Topic: **Update 9/4/10, outcome of insurance appeal
sammy
Frequent Contributor (5K+ posts)
Member # 13952
posted
**Scroll down a few posts to see the update**
So here's the problem, I received a denial letter from my old insurance company on Sat. I called Anthem today to try to find out what I'm supposed to do next but now I feel more confused and upset.
The problem began last Feb. My doctor recommended that I start IV antibiotics. Tried to get a prior auth, was told it wasn't necessary, IV was covered under my plan. I was on the IV rocephin for 3mo before I learned that Anthem had not paid.
They eventually paid for the first 4wks of IV therapy and denied the other 8wks of claims. My doctor filed an appeal, sent a letter of medical necessity. I began paying out of pocket for the IV rocephin in May.
In Aug I was told that the appeal was partially overturned. Anthem agreed to pay one more week, leaving me with 7wks of unpaid claims ($20,000). I'm not rich, I can't afford to pay that.
Since Aug, Anthem has sent letters to my doctor requesting more information to support medical necessity at least once a month. And every week or two I kept calling Anthem to check on the status of the Appeal. Each time I called I was told repeatedly that it was still in the process of review.
So now you know why I was confused when I received this denial letter on Sat. It did not mention the Appeal but includes claims that were involved in the Appeal and all the claims since then.
I called Anthem again and spoke with another rep today. She told me that my Appeal was closed back in August. That this new letter was sent from medical review "an entirely different department" than the appeals review. Apparently these departments do not talk/share information with each other.
So now I'm supposed to write a level 2 appeal for the one set of claims and a level 1 appeal for the second set of claims. Even though I've been told all along that all my claims for IV rocephin would be reviewed with the appeal claims.
This Anthem rep told me that all my claims were reviewed separately. So my doctor was sending information and it sounds like no one person was getting it. For all I know it was spread around to various reviewers in medical and appeals dept. How could this happen?
I don't know what to do now. I thought about contacting the Ohio dept of insurance but their website clearly states that you must go through the appeal process before they will get involved.
It's not fair that insurance companies are allowed to deny necessary treatment. I'm asking for antibiotics not botox. It's not like I enjoy taking antibiotics, I just want to get well.
Sadly, my new insurance is terrible too. They are denying meds up front. The plan clearly states "no injectables".
So what do you all think, do I need a lawyer? Do you think that one would actually be able to help me? I feel so helpless.
I hate being sick.
[ 09-04-2010, 08:45 PM: Message edited by: sammy ]
Posts: 5237 | From here | Registered: Nov 2007
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posted
Insurance has all kinds of tricks to avoid paying and to wear people down. Doctors will get tired of all the paperwork too.
What may appear to be confusing and lack of communication between departments may be intentional.
Be sure you are keeping a log of all contacts with them. Anthem has a lousy record with lyme.
Have you looked at the Lyme Times insurance appeal information? It has been mentioned a number of times on lymenet, and the url for it has been given. Maybe you will find something useful in here:
The problem with believing ins cos will pay because you and your doctor say it is medically necessary, and the ins co says it isn't required to get advance approval......is that they will let you run up big bills before you find out that, in fact, they will not pay. This has happened to a number of people. In view of that, some have decided not to take the chance, and done it other ways.
[ 01-19-2010, 07:16 PM: Message edited by: lou ]
Posts: 8430 | From Not available | Registered: Oct 2000
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Keebler
Honored Contributor (25K+ posts)
Member # 12673
posted
- Ask people in your closest Lyme Support group about their experiences with insurance carriers in your state.
Much depends on how willing the medical board in your state is to accept that lyme even exists. -
Posts: 48021 | From Tree House | Registered: Jul 2007
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sammy
Frequent Contributor (5K+ posts)
Member # 13952
posted
** UPDATE** Sept 4, 2010
The appeal process has taken 16months. I did hire a lawyer at the beginning of the year.
Unfortunately I received the final determination just a couple days ago. The review was done by an "independent external review organization". Sadly they agreed with my insurer that treatment was "not medically necessary" and upheld the denial.
They sent me a copy of my "Confidential Ohio State Appeal Determination". One of the main conclusions made by the expert review was this:
"There is no objective evidence that the patient has Lyme Disease. The member had both a positive Western Blot IgG and IgM. Usually this pattern would indicate a nonspecific reaction, since by this time in her course there should be only IgG positivity in the Western blot".
Can you believe that? He said I couldn't have Lyme because I tested positive for both IgG and IgM antibodies. How ridiculous! He also said that I had been "significantly over treated for Lyme Disease". There was much more.
After reading that I got to read my reviewer's credentials: Board certified Internal Medicine and Infectious Disease and Geriatrics. Associate Chief of Medicine of a Med School's teaching hospital system. Medical director of a hospital. Chief of Medicine at another hospital. Assistant Professor at a "prestigious medical school on the East Coast". He's also an infectious disease consult for 3 hospitals. One of his listed area's of expertise is "antibiotic control". He's also published regularly in his areas of interest and co-authored a textbook. Has been practicing for 25yrs.
I had no chance with him reviewing my case. He's a self proclaimed expert in "antibiotic control". Sadder still is that he seems to have so much influence.
So, now I'm stuck with a very large bill because I believed that my insurance company would pay for treatments that they said they would. Lesson learned.
I wish that I had payed out of pocket from the very beginning of my IV therapy. It would have saved me an unbelievable amount of time, frustration, tears, and money.
I just wanted to tell my story so that no one else would have to go through what I did.
Thank you all for listening.
Posts: 5237 | From here | Registered: Nov 2007
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posted
Optimistick should take this area up as a second career. Got some real expertise....should be hired instead of a lawyer probably!
I am not clear on who was being appealed to. Was it the insurance company and their supposedly outside independent expert? Or was it thru the state appeals process which usually follows any appeal to the insurance company (when it is turned down by that company).
Posts: 8430 | From Not available | Registered: Oct 2000
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Rumigirl
Frequent Contributor (1K+ posts)
Member # 15091
posted
Was this a Third Level Appeal? There usually are 3 levels of appeals, and you want to go through all 3. the first two are internal, the third external.
Also, file a request for ERISA information, asking for ALL information, criteria, guidelines, etc. used to make this decision. You request this of your insurance company.
PM me or call me---I've been through it all! And, yes, the CALDA insurance issue is invaluable.
Posts: 3792 | From around | Registered: Mar 2008
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littlebit27
Frequent Contributor (1K+ posts)
Member # 24477
posted
Wanted to say I'm sorry. That royally stinks. I don't have insurance so I know how costs get high and quick. Good luck to you, I hope it works out.
And Optimis has got some serious good advice and knowledge it seems!
sammy
Frequent Contributor (5K+ posts)
Member # 13952
posted
I've read my insurance book/certificate cover to cover (yes I'm weird like that). I did this before initiating my IV treatment and again many times as I went through the appeal process.
This was actually my 5th and final appeal.
After my 3rd appeal was denied, I contacted my local congressman, told him my story. He was appalled that I was not being treated properly. He wrote a letter on my behalf and got me another appeal.
When that appeal was denied I got the lawyer to submit my final appeal. He consulted with a couple lawyer friends, gathered and submitted the most up to date medical records along with research supporting my treatment. This last appeal was done by a independent review organization for an "external and impartial opinion". The reviewer agreed with Anthem that treatment beyond 4wks was medically unnecessary.
My lawyer said that there is nothing more that we can do. I've read through the Ohio Dept. of Insurance website but it doesn't look like they would help me. They only mandate that the insurance company offer an independent external review. If the review upholds the denial that the treatment is medical unnecessary or experimental then that decision is final. According to the Ohio Dept. of Insurance website they will not investigate this type of case. They even said that if the review found the treatments necessary then they could only recommend insurance payment. They cannot/will not force the insurer to pay.
OptiMisTick, I wish that I had talked with you earlier in this appeal process. I might have had a better chance.
I've been paying out of pocket for all my IV treatments since May 09. Infuserve submitted all of my receipts to Anthem for reimbursement but they refused to pay for anything this way too.
My new insurance company (UHC since 1/10) denies payment flat out, no appeals available. They did not even consider my doctor's letters, information, and records sent. Apparently, no "Injectables" are covered under this particular plan.
So I don't know what else I can do at this point. The home health infusion company knows that my appeal was denied. They received the same letter that I did. They also sent me a bill.
Last time I talked with the company I explained my situation and asked if they had any type of financial hardship assistance programs. They sent me a form, I filled it out and submitted it a couple months ago (May or June).
Now I have to get brave and call them again. I've not been able to work for over a year now. I have no money. I live with my parents and am at their mercy to provide for all of my needs. I've applied for disability but have not received a decision yet.
I simply don't have the money to pay the bill, not one penny. I wish I did. Then I wouldn't have to worry about it any more. If I had any income I could make payments. But I don't have income.
So I don't know what to do besides call and beg for mercy, pray that they accepted my application for financial hardship assistance and greatly reduce or write off my bill.
Do you all have any advice or thoughts?
Posts: 5237 | From here | Registered: Nov 2007
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posted
I'm REALLY sorry to read this. You must be angry and devastated all at the same time!
That is so ridiculous... and that ID DUCK makes me want to throw up!! What a stupid and evil man he is. He's sold out just so he can make $$$$.
I would bank on this:
"So I don't know what to do besides call and beg for mercy, pray that they accepted my application for financial hardship assistance and greatly reduce or write off my bill."
Can they get blood out of a turnip?
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96239 | From Texas | Registered: Feb 2001
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posted
"There is no objective evidence that the patient has Lyme Disease. The member had both a positive Western Blot IgG and IgM."
Good grief! They denied it because your test was TOO positive????
This whole thing is so surreal.
-------------------- Don't forget to laugh! And when you're going through hell, keep going!
Bitten 5/25/2009 in Perry County, Indiana. Diagnosed by LLMD 12/2/2009. Posts: 756 | From Inside the tunnel | Registered: Jan 2010
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sammy
Frequent Contributor (5K+ posts)
Member # 13952
posted
Thank you all. It feels like I'm stuck in a terrible nightmare.
I just turned 28 and do live at home with my parents. It was (still is) hard for me to lose my independence and to have to admit that could not make it on my own any longer. I've always been such a hard worker, careful with my money. But this disease has taken away my ability to work and completely depleted all of my savings.
So I feel grateful to have parents that care. They not only let me live here, they also pay for my current treatments (including IV meds from Infuserve). It breaks my heart to have to take from them. But my dad told me that he'd rather live in a card board box than to let me go without treatment. I never ask for anything extra, just medicine and food and I'm thankful for that.
I have applied for disability but am waiting on their decision. I realize that because of my age I will probably be denied. The two doctors that examined me were shocked by my condition. The psych doctor said that I did not have any psych problems. His tests confirmed that I have severe cognitive impairments but he said that it might not help my case because the symptoms are from my medical condition not a psych condition. The internal med doctor just looked at me in disbelief (concern and sadness) as he had me summarize my history, current symptoms, and treatments. He said multiple times "you can't work like that". Social Security sent me to those appts because they supposedly didn't have enough proof to qualify me as disabled. I hope that those two doctors will be supportive of my case.
I don't want to think of myself as disabled. My parents, friends, and doctor basically forced me to apply. It made me admit the seriousness of my condition, that I am unable to work and need assistance for basic necessities like medicine.
My parents did talk with a lawyer about the possibility of me filing for bankruptcy but I think that they were advised to have me wait. That this amount from one bill was not enough.
Hopefully I will soon receive disability assistance. Then I could call the infusion company to negotiate cost and monthly payments. Maybe I'll ask my sister to call for me? She is the negotiator of the family. She always gets reduced prices for whatever she wants. So maybe she can help me. Not sure if it is a good idea though.
For now, I have other important things to take care of (PICC line broke last night, have to arrange for it to be pulled and replaced). So that phone call is going to have to wait.
So I'm still open to any other opinions and advise for dealing with this situation.
Posts: 5237 | From here | Registered: Nov 2007
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posted
Sammy.... I really think you have a good chance of qualifying for disability. Those drs sound like they really "get it."
It may still take two tries though.
Admitting that you are that ill IS REALLY hard. I know. It's such a shame that you are so young. But you DO have a good chance to GET WELL!! It's just taking a lot longer than anyone would like for it to.
God Bless you and and God Bless your wonderful parents.
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96239 | From Texas | Registered: Feb 2001
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posted
I just went through this countless submitters doc notes and then denied. Also I called a few attorneys who were also scammers!! Does anyone have a good erisa attorney to referr I've been calling for months!!!
Posts: 17 | From BayareANa | Registered: Sep 2012
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sammy
Frequent Contributor (5K+ posts)
Member # 13952
posted
@@Artemis, you will get the most help if you start your own post. That way everyone can see your questions.
When you post a question at the bottom of an old thread, few people seem to stop by to look and respond to it.
I'm sorry I can't help you with more advice, I didn't have an ERISA attorney. I did have a lawyer to help me with the SSD application process. He proved to be invaluable.
So if you have not found one yet, keep looking, there has got to be a good lawyer close to where you live. They will be a great help to you.
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