posted
Not sure if this should be in medical or general, but because I am asking about medical insurance, figure I would put it here.
I was so excited to finally figure out what my daughter's illness was. Great, a cure! Put her on antibiotics for a long time, eat healthy, and since she is young and active, she will eventually get well. Not easy, but doable.
I thought my insurance company would reimburse me for the expenisve testing and LLND visits. I knew it was going to be expensive, but thought at least I would get some help from my insurance company... Then I watched Under Our Skin, spent hours on the internet and read several books. All the while I was still hopeful that the insurance would pay for a portion of the treatment.
Well my insurance won't pay for the LLND visits. They haven't denied the claims, but closed them and requested the chart notes. They won't pay for the Igenix labs either. Our intial outlay was $1800 (2 LLND visits and Igenix Labs). They haven't reimbursed us.
Then we went for a 2nd opinion. The new LLND wanted to run a bunch more tests which cost me $1900, the visit and supplements over $800. The LLMD psychiatrist was $450+.
In the last 3 months my out of pocket expenses have been well over $6K. I am almost maxed out on credit cards, and my savings is gone. I am afraid that I will choose to treat my daughter rather than make my house payment, and will eventually end up losing my home.
The insurance has paid for the abx which have a cash cost of more than $2500 per month. The Lyme came back +, but the co-infections-. I really need to have my insurance continue to pay for the abx, but I also need them to pay for at least some of the LLND expenses. I am hoping that these next labs will actually show up something + for co-infections becasue then I think they will pay for ongoing abx.
When I called the insurance company to ask about the need for chart notes etc... They said they needed them before they could evaluate the claims for the labs and doctor visit to make sure that they were medically necessary. I am afraid that once they find out that she has Lyme, and that she has only a 'clinical diagnosis' for the co-infections that they will only pay for 30 days of abx.
They suggested that I sign up for their case management services after I explained that there are no in network specialists for my daughter's condition. They said with these services that the case manager would make sure that our labs and visits were approved and that the claims would be paid.
If that really happened, that would be awesome. My child has been sick for so many years, and just recently diagnosed that she will be in treatment for years most likely.
It just doesn't seem right to me and it so unfair. How is that in this country that only the rich can afford treatment? I work hard, have what I thought good insurance. I can't afford to pay for my child's treatment out of pocket. If I don't get help for the LLND visits and the labs, but they continue to pay for the abx, I may be able to afford a few more months treatment, but that's it.
If they quit paying for abx, we're done with treatment, and my child will eventually die from Lyme and Co.
We don't live on the east coast, we're on the other side of the country. In my state there are only a few cases of Lyme reported each year, so it's not a political issue where I could get help form my elected officials. I can't afford an attorny and I don't know what to do.
I can't get a 2nd job to help pay for expenses becasue my famiy needs me at home after work.
Help please!
Posts: 333 | From Lyme Here Too | Registered: Mar 2010
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There is a lot that can be done. Doesn't look like you have even gotten to the appeal process yet regarding insurance claims.
It would help if you told us who the insurance company is.
Hubby has lots of experience in fighting insurance claims. At one time he was filing so many out of network claims that his insurance company gave him his own personal insurance claims processor to handle all of his claims. This worked out very well for him.
It does not matter whether you have positive test results or not regarding oral antibiotics -- the big difference is if you are dealing with IV antibiotics. Most insurance companies will just process whatever prescriptions are filed without any reviews.
Unfortunately if you are dealing with IV antibiotics then the 30 day "rule" will come into play. Again it depends a lot on what state and what insurance company you are dealing with as to what you can get them to pay.
As to the LLND appointments -- the insurance company should pay whatever percentage (usually 70 or 80 %) of whatever they consider reasonable and allowable per appointment.
For example hubby's LLMD charges $200 per follow-up appointment -- insurance allows $167 and pays 70% of that or $116-- after out of network deductibles are met. For a new patient appointment the allowance would be considerably higher because it is a different CPT code.
Hubby just learned recently that the diagnosis code of babesia actually is paid as if it is an in network claim because Anthem BCBS now considers that a life-threatening infection. Don't know if any other insurance companies do this or not.
Actually it doesn't matter that your daughter has a tick borne diagnosis -- legislators etc should help if all other resources have been exhausted.
Most states have some sort of claims arbitration that would be the 2nd step after you go through the appeals process.
But the claim has to be actually denied before the appeals process can begin.
If it was me -- I would first talk to whoever handles the insurance claims in your docs office. Ask them to give you a copy of whatever they sent to the insurance company when the insurance company asked for the chart or whatever. If the doc's office has not done this -- then I would call them about once a week to request that they respond to the insurance company.
As for the phrase -- medical necessity -- that is just standard insurance company language. Nothing to get overly worried about.
I noticed that you said you bought some supplements from one of the docs -- unfortunately that will not be covered. Only prescriptions such as B-12 etc -- but not just regular supplements.
If the worst happens and the insurance company won't pay for antibiotics then there are programs from many of the drug companies that will give you free or greatly reduced price antibiotics based on income. But that belongs in another post.
My guess is that the insurance company is dragging their feet simpl;y because you submitted a lot of claims in a short period of time.
As for the IGeneX claims -- most out of network labs usually end up being paid at 50 % or less of the actual cost of the lab.
Bea Seibert
Posts: 7306 | From Martinsville,VA,USA | Registered: Oct 2004
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posted
Thanks Bea. I appreciate your thorough response. We live in WA state and have Uniform Medical, which is for state employees.
So they should keep filling the orals? Only when/if she needs to go IV is when the 30 day rule will kick in?
What do you think about the case mgr through the insurance? I am thinking that it may be the way to go based on your feedback.
Sounds like I need to bug the first LLND for the chart notes, and then ask the 2nd to send them as well. Right now I have over $5k in labs and LLND visits that if I could get some reimbursement from, it would help.
Thanks again for everything!
Posts: 333 | From Lyme Here Too | Registered: Mar 2010
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posted
It depends on what the rules are with your insurance. They are all different. Read your contract first. See if it is like an HMO, in which only in-network medical providers will be paid. Or is it like a preferred provider company, which will pay out of network providers at a lower rate, and typically the patient has to pay upfront and then file a claim for reimbursement with the ins. co.
Medical necessity is a sort of catch all term for the ins. co. to use as a way of not paying.
As Bea said, appeals can be filed after a denial has been issued. But it sounds like they have not denied it yet. Being asked for chart notes is not a good sign. If there was a diagnosis code on your claim, they already know she has tickborne diseases.
Is there anyone in the human resources dept. of your state agency that can help you with this? Might be worth checking into it.
Posts: 8430 | From Not available | Registered: Oct 2000
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posted
Bea you mentioned that drug componies may give you reduced prices on ABX. Where can this information be found. I started a thread inquiring about what to do after the insurers cut off IV after 30 days but didn't get any replies. Does this include IV drugs or just orals. I'm in the same boat as Lyme Mom and am afraid that I will not have the resources to continue the fight if IV bills are thousands per month.
-------------------- Neuro symptoms since 1995. Dx'd Bart in 10-09. Biaxin/Tindamax 10-10 thru 2-11 Factive 3-11 thru 5-11 Factive/ Rifampin 9-11 thru 11-11 IV Rocephin/ Tindamaz. 11-11 thru 1-12/ IV Rocephin/ Flagyl / Factive 1-12 thru present Posts: 69 | From Florida | Registered: Dec 2009
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