Insurance issues

[mlzippy7]

Does anyone have any ideas how to deal with the most impossible insurance company?? I have it through COBRA so I no longer have an HR department that will help me.
The issue is with in network and out of network costs. Does anyone work or know a lot about this?
I called and had a doctor that was listed on this website for IC approved for 6 visits and now the insurance is telling me they never approved anything and I can go to a doctor in plan...I tried explaining I have seen every doctor in the county and the next county..HONEST that is in plan and they can not help me. So I find a guy that wants to handle my complex case and they will not pay. What do I do? I did write down the name, case number, time of call and approval # but they claim it is invalid. I knew I should have gotten something in writing.
Any ideas???
Thanks all.

[kuntrygurl78]

Call back and keep asking for someone at the top of the chain if the person you are talking to wont help you. Just keep asking for the person you are talking to's boss.

Good luck:toilet:

[mlzippy7]

Good idea....I just don't have the energy to keep fighting the insurance but I know I have to. Maybe just maybe this doctor can help turn things around for me. WHO KNOWS but I keep trying!

[ICNDonna]

You might suggest to the insurance company that you will be seeing an attorney. And if they don't change their tune then, then see an attorney. If they gave you an approval claim number, it's hard to see how they can deny coverage.

Warm encouraging hugs,
Donna

[lisabar36]

I thought if you went out of network you just had to pay more but they can't deny you coverage? Just make you pay more for the visit since its out of network. I would ask for higher up or do as Donna suggests, that does not seem fair. :( I had to go out of network for therapy and they really gave me a hard way to go but my doctor ended up calling them and if you have a primary doctor, maybe they can help you also, they can call them directly. Good luck and keep us posted.

[GriffsMommy]

I agree with both Kim and Donna. Don't they always say the sqeaky wheel gets the grease. I work in customer service for insurance actually but I don't do claims and approvals and stuff like that. I have seen that the person who complains and won't stop and goes higher and higher up tends to get things that others wouldn't. I have seen others get exceptions to things that we have to tell people can't be done because they went up high enough and complained enough that the higher up person wanted a happy customer and made an exception to get it. I think Donna's suggestion is also a good one. If you have all of the info documented about the confirmation number and when you talked to them then call an attorney. It may be enough to scare them into getting things fixed for you and if not then you will need the attorney and will have already talked to one. I hope you get it straightened out quickly. Having insurance problems can really be a pain in the butt.

[Berkshire Road]

Right -- a lawyer won't charge you much just to write a letter. Often that's all that's needed. Maybe you know a lawyer, or have one in your family, who could do that for you? If the letter doesn't work, then you really need a lawyer who specializes in employment/insurance/health care law.

I once started getting letters from a collection agency, claiming I owed this chiropractor $400.00, which we would have been hard-put to come up with at the time. I think it was that they were in my HMO at the time I started seeing them, but then they dropped out of that network, but neither the doctor's office or the insurance co. ever told me that. ! I got a friend to write the lawyer's letter, and that was it. Matter closed. Definitely worth trying!

[mlzippy7]

Thanks all for the suggestions! If I do go out of network I have to pay 10,000 before the insurance will then pay 60/40. I don't have that kind of money. I don't have enough to pay the things I have to each month much less that amount.

[sickofmybladder]

I agree that you should ask to speak with a supervisor and keep going up from there - also - they may have a formal appeal process that you could take advantage of (information should be in your benefit handbook) -
Insurance issues can be a huge pain - I am to a second level appeal regarding one of my meds - unfortunately you just have to keep on it.

[lisabar36]

Thats alot of money. I didn't know it was that way :(, I thought it was just a higher copay. Like instead of 25 you pay 50. I am sure all insurances are different. Good luck, I hope you can get it figured out.

[HGC]

I know a fair amount about insurance - was the Dr. you were trying to see in or out of network? If he/she was out of network and you have a $10,000 deductible then it would not be covered until you paid the $10,000 deductible. Once you reach the $10,000 deductible then they will reimburse you 60/40. Since it sounds like you don't have that kind of $ it leads me to believe that the Dr. was in-network. I have found that you have to document everything with insurance companies. I had some gynecological surgery a few years back and I had multiple procedures (I have out of network benefits). The insurance company approved (in writing) all the procedures but when it came to paying they said that they pay x amount for the first procedure and then 50% for each additional procedure. I am the benefits administrator for my company so I read everything from the insurance company and there was nothing that said this. Basically they were telling me that if I had each procedure done separately meaning going under anesthesia 3 times they would pay in full. I took them (they are a well known insurance company) to small claims court and they showed up with an attorney and a claims adjuster and I won! The insurance companies think that people don't read their policies when in fact they do. The arbitrator who decided the case asked them where it said that if you have multiple procedures that they pay at a discounted rate and they couldn't answer him. The arbitrator said people from NY are very savvy and they read everything so if this is the policy then it should be in writing. It was one of my best victories and it wasn't so much about the $ - it was about the insurance company trying to get away with something. I would call the insurance company and ask to speak to a supervisor especially if you have a case #.

[GriffsMommy]

Things are always changing with insurance Lisa. I have a PPO and we can go out of network but then I have an additional $500 deductible I have to pay even if I have met my regular deductible. The out of network deductible applies to everything including dr visits where the normal deductible does not. I think they also pay a lower percentage once you meet the out of network deductible. I will never find out because I will never go out of network. As Zippy said I can barely afford all my medical costs as it is let alone have to pay more for an out of network provider. I was so relieved when my specialist was in my network so that wasn't an issue. I think I would have cried if there were the case. That's one of the other reasons I never went to pain management. There were none in my network in my county and at the time I couldn't afford the gas and time off work to drive 45 minutes or more to go see someone who was in network but farther away. I really hope you can get this straightened out. Having to fight with insurance companies when you're already so sick just takes so much out of you in my opinion.