LymeNet Flash: Medical Insurance vs. my LLMD

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»	LymeNet Flash » Questions and Discussion » Medical Questions » Medical Insurance vs. my LLMD

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Author

Topic: Medical Insurance vs. my LLMD

abacomah
Member
Member # 5633

posted

This may open a can of worms but I need some help and advice. I am under the care of a wonderful Lyme Doctor. We have done the oral abxy route for 15 months and seem to hit huge roadblocks each time we switch. He is recommending IV therapy for a period to be determined by my response but proabably 4-6 months. In getting this prequalified, my insurance company says they will approve 28 days IV for Lyme and that's it!
I know my Dr. is having discussions (frustrating albeit) with this particular insurance company and I have started the appeal process myself. There is no question I will do the IV therapy...even if I have to pay for it myself. I cannot believe the insurance company and the company I work for (in Fortune Top 50)are dictating medical treatment against the Dr. recommendation.
Here are my questions:
Has anyway experienced this frustration and if so do you have some advice on how to deal with the insurance company?

The appeal process is paperdriven (mail a letter!!!!)and the insurance company has 30 days to respond.....remember they only approved 28 days. Any advice on what to put in the appeal other than the Dr treatment plan recommendation?

Are there Lyme literate and compassionate insurance companies out there? My enrollment window is coming up in November and I may be able to switch.

Thanks for any help...needless to say this last development has added significant emotionaly stress at a time I don't need it. My hubbie says we'll do whatever we have to do....I just expect the insurance company to pay for what the Doctor recommends. He has been treating Lyme patients for many years with remarkable success.
MA

Posts: 58 | From SC | Registered: May 2004 | IP: Logged |

beachcomber
Frequent Contributor (1K+ posts)
Member # 5320

posted

The insurance company is following State mandated guidelines, based on CDC recommendations. In my State (not NC) the fine print in the statute says that an insurance company must consider longer IV therapy if the need is backed up by an Infectious Disease MD or a Neurologist. Since lots of LLMDS are not IDs or Neuros, they will often refer their patients to one of the specialists to get a second opinion and a letter to back up the original diagnosis.

There is an old thread that has an example of the type of letter that is needed. That is pretty much all it takes.

Hang in there.

Posts: 1452 | Registered: Feb 2004 | IP: Logged |

Pitnum
LymeNet Contributor
Member # 4906

posted

I also am experiencing major problems with the insurance company! I had 56 days of IV treatment(which was precertified and authorized by the insurance company). Now, when it is time to pay the bill, the insurance company is trying to back out.

The IV was removed in May, and they still have not paid. It is now out for an independent review by DUCKS to determine if it was medicaly necessary!! What do they know about Lyme disease......NOTHING!!!

I am supposed to do another 56 days, but I have put that on hold because the first bill of $6,700 hasn't been paid. I don't want to get stuck with a $14,000 bill that I can't pay.

So feel better, you are not alone in your battle. We need to stop letting insurance companies dictate over the doctor's.

Posts: 195 | From NJ | Registered: Nov 2003 | IP: Logged |

cbb
Frequent Contributor (1K+ posts)
Member # 788

posted

Hi abacomah,
Welcome to LymeNet.
I don't have the info you need about dealing with insurance problems, but hopefully, you'll get what you need to solve the problem.

Just want to welcome you to the LymeNet group.
We're almost neighbors. I live in Columbia and we have a lake house in Ballentine.

Will e-mail you with a few questions to see if your Lyme Dr is the same one I see.
(I guess you've noticed we don't give drs' names here unless they've given permission.)

Posts: 4638 | From South Carolina | Registered: Mar 2001 | IP: Logged |

riversinger
Frequent Contributor (1K+ posts)
Member # 4851

posted

Here are two resources to help in your insurance appeals. they are both CA based, but most of the info should be good anywhere.

CALDA has form letters for insurance appeals. Browse through to find what else can be helpful.

CALDA Intranets
Enter the site as a guest.

Health Care Rights

Most important is to PERSIST. Insurance companies have a policy of automatically turning down everything they can possibly get away with. They presume most won't go to the trouble of arguing.

I can't say you will always win, but I have managed to get mine to pay for a number of things without going to court.

If this doesn't work, remember Roche has a needy meds program.

------------------
Sonoma County Lyme Support
[email protected]

[This message has been edited by riversinger (edited 24 September 2004).]

Posts: 2142 | From California | Registered: Nov 2003 | IP: Logged |

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