. Don't let this royally moronic idiot threaten you like that, especially when he may quite well be bluffing. If all else fails, there is a state agency where you can file a complaint against the insurance (if they indeed do go and pull the 80% offer)--I'm 99% sure it is the Attorney General. Look it up, learn your rights, and stand up to them with such information.
I'm rooting for you, hopefully you do win your appeal! Let us know what happens!
Quote by @%username% on %date%
%body%