LymeNet Flash: urgent HMO question

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»	LymeNet Flash » Questions and Discussion » General Support » urgent HMO question

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Topic: urgent HMO question

mik
Member
Member # 7261

posted

I just got off the phone with our insurance company. I didn't tell them that I had to post a question on LymeNet before I could continue our conversation, but that's exactly what I needed to do.

I'm appealing their decision to deny our doctors referal to our llmd. The agent asked me whether I prefer to do an over-the-phone "complaint resolution", or a "written greivance". The phone call is a 20-day waiting period, while the written greivance is 30 days. Which is better? I also want to know what verbage I should and should not use. Our next appointment with the llmd is in about 20 days, so time is of the essance. Any thoughts? Thank you

Posts: 23 | From Prairie du Sac, WI USA | Registered: May 2005 | IP: Logged |

mlkeen
Frequent Contributor (1K+ posts)
Member # 1260

posted

Hi mik-

I can't answer your question. I tried to get my first llmd covered, because he was part of the group but in another state. That was the reason for denial. I was just to sick to fight.

What I did discover was that the lab work and drugs were covered when ordered by the llmd. So paying for the llmd isn't too bad because everything else is covered. I hope your HMO works that way too.

Posts: 1572 | From Pa | Registered: Jun 2001 | IP: Logged |

pq
Frequent Contributor (1K+ posts)
Member # 6886

posted

http://www.hmohardball.com and like-sites.

Posts: 2708 | Registered: Feb 2005 | IP: Logged |

NP40
Frequent Contributor (1K+ posts)
Member # 6711

posted

So you have a referral to an LLMD and they don't wanna' pay ?

First of all, lyme is a clinical diagnosis, testing doesn't matter. How do we know this ? Just follow the link below because the HHS says so. Oh and by the way, they also talk about the seriousness of chronic lyme, so I would think a "Specialist" is in order. Does your insurance company really want to run afoul of the Health & Human Services criteria ?
http://www.hhs.gov/asl/testify/t040129.html

Posts: 1632 | From Northern Wisconsin | Registered: Jan 2005 | IP: Logged |

NP40
Frequent Contributor (1K+ posts)
Member # 6711

posted

http://flash.lymenet.org/ubb/Forum1/HTML/030280.html
http://www.legallawhelp.com/legal_law_channels/insurance_law/

Posts: 1632 | From Northern Wisconsin | Registered: Jan 2005 | IP: Logged |

minoucat
Frequent Contributor (1K+ posts)
Member # 5175

posted

I've never had this option, so I truly don't know what to suggest.

But, every time we've won an appeal or gotten reimbursed for a claim, documentation of all sorts played a huge role.

You might have the best of both worlds if you do the over-the-phone thing, but send them all the documentation you would for a written appeal (as in, all the studies that support your point of view, plus blood work, plus supportive info from the doctor's notes, etc. Overkill is good.), plus a list of talking points. Then, after the discussion, send them a summary of what you talked about and any info to resolve any of the areas they are squirrelly on.

I think the big question is -- what is the appeal process for each of these routes? Is the "complaint resolution" supposed to be more final than the written grievance?

It helps to remember that the intent of the company is usually to screen you OUT of getting care, not to have a reasonable exchange of information and an honest assessment of appropriate treatment. There are exceptions and we've come across a few consciencious, helpful, and honorable claims reps, but we've also encountered astonishing levels of either outright dishonesty or phenonenal determination to disregard every scrap of (the very solid) evidence that we had.

Posts: 2331 | From WA | Registered: Jan 2004 | IP: Logged |

mik
Member
Member # 7261

posted

Hi. In the process of reading all the links you've sent and going to take your advice minoucat, over the phone with follow-up of paperwork to support. I'll let you know how it all turns out. Thanks seems inadequate, but I'll thank you anyway.

Posts: 23 | From Prairie du Sac, WI USA | Registered: May 2005 | IP: Logged |

minoucat
Frequent Contributor (1K+ posts)
Member # 5175

posted

mik, just be sure that the over-the-phone consultation doesn't preclude you from legal follow up later. The "complaint resolution" tag makes me nervous that it might be a final arbitration kind of thing, leaving you with no other recourse after their decision.

Best of luck.

Posts: 2331 | From WA | Registered: Jan 2004 | IP: Logged |

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