posted
Our insurance company told my husband's employer that they deny all claims associated with our LLMD. They even went so far as to recommend that we get another doctor. Like there is a LLMD in every strip mall. Is this even legal?? They have denied over $15,000 worth of labs, visits and a spec scan. We are filling out the appeals paperwork, but I wonder if it is even worth the effort.
Any recommendations-should we go ahead and start talking to a lawyer? Please advise.
Posts: 28 | From USA | Registered: Aug 2010
| IP: Logged |
posted
Do you have the Lyme Times special issue on insurance? It has some helpful info for people in your situation.
Insurance companies do a lot of things that are illegal, and get away with it, unless people fight them. Not much fun for sick people.
Is your insurance under the ERISA system? If it is, then you will not be able to use the state insurance commissioner to appeal if your appeals thru the ins co do not succeed. You should look into this. And make sure you do all the appeals procedures correctly and in the right time frame.
I have known of some people who have been their own attorney, but most cannot do it. And the cost of the attorney shoud be weighed against the bill that the ins co won't pay.
This subject has been discussed a lot here. Not sure what search word to use, but it is there.
But do get that issue of lyme times.
Posts: 8430 | From Not available | Registered: Oct 2000
| IP: Logged |
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96223 | From Texas | Registered: Feb 2001
| IP: Logged |
Rumigirl
Frequent Contributor (1K+ posts)
Member # 15091
posted
Yes, you MUST appeal this with everything you've got! Don't let them get away with this $%#*!!
Get the Lyme Times Insurance Issue, as mentioned above. It's worth it's weight in gold.
Also, make a complete complaint to your state's Attorney General's office in their Health Bureau, giving them all the appropriate denial letters, letter of medical necessity from your LLMD, a letter from you with all the details, studies to back up you claim, etc.
And the same complaints to your state Insurance Board.
Follow the instructions in the Insurance Issue about asking for ALL of the criteria, documentation, etc. that they used in each an d every denial (write separate letters for each denial).
Let them work plenty with all this.
Posts: 3771 | From around | Registered: Mar 2008
| IP: Logged |
posted
I concur, you need to appeal. A lot of times insurance reject expensive procedures just because they can in the hopes you will become discouraged and not appeal, even with less controversial disease processes.
Also, read your fine print for your insurance about out-of-network coverage. If you don't have any specified, sometimes it helps to find a "Service Authorization Request (or Form)" which basically will get a LLMD paid as in network because there is no other ILADS physician within your network and in close proximity. Note that if you have out of network coverage, this probably won't work - you'll just have to get back the out of network reimbursement instead of the in-network one....
Appeal, make a complaint to your state insurance commission and request an inquiry, write your state and federal congress people!
Posts: 690 | From East coast, USA | Registered: Jun 2006
| IP: Logged |
map1131
Frequent Contributor (5K+ posts)
Member # 2022
posted
My insurance co was paying for my LLMD(out of state) back in 2000. They paid for the first and second visit, no problem....
3rd appt within one year and the red flags came out. They refused to pay anything on this visit.
I appealed and they sent me a letter wanting me to see an Infectious Disease in my area. I appealed that with been there done that.
Insurance called every ID doc in city and asked the person that answered the phone...Does your office/dr treat Lyme Disease? All of them said yes.
The 1st ID doc after 6 mths of early abx from my angel primary doc laughed at his "Lyme" dx. He called it Toxic Shock Syndrome.
I called another ID office (someone local had been treated by him)for three weeks. I was put through to answering machine.
I begged, cried, acted normal everything trying to get them to call me back and get an appt. They never called me.
I was done with Louisville ID ducks and found a LLMD 8hr drive one way.
Insurance companies are sneaking money hungry vultures. You can use alot of your energy fighting with them.
I would recommend a fight/appeal process using someone to help you with the writing and appealing. Spouse, parent, sister, friend someone that know something medical fight if possible.
Go get 'em!!!!!!!!!!!!!!1
Pam
-------------------- "Never, never, never, never, never give up" Winston Churchill Posts: 6478 | From Louisville, Ky | Registered: Jan 2002
| IP: Logged |
Tincup
Honored Contributor (10K+ posts)
Member # 5829
posted
Look under "Insurance Issues" here. It has what you will need all in one place, without having to retype the documents.
When the Lyme Times info was created for the publication, I sent it out to others by email till it was published. Then added to it and posted it here.
posted
Not sure they are allowed to deny the labs -- but the issue may be whether or not the labs were in network or out of network. The docs fee is a different issue. Surprised you were not required to get preapproval for a SPECT scan -- if that should have been done and was not then they could deny that test and an appeal would not do any good if you didn;t follow the rules.
If the insurance policy is thru an employer then the employer may be able to help with filing appeals or at least explain any rules regarding in network etc.
Do you have an insurance manual? -- they usually only cover the basics but will have contact numbers to call for more info.
Appeal everything you can, but without knowing which insurance company and more specifics about your policy I have no idea what would or would not be covered.
Bea Seibert
Posts: 7306 | From Martinsville,VA,USA | Registered: Oct 2004
| IP: Logged |
The Lyme Disease Network is a non-profit organization funded by individual donations. If you would like to support the Network and the LymeNet system of Web services, please send your donations to:
The
Lyme Disease Network of New Jersey 907 Pebble Creek Court,
Pennington,
NJ08534USA http://www.lymenet.org/
UBBFriend: Email this page to someone!
Printer-friendly view of this topic