Topic: How much information to provide insurance company for claim reimbursement
dbpei
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posted
I went to see a lyme literate neurologist a few months ago, who was recommended by a lyme support group leader. He does not accept insurance but provides you with a diagnosis and receipt so you can submit your own claims.
I purposely enrolled in a new health plan this year that includes out of network provider coverage of 70%. I assumed I would get at least something reimbursed since he is a board certified neurologist.
Well - my claim has been pending for months now and I just learned that the LLMD will NOT submit requested medical records and test results that have been requested by my insurance company. When I called his office, his administrative assistant told me this is his policy.
Do I have any recourse here? I know that I have a right to my records. Would it harm me in any way to request a copy of all of my records from this neurologist and submit myself to my insurance company so I can get at least something reimbursed? My insurance co. suggested I send in an appeal.
This disease is so @#!%$ expensive! I also just got hit with a huge bill from Quest Labs as my insurance co. will not cover the various tests this neurologist took at my last visit because the diagnoses were not acceptable according to my insurance co. These were homocysteine and MTHFR related testing.
What have your experiences been with reimbursement for this type of testing?
Posts: 2386 | From New England | Registered: Aug 2011
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posted
Tell the doctor you want the copies of those tests for your own records. You own them. You can also request the medical records.
Never heard a doctor not give them to you as you own the records and copy of the tests. He may charge you per page.
I would find another neurologist. Any other out of network doctor I have had did not have a problem giving me the records and I submitted them to the insurance company.
My insurance never paid for the homocysteine test and many wont pay or the MTHFR.
Get rid of this doctor, he is a jerk.
-------------------- Faithful
Just sharing my experience, I am not a doctor. Posts: 2682 | From Colorado | Registered: Oct 2009
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dbpei
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I agree Faithful. I am done with him. Thanks for the advice.
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Ellen101
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I never realized the insurance company needs the actual medical records. I'm surprised the diagnosis and receipt don't provide enough info. I frequently go out of network and a receipt with a diagnosis code is usually all they require. If his fees are higher than the norm that may be why they are flagging it. As far as the testing unfortunately there are many tests insurance won't cover and these are probably two of them.
Posts: 1748 | From United States | Registered: Dec 2011
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posted
Do you suppose he did that to protect himself? (not justifying it)
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96222 | From Texas | Registered: Feb 2001
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dbpei
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Yes, Lymetoo. I have thought of that. This doctor lies low in his belief in chronic lyme because of the professional circles he is in... That is my guess, anyhow. But he could at least cooperate by sending the lab results. I am going to do this myself, hoping that will help.
The visit in question is my initial visit, which was very pricey. I am sure the insurance company is questioning the cost of this initial visit, as Ellen suggested. He spent over 2 hours with just me. The irony is that insurance companies hand out a lot more money to traditional doctors who probably see 8 - 10 patients in the same amount of time...
Regardless of this, I am irritated with both this doctor and the insurance company right now! Posts: 2386 | From New England | Registered: Aug 2011
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Keebler
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- "This doctor lies low in his belief in chronic lyme because of the professional circles he is in..." (end quote)
Then he is not a lyme literate neurologist, after all. -
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Ellen101
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quote:Originally posted by Keebler: - "This doctor lies low in his belief in chronic lyme because of the professional circles he is in..." (end quote)
Then he is not a lyme literate neurologist, after all. -
agreed..
Posts: 1748 | From United States | Registered: Dec 2011
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dbpei
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I hear you both and when I wrote that statement, I hesitated because I knew it would get some heat. I am learning that there are many good (and possibly great) lyme doctors out there who are not necessarily those you would find on the ILADS lists.
This doctor was recommended to me as a brilliant neurologist who believes in chronic lyme disease, who specializes in diseases of the nervous system - by the leader of a local lyme support group.
I went to him, not so much for lyme treatment, but for his take on my illness and wondered if perhaps, he might be able to figure out that I was suffering from some other type of systemic illness - because I do not have the typical fatigue and pain that so many have with this illness.
His office was loaded with awards and plaques associated with his compassionate and extensive treatment of lyme disease. He is a far cry from the neurologist I saw during my first year of lyme treatment who blamed my head tremors on nerves...
Unfortunately, he was not able to help me. I think many of us have been through similar experiences when it comes to finding the right doctor. I now regret having wasted my money, but I also know some who regret wasting their money on various ILADS doctors who are well known and respected.
Posts: 2386 | From New England | Registered: Aug 2011
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poppy
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Actually it is the insurance company that is over the line here. They do not need these records and are looking for ways to deny this payment. Don't think I blame the doctor much in this situation. Leaves patients holding the bag unfortunately.
When people have tickborne diseases they sometimes go on wild goose chases, in hopes of finding some other villain that might be easier to treat. Sad to say, chronic can mean chronic when it comes to lyme. Not saying there aren't other avenues to consider, but you have to know when you've done enough searching. And the right doctor may not exist for those who have entrenched disease that requires open ended treatment. Then you need miracles, which are pretty scarce.
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Ellen101
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quote:Originally posted by Ellen101:
quote:Originally posted by poppy: Actually it is the insurance company that is over the line here. They do not need these records and are looking for ways to deny this payment. Don't think I blame the doctor much in this situation. Leaves patients holding the bag unfortunately.
When people have tickborne diseases they sometimes go on wild goose chases, in hopes of finding some other villain that might be easier to treat. Sad to say, chronic can mean chronic when it comes to lyme. Not saying there aren't other avenues to consider, but you have to know when you've done enough searching. And the right doctor may not exist for those who have entrenched disease that requires open ended treatment. Then you need miracles, which are pretty scarce.
I certainly wouldn't call it a wild goose chase. In fact I think to lay back and accept the fact that this may be chronic lyme and not seek out alternative diagnosis/treatments etc would be giving up. Just as there are some with undiagnosed lyme there are also those diagnosed with lyme, that may actually not have it at all, or have lyme along with other ailments.
I do believe unfortunately there is a business in lyme..one in which some can prey on the sick, the desperate, those just seeking to get well. While I can understand the need for protecting those who treat, who protects us???
I think I misunderstood. When Dpei said He believes in chronic lyme but lies low due to his professional circles I was taken aback. Usually those who believe in chronic lyme are advocating for their patients, not lying low. I'm not quite sure how his belief would impact his professional circles. I do agree there are some ILADS doctors that are not so great just as there are some not affiliated with ILADS that are brilliant. Whether one is a member or not does not necessarily matter, what does is that the doctor treating you is open to all possibilities and is providing the best treatment in an effort to accomplish one goal, getting you well...
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beaches
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I'm with you Ellen. I might be willing to sit back and accept such a fate for myself. But kids? No way. I will go to every corner of the earth and sell whatever I have if needed to get them well. I owe that to them as a parent.
I won't give up til they're well and have a reasonable semblance of a normal life. I don't care how many doctors I have to go through to get there. I don't care if I end up bankrupt. I will do whatever it takes to get them to have a better life.
And, yes Lyme is definitely a business where many prey on sick and desperate and broke and broken people. I call them parasites.
And, I too understand the need, given the climate we are currently in, to protect the docs who treat us but I too wonder who is protecting us? Apparently nobody.
We are left to stand up and fight for ourselves and that is exactly what we must do, individually and collaboratively.
We need to write to our legislators and appeal insurance company decisions and bring awareness of this horrid disease to the public to the best of our abilities.
Those are tough things to do when you're sick. But we've just got to fight for ourselves.
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-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96222 | From Texas | Registered: Feb 2001
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beaches
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Technically no, he's not. I hope I am wrong but from what I know he's one of just two neuros in the US who "get" it and the other one apparently sucks.
Hard to believe there's just two choices for neuro docs when it comes to Lyme/cos considering how many suffer from neuro symptoms.
If there are more than two in the country, I'd sure like to know.
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Catgirl
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quote:Originally posted by poppy: Actually it is the insurance company that is over the line here. They do not need these records and are looking for ways to deny this payment. Don't think I blame the doctor much in this situation. Leaves patients holding the bag unfortunately.
When people have tickborne diseases they sometimes go on wild goose chases, in hopes of finding some other villain that might be easier to treat. Sad to say, chronic can mean chronic when it comes to lyme. Not saying there aren't other avenues to consider, but you have to know when you've done enough searching. And the right doctor may not exist for those who have entrenched disease that requires open ended treatment. Then you need miracles, which are pretty scarce.
So true!
-------------------- --Keep an open mind about everything. Also, remember to visit ACTIVISM (we can change things together). Posts: 5418 | From earth | Registered: Mar 2011
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lax mom
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beaches: no one is protecting us. The Lyme Drs, even the famous out in the open ones, leave you to fend for yourself when something bad happens.
I found this out the hard way. When I had e coli in my blood, my LLMD's office was only concerned that I didn't mention Lyme to the hospital.
The same thing happened today. I'm having liver/pulmonary issues and their PA called me to make sure I don't mention Lyme to the specialists I'm going to see.
beaches
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lax, yeah I know. No one protects US! We do indeed have to fend for ourselves when something bad happens.
I am SO sorry to hear of your situation. Really, it's disgraceful on so many levels.
The good news I had today was at a cardio visit. I mentioned Lyme (as I ALWAYS do because I do not believe in denying what is true) and THE DOC used the term "chronic lyme." Granted, we are in an endemic area so this scenario is more likely.
I didn't know whether I should shout "Hallelujah," give him a bear hug or pee my pants.
So I just sat there smug as a bug as if he SHOULD know about Chronic Lyme. And really they ALL should know.
So I think we'll stick with him as the cardio.
But back to you, did you end up telling them that you had LD? IMO you should. The PA's phone call is out of order. I know the practice you are referring to. That is just one reason why we stopped going there.
At some point our docs need to stand up for US, their out-of-pocket, high-paying patients.
For you to have had an e. coli infection in your blood (sepsis?) and the LLMD's office ONLY concern was that there was no mention of LD to hospital personnel? OMG. What a disgrace and what a disservice to a patient.
For a PA to call you specifically to request that you don't mention Lyme Disease as a diagnosis is extremely inappropriate and medically unsound and plain out of bounds IMO.
Hugs to you and hoping you are feeling better soon.
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Ellen101
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Don't mention lyme????Seriously??Your having liver and pulmonary issues and they don't think you should bring up the fact your being treated for lyme? I really hope you don't follow their advice. That could be dangerous to your health! Personally I would find a new LLMD.
Posts: 1748 | From United States | Registered: Dec 2011
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posted
@lax mom, You should tell them your complete medical history as much as you can remember. Any recent abx are going to impact any blood cultures they draw so your hospital physicians will need to know any you've been on recently.
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poppy
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When people post complaints like this against their lyme treating practices, I always look to see when they registered on lymenet, that being a good indication of how educated they are about lyme politics.
You are expected them to protect YOU? No one is protecting them and many of them have paid a price for treating us. It is very naive to assume they can do normal things when they live on a knife edge themselves.
One neuro I saw gave me a furious lecture when I told him I had lyme, and he demanded to know who my doc was.
A lyme doctor I used to see before I moved has been reported twice for treating people like us. Evidently poor ignorant lymed people went for a second opinion to an ID doc, who of course told them they did not have lyme and asked who was treating them.
So, please don't keep expecting the impossible, and work toward getting our doctors protected and the legislators and the public educated.
I have been to a number of specialists over the years, especially the early ones: cardio, neuro, ENT, had various types of scans done. The only doctor that helped me with the symptoms was my lyme doc. The others knew nothing about lyme and could not (would not) have helped me even if I had explained the underlying cause.
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lax mom
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poppy: my date of registration on Lymenet is not an indication of my knowledge of the political environment surrounding Lyme.
dbpei
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I cleaned up my mailbox, laxmom. Thanks.
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Ellen101
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I totally disagree. I may not have been on lymenet as long as you Poppy, but that doesn't mean that I am not fully aware of the politics involved. The thing is when it comes down to it to purposefully withhold information in regards to meds, treatments etc could be dangerous to ones health. That has to be a top priority. To expect someone to seek treatment in a hospital or otherwise and not disclose medications they are taking is just plain ignorant.
I'm tired of hearing about how much we need to protect them. For petes sake you have some advetising their services on web sites, webinars,books they've published etc..not quite in hiding.. Yes, there are some great LLMD's, but lets be honest there are some money hungry ones as well..Lyme has become a business for some and a very lucrative one at that. I'm totally fed up with the means that some will go to protect their docs.
Any ethical physician that truly cares about their patients would never tell you to withhold information.
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poppy
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You're sick of being told to protect doctors, and I am sick of losing them or having them afraid to treat aggressively. For those reasons I have had to travel to 8 different states to get treated in ten plus years.
I think it is hard on the current and future patients of doctors who are endangered by patients giving out information that is not needed.
If it is really needed, then of course do it. Most of the time it is not needed.
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lax mom
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Ellen: I agree.
poppy: In my cases, the info needs to be given. If a patient has a life threatening infection and their immune system is too weak to fight, and the hospital cannot figure out why...the info is needed.
If the patient has an enlarged liver and spleen and wheezing for no reason, yet that same patient was at one time on 53 diff meds/supps including IM Bicilln, then that info is needed. Lyme and co can cause these problems AND the treatment can cause these problems.
My liver, spleen and breathing were all fine pre-Lyme treatment. Either the treatment caused damage or the treatment stirred up pathogens that are causing damage.
Either way, it's disgusting to think I need to go to Gastro and Pulm Drs and play dumb like "I don't know what's going on. I was fine until these symptoms started." That's a recipe for disaster.
This Lyme Dr is WAY out in the open.
I would never give his name/address...but I have the right to disclose my own personal health/treatment history in cases I feel are warranted.
However, I realized that when it comes down to it, no one is there for us.
beaches
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Poppy, please do not assume a member's registration date is an indication of one's knowledge of either the disease itself or the politics involved.
I agree with Ellen's assessment. Yes, there are docs who have been investigated, and they will continue to be investigated. But that IMO is due to insurance companies not wanting to pay claims, thus initiating complaints against the docs.
Please do not blame sick and desperate patients looking for answers and help. It is plain wrong for a patient to show up in an ER with dire symptoms and not be expected to be forthcoming about his/her diagnoses and treatments. And it is unethical for ANY medical professional to advise a patient to do so.
And from what I've experienced, many docs are living a good life and making damn good money at what they do (with the exception of the great Dr. J.) Many sell supplements, books and other things like acupuncture, hyperbaric, ondamed. I suspect for some this is quite a profitable endeavor.
And yet, as a patient paying thousands out of pocket each year, I have the responsibility of protecting a doc like this if I am in an emergency situation? Don't think so. I deserve intervention/communication from a doctor if I end up in a crisis in the ER, Lyme Disease or not. They ALL took the Hippocratic oath, did they not?
Granted, they are in a kitchen with a lot of heat, and a good many of them are being very-well compensated for doing so and would not stay in that kitchen if the money wasn't good enough to tolerate the fire.
There are many others, who, out of the goodness of their hearts, have dedicated themselves to their sick patients, who charge reasonable fees, who will intervene in emergency/critical situations. God bless them.
Poppy, I do understand your point of view. Yes, we have lost doctors, and yes, far too many of us have to travel unbelievable distances for treatment. This is just part of the bigger picture that is the Lyme Disease debacle. There should never have even been a need for us to be having these types of discussions.
My overall opinion is that we need to be open and honest about this disease. We need to fight our insurance companies. We need to write our legislators. We need to take every opportunity we can to educate whomever, however, whenever, wherever. This is a tall order for sick people I've found that the sicker you are, the stronger you have to be.
We need to learn a lesson or two from the AIDS/HIV movement from back in the day. We need to be proud and loud to effect change.
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lax mom
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beaches
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Thanks lax. I hope you are doing better tonight.
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Rumigirl
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This particular doc, because of where he teaches, clearly has to watch how much he dx's & tx's Lyme & co. I'm certainly not defending his actions, just explaining.
I go to this dr. I have found that insurance is now not paying for my visits there, the same as to my LLMD, even though we pay for out of network coverage. They are black-balling these drs (well us for going to them).
He has gotten MUCH more on the IDSA side, due to the pressure. Again, I'm not defending it, but this is what appears to be happening.
The situation re LLMD's & the state medical boards, etc. is atrocious now. We have a lot of work ahead of us to change it.
This doc can be very helpful re neurologic a issues, however. I wouldn't throw the baby out with the bath water, if I were you. Don't know what happened to you there though.
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