JillF
Frequent Contributor (1K+ posts)
Member # 5553
posted
I'm just curious if there is anything I can do about this:
I have a HMO health insurance that does not cover out-of-network physicians or blood labs.
As like many of us, our LLMD does not take insurance and is out-of-network.
My health insurance does pay for all my medications, minus the co-pay.
When I started with my first LLMD, I called my insurance company and asked if a referral to the out-of-network physician would be considered for reimbursement. I was told no. Therefore, I never had a referral to see any LLMD.
The LLMD I see now has her patients pay upfront and the LLMD office sends in a claim for the benefit of their patients.
I never expected to see a dime.
My insurance company sent me a remibursement, minus my copay, for one of my appointments and then sent my doctor a decent $200 reimbursement for my inital $500 visit.
My husband never received anything even though he sees our LLMD also, on the same dates.
The LLMD's office told me to call my insurance company and have them re-issue the check to me, since I had already paid my LLMD. I called today and the girl said she would do so and, to expect my check in the mail.
Against my better judgment (my husband thought I should ask), I asked her why I was getting reimbursed and my husband was not.
She said that it was because the LLMD was my primary physician but was not my husband's. I told her that we both had the same primary. She said that it was because I had a referral and my husband didn't. I said, ok, I didn't think I had a referral but I guess I did (I knew I didn't).
She then said that I did not have a referral and I would not get this check re-issued to me. That it had been a mistake.
I asked, if I had had a referral, would I have gotten that check and she said yes. I then asked if I could send in a referral in order to get this re-imbursement and she said yes. She gave me the fax number to fax it to.
I then asked, so as long as I have a referral, I will be reimbursed for all my appointments? She said yes (and, boy, did I get excited).
I said, how can I get reimbursed for a blood lab that is out-of-network. She said just have your primary give you a referral.
I called back about an hour later just to verify what this girl had told me. I asked if a referral would get me reimbursed for all the visits my husband and I have seen this doctor. The new customer service rep said no, referrals don't count when it's an out of network doctor. I told her what the girl before had said to me and she transfered me to a supervisor.
As many of you probably know, the supervisor's aren't the nicest, customer oriented people.
Anyway, she said that I had misunderstood the first girl and I would have only been considered for re-imbursement (a one-time reimbursement) if my primary had sent me to the doctor with a referral thinking that the doctor was in-network and it had been a mistake.
She said that I am aware that I am not allowed to see out-of-network physicians and therefore a referral will not be considered for reimbursement ever. She said a referral will never work for an out-of-network physician or blood lab.
She said I should have never been reimbursed for anything.
I asked what I needed to do to take this further (just curious) and she said there was nothing to take further. She said if the claim could be denied, I could go through the appeal process but that an out-of-network physician is not even considered for re-imbursement, per their policy, and so the appeal process was not available to me.
She said I could have had my physician to call their special authorization line for a one time visit but the fact that they have many good physicians in-network who can see me for my Lyme that there was no reason for me to have to go out-of-network (or something to that extent). (IMPO, I don't think my primary WOULD do that for me anyway).
By now she was extremely ticked at me. When I said that I was seeing an out-of-network doctor because their in-network doctors could not diagnose me for more than three years and, due to the medical community being naive, many with Lyme are in the same boat as me and have to see out-of-network providers, she became furious (she shouldn't have asked what I was seeing the out-of-network physician for and why not a in-network physician). Then told me that she wasn't going to argue with me (I wasn't arguing with her or being rude, I just stated the fact).
First off, I'm worried that the first check they sent me will be expected back now. I never mentioned it but who knows if she noticed it or will go through my file with a fine-tooth comb now.
I'm also worried I may have started something I didn't need to/want to. No idea what kind of repercussions (sp?) there could be but I'm a little worried. Is there any way they can deny the prescriptions my LLMD writes me??? That would = us not getting treatment. No way we could afford to pay for our LLMD and our prescriptions out of pocket.
I'm also ticked. Before all of this, I just didn't care that I wasn't going to get reimbursed. Now, though, I feel that I *should* be reimbursed. I'm paying for health insurance. I'm paying for a service. It's ridiculous that I'm paying more for our monthly LLMD visits than I am paying for my medical insurance - that doesn't even cover our doctor visits! How does that make sense?!?!?!?!?!
Is there any way to fight them when it comes to out-of-network physicians and services??? Is it worth it? Can they cancel your insurance if you try to?
Posts: 1485 | From USA | Registered: Apr 2004
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posted
If I had a dollar for every time an insurance rep gave me the wrong info...
You can call 5 times on the same day and ask the same question. I guarantee that you'll get 5 different answers.
If your policy clearly states that you do not have out-of-network benefits, then they did make a mistake (happened to my husband before) and are not likely to make the same mistake again. You'll get to keep their check though.
When it happened to my husband, we tried to fight it with everything we had. We even requested phone calls transcripts to build our case (were told only some calls are recorded for customer service improvement).
After several pretty stressful months, we decided to let it go. His policy clearly stated that he didn't have out-of-network coverage (although we didn't understand it that way at first and were told over the phone that he would with this specific doctor).
I don't know about you but personally, fighting lost causes stresses me more than paying the bills.
Some will tell you they managed to win insurance battles, and that's true. But if your policy states something on paper, there's little you can do about it.
Good luck with your treatment!
Posts: 159 | From CT, USA | Registered: Jan 2005
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JillF
Frequent Contributor (1K+ posts)
Member # 5553
posted
Is there any way to get them to reimburse something of each visit? That is what I'm wondering about.
I mean, I just don't think it's fair to pay for health insurance when I'm paying alot of money out-of-pocket every single month to see a doctor!
Posts: 1485 | From USA | Registered: Apr 2004
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