Insurance Mess!

I was put on bed rest on September 26th for multiple high risk factors. The company I worked for has used Aetna as their health insurance provider for the past 2 years. On 10/25/12 I was asked for my doctor's information (both OB and perinatal specialist) to give to our insurance company for benefit verification. We were switching from Aetna to Humana on 11/01/12 and they wanted to double check that all my benefits would stay the same since I am already 29 weeks. Received a call back from my employer and was told everything was good to go! I had not received a new group or id number by 11/02/12 and had an appointment with my specialist - I went to this - paid my $60.00 copay and just thought the claim would have to be resubmitted when I got my new insurance info. I had 2 more appointments on 11/06/12 - still no group or member ID numbers - I had an ultra sound and blood test done - also saw both my OB and specialist. On 11/08/12 I received a phone call from my doctors office asking for new insurance information because mine was expired - I told them I did not have it yet but would contact my employer and get back with them ASAP. After contacting my employer - I got forwarded an email dated 11/05/12 from the insurance agent saying if any employees had doctors appointments to contact her first before scheduling. I did not know about this - so I hadn't contacted her before. I decided to contact her on 11/09/12 about my next appointment and asking her what to do about prescriptions (I have 3 waiting for pick up but am being charged as if I have no insurance) - she emailed me back and said she put a call into Humana to find out what to do about prescriptions but wanted to let me know that my specialist was considered "out of network" - wow! I am currently seeing my specialist weekly and cannot afford to pay the first $9000 out of pocket - I was livid. Why couldn't they have given me this info on 10/25/12 when I submitted both doctors information to them? I have now seen my specialist twice and accumulated over $2000 in bills that I am now responsible for. I was told I could try a "continuity" form - after speaking with my specialist insurance department - they informed me they do not accept those. On 11/09/12 - I tried all day to get information as to what I could do about my prescriptions - got NOTHING! I am almost out of my meds now and refuse to pay that much out of pocket (I can afford to - but what about the people who can't?). My OB is trying to get me referred out to a new specialist because I have weekly appointments and cannot continue going to the out of network doctor - however, he cannot refer me because I still have no group # or member id! Specialists take weeks to get into. I'm aggravated and cannot see how this is legit? Its going to be 12 days tomorrow that I should have had at least an ID number but still have nothing. Also - when calling Humana (the new insurance company) and giving them my SSN # - they say they do not have me on file - so obviously I do not have coverage yet and they will have to back date it to 11/01/12! Is this right? What can I do to get this taken care of? Are they responsible for anything??

Comments

MissyJ's picture

Submitted by MissyJ on

I'm so sorry that you are going through this! It definitely sounds like a nightmare! I have reached out to some members from our community to see if others may be able to offer advice. While I did have transitioned to a new insurance company (same employer) during a pregnancy, I did not experience any of the issues you are.

I know that you have been in contact with your employer, but do they have a specific HR department that may have a team in place to deal with transitional care? Maybe they can step in and rattle a few cages to #1)Get your new member ID #; #2)cover those previous appointments; and #3)Make certain that you ARE receiving the care and prