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» LymeNet Flash » Questions and Discussion » General Support » Referral to see Dr. J Denied - suggestions

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Author Topic: Referral to see Dr. J Denied - suggestions
DJP
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Our insurance denied a visit to Dr. J for our two children who have Lyme. They both have positive test results. Reason - they aren't contracted with him.
I know Dr. J doesn't take insurance, but I was hoping to be able to submit his bill for reimbursement.
We have an HMO and it doesn't say anything about out of network coverage.
They suggested an ID doc in their network, but I know he doesn't believe in persistent lyme and fear putting their treatment at risk if we see him. I spoke with this doc when my first child was infected and he gave the whole 3 weeks of antibiotics speech.
Any suggestions how to proceed? Anyone else from MA been successful in getting insurance to pay?
Thanks

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Lymetoo
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quote:
Originally posted by DJP:
[QBWe have an HMO and it doesn't say anything about out of network coverage.
[/QB]

Hopefully someone will have better help than this....but, have you called your HMO to see if they cover anything out of network?

Stinks....and so do HMO's unfortunately.

--------------------
--Lymetutu--
Opinions, not medical advice!

Posts: 95723 | From Texas | Registered: Feb 2001  |  IP: Logged | Report this post to a Moderator
pab
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Can you call your insurance company and ask if you have out-of-network benefits?

I call our insurance company a lot. If you have an insurance card, the phone number should be on the back.

We have out-of-network coverage. Our insurance covers 70% of a "reasonable" cost. We pay our LLMD and LLMD's office submits it to our insurance company.

My kids did see Dr. J. They would give us a copy of the bill and I would submit it to our insurance company.

--------------------
Peggy

~ ~ Hope is a powerful medicine. ~ ~

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hiker53
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I don't know about other states, but here in Illinois if there is no specialist within 30 miles of your need, you can ask your insurance to add the doctor and a lot of it will be covered.

--------------------
Hiker53

"God is light. In Him there is no
darkness." 1John 1:5

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fatigued15
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Our HMO will only cover the meds Dr.. J. has ordered. The office visits, labs are not covered. Let me know if anyone finds a way to get this covered.

If I have our local doctor order the labs than some of those are covered.

Good luck!

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DJP
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lymetoo and pabs,
Thanks for the suggestion, it was an obvious suggestion that I needed to hear...one of those lightbulb moments. Will call in the morning.

hiker53, unfortunately there are ID docs close enough within the network, problem being I know how they treat and it's not long term.

I thought it was weird that in the message that my ped's office left said that Dr. was not contracted but there is a doctor so and so who can see you on ( and gave me a specific date and time). I'm not sure it came from the ped talking to that dr or the insurance company.

It was obvious that someone had talked to that office to know when they had time available. Maybe I'm reading too much into it.

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Julie-MA
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We live in MA and were able to get some of my son's initial visits to Dr. J covered because our dr. wrote a convincing letter indicating that specialists had dismissed his problems as not Lyme (ha) but had not come up with any definitive diagnosis.

She included that with positive WB bands & continuing symptoms and no diagnoisis from in-network docs, we needed a specialist out of network. Ins. paid for a couple of visits. At least it helped a little.

Try to enlist your dr.'s help, though I realize you may be battling your own dr. too; we were fortunate that our ped. has a husband who has gone through what many of us have, so she understands it.

Julie

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DJP
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Julie,
Thanks for the suggestion, our ped did say she would write a letter. I'm not sure what to ask to write though.
We didn't have trouble getting a diagnosis because she had the bullseye and developed symptoms.
Our ped had been working with Dr. J to treat her. Hey, maybe I just answered my own question! Maybe I should her to state that in the letter and that there are no other doctors in the area who are pediatric lyme Disease specialists that treat persistent Lyme Disease.

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lymex5&counting
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Do you have an appt with Dr J the same day we do? I will email you.
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fatigued15
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DJP, If you do see Dr. J you can save by staying at the Ronald McDonald house. You have to call ahead so I would do that as soon as you have an appointment. It is very nice there and only $15.00 a night. Any questions about it let me know. The RM House is only 2 blocks from Dr. J.
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Lymetoo
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quote:
Originally posted by DJP:
Maybe I should her to state that in the letter and that there are no other doctors in the area who are pediatric lyme Disease specialists that treat persistent Lyme Disease.

Excellent!

--------------------
--Lymetutu--
Opinions, not medical advice!

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vitch
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Get the denial, and everything else, in writing, go to Dr J, saving all receipts and get a lawyer.

I suggest, everyone who is able...
LEAVE HMOs!!!!!!!!!!
They're killing us.

