posted
Ok, i need a creative writing lesson. I have the opportunity to try and get my medical insurance to pay some on my visits to my LLMD, which would really help out. I do not get reimbursed anything from them and that is making it tough.
Anyway the insurance company called and said that they could not grant this waiver because their is a Dr Y at Cleveland Clinic that treats lyme. Have never even heard of this guy. They are sending me out an appeal letter to try and get this covered. I do not want to switch dr's, only trying to get some of my medical bills taking care of at my current dr (that is out of my net work)but he is wonderful and i want to continue going to him.
I think i need to come up with some creative words for lyme or something like that to get this paid for or at least partially paid for. I know that if i just put lyme on the appeal that they will be able to find dr's (like the one above) that supposedly treat lyme.
We all know that all Dr's are not LLMD.
I am not trying to pull a scam at all and hope that it does not seem that way but you all know as well as i do sometimes it is in the way that you write it and you also know that not all dr's that say they treat lyme do or can.
Hope you all have some ideas. They are sending me an appeal letter and i want to have my ducks in a row when i get it.
p.s. i have several co-infections and i plan on listing those, also have seizures, encephalitis and many other things. Maybe i just need to list everything.
Thanks and any help is appreciated. Ang
Posts: 55 | From ohio | Registered: Aug 2008
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bettyg
Unregistered
posted
ang, try these links
now, is this correct? you are appealing GOING OUT OF NETWORK FOR 1 OF OURCHRONIC LYME LITERATE MDS,
VS. infectious drs. in newwork, right? not sure if any of below will help you, but look it over anyway ok. good luck xoxox
INSURANCE ISSUES!
Appeal Letter to Insurance Company for IV COVERAGE from TIMACA !! She was reimbursed thousands $ back! http://flash.lymenet.org/ubb/ultimatebb.php?ubb=get_topic;f=3;t=014009#000000 California Lyme Disease Association, CALDA has a very handy form letter to send to insurance companies that deny you care. It was written by someone who has a lot of experience in dealing with denial of care for lyme.
You go to the link I have below, read through the brief description, then download the forms. Add your personal information and the insurance companies address, and presto, you have a good letter.
Be sure to cc your state's attorney general. They are increasingly becoming involved in cases where insurance companies deny care to sick people. Added 2.3.0907
INSURANCE HELP FOR APPEALS from SARAH aka californialyme 11-07 Another good site for insurance help is HARP.org run by an oncologist who got a JD (became a lawyer) because he was tired of his patients being shafted in their treatment because of insurance companies, specifically HMOs for him. He knows ALL about Lyme- his name is Harvey Frey and he is actually a family friend (if you write him from his site tell him Karen Leonards daughter Sarah told you to write hiM!)(that's me*)!
He helped the Lyme patients going after Kaiser as much as able- he won't be your lawyer but we can help you figure out what to do sometimes!!!
from ANN-OHIO There is tons of good info at the site mentioned below,. this is the home page http://www.patientrights.com/index.html It was put together by a Michigan law firm and is one of the best I have ever seen
posted
Betty, Yea that is correct. I have been going to MO and have no intention on changing Dr's. I love the one that i have but i would like to get my insurance to cover at least some of it.
I do not think that they realize that in Ohio you just can not go down the street and find someone to treat you.
Thanks so much for the help. I will look over everything and hopefully come up with a good appeal letter. Ang
Posts: 55 | From ohio | Registered: Aug 2008
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seekhelp
Frequent Contributor (5K+ posts)
Member # 15067
posted
The thing is you're trying to treat a condition that medically doesn't exist so the insurance company sees no reason to cover it! Things that don't exist can't be a 'medical necessity.' lol. Obviously, patients here don't believe this, but the insurer follows IDSA BS.
Are you making good progress with your MO LLMD? How long have you seen him?
Posts: 7545 | From The 5th Dimension - The Twilight Zone | Registered: Mar 2008
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posted
I am making some progress. i can see some good things happening but i still have a really long way to go.
I have only went there since February so i am sure that i have a lot more visits to get better. I really love the Dr though. I will continue to go there even if i have to come up with ways to pay for it on my own.
I have had this undiagnosed for at least 6 years maybe more.
It sure is a hard road to travel. Hopefully all of this does some good.
Ang
Posts: 55 | From ohio | Registered: Aug 2008
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sammy
Frequent Contributor (5K+ posts)
Member # 13952
posted
Hey Ang, I think I know what you are asking. Take a look at your doctors fee tickets/bills. They should include multiple diagnoses and ICD9 codes to match.
Insurance reimburses based on these codes, procedure codes, and length of time the doctor spent with you/ complexity of the visit.
When you have a chronic illness such as Lyme your doctor always has to include that diagnosis on your fee ticket. Then he adds to that depending on the current reason for your visit such as pharangitis, myalgias, arthralgias, fatigue, cognitive disfunction, etc...
If he is not marking the codes for these other symptoms/diagnoses than maybe you can have the office manager review your chart and correct the fee ticket so that you can submit the claims correctly.
Hope this helps. Good luck Posts: 5237 | From here | Registered: Nov 2007
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Tincup
Honored Contributor (10K+ posts)
Member # 5829
posted
To distinguish the treatment your LLMD provides from general ducks...
You must continually refer to your condition as "chronic Lyme".
Supposedly insurance ducks follow the IDSA guidelines, therefore, they don't treat or even acknowledge CHRONIC Lyme.
YOU need a doctor to treat YOUR chronic Lyme. Their ducks don't do that.
Impress on them you follow the ONLY guidelines that address the CHRONIC form of the disease, something their ducks do not know how to treat.
Aniek
Frequent Contributor (1K+ posts)
Member # 5374
posted
Is your insurance through your employer? If yes, contact the insurance contact and ask them if the insurance is self-funded or fully-insured.
If it is self-funded, your employer actually pays the bills at the end of the day, not the insurance company. If this is the case, ask them who decides the final appeal.
Sometimes it is the employer that decides the final appeal. That can give you a little more flexibility because they may be convinced of something the insurance company will refuse to see.
-------------------- "When there is pain, there are no words." - Toni Morrison Posts: 4711 | From Washington, DC | Registered: Mar 2004
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