--------------------
[email protected]

www.lymediseaseassociation.org/Conflicts.doc

Worthless tests & labs, a dangerous vaccine, insurance companies refuse to pay, undertreatment the norm, all about money. MO.

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lymebrat
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Hi DJP,

We had the same problem. We had to pay for the first few visits for both our children ( luckily we had some help from a couple LymeNet Angels) but we did eventually get our insurance company to pay.

We had our children's PCP call the insurance company and tell them that as there wasn't a qualified PEDIATRIC lyme disease specialist in our state, that he felt it medically necessary for them to see Dr. Jones in CT who is a PEDIATRIC specialist.

If you have a card from Dr.Jones's office, it states that he is a MD who treats: " Pediatric & Adolescent Medicine and Lyme Disease."

Our PCP used this card to prove that Dr.J is in fact a pediatrician who specializes in Lyme Disease and he challenged the insurance company to find a doctor in NH who could claim to be a pediatric lyme specialist. There weren't any...

And he went on to state that in his opinion, it would be negligent of the insurance company to deny this referral as there is much to learn about lyme.....

And by denying our children the care they need, that the insurance company could be (and would be) held liable if there was ever any new medical evidence in the future, to support that by denying our kids to see a pediatric specialist, they hindered their recovery or jeopardized their health.

2 weeks after this consult, I got a referral acceptance notification and they have been paying of both my children to see Dr.Jones ever since.

I also wanted to say, that Dr.Jones does take our insurance. His office supplies us with the correct form, I fill it out and submit it to the insurance company and they either pay Dr.J direct or send me a check to mail to Dr.J.

So if you have a PCP who is willing to step up to the plate for your children, ask him/her to call the insurance company on behalf of your children. If you don't have a pcp willing to do this, maybe it's time to look for a new pediatrician.

I hope this helps, and I wish you and your family luck and wellness!

~LymeBrat

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fatigued15
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DJP,

Our peditricina has done the same.. wrote letters stating our dughter needed to see JOnes. We have always been denied. I am in the process of fighting it once again now that I have 2 with Lyme in our family. Don't put off making your appointment to see Jones. Your children need to be treated.

We do max out our flexible spending account. That does help some. The Ronald McDonald House has been a great help. Our insurance does pay for medication.

Good luck wiith everything.

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ponytail
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I know how aggravating this can be!

Dr. Jones takes credit cards - that's how we did it!! LOL - then payed it out!

My PCP has always obtained an out of network referral for us but, after the ins company "disallows" for the amount they deem as too much - the reimbursement isn't much! Same w/ IGENEX but, something is always better than nothing!!

Between the airplane, labs, doctor charge, rental car and food it can get quite expensive!

The Ronald McDonald house has been WONDERFUL and I can't recommend them enuf!

I DO NOT regret taking Katie to see Dr. Jones by any means and feel like of all the expenses we have incurred in our life, this one is definitely WORTH it!!!

Believe in your strength as a parent. You know what your kids need and, at least for us, it always manages to work out somehow!

One time we sat next to an off duty pilot on the plane and during the flight visited about where and why we were flying. We deplaned in Cleveland, OH to change planes (this was his end destination) said our goodbyes and Katie and I left.

While we were at the gate waiting to board, he approached us. He said he wished he could do more but hoped the $100.00 he placed in my hand would help us have at least a little fun on our trip.

I tried to give it back but he wouldn't take it. He was so kind and you could tell by the look in his eyes - very sincere.

Katie and I decided to give 1/2 the money to the Ronald McDonald house and we PLAYED on other half - at the MALL!!! We still hear from here periodically as we exhanged email addresses!

It really made me see how God doesn't give you more than you can handle - even when you think it is!!

Bug that insurance company. Talk to your friends etc. You never know where or how your prayer will be answered or your needs met!

When Katie needed surgery, several of our friends and family hosted a BBQ fundraiser. That really helped w/ some of the expenses!

Best wishes and hope you ALL feel better soon.

Sherry

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partnerinlyme
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DJP, HMO's will not cover any doctor that is not in the network.

Since it is almost the end of the year, most companies have open enrollment for the new year. If your company is having open enrollment and they have a PPO option, I suggest that you switch to a PPO.

Under a PPO, you have the option to go to an out of network doctor and once you meet a deductible, the insurance company will pay something. It might not be much, but it'll be better than nothing.

Just my 2 cents [hi]

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DJP
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Thanks everyone for your help. I have an appointment and I will bring my kids to Dr. J no matter what it takes. I just believe the insurance company should pay.

With three of us with Lyme it's going to get really expensive fast. So I want to do whatever I can to get the insurance to pay.

Deb

Posts: 441 | From USA | Registered: Jul 2004  |  IP: Logged | Report this post to a Moderator
   

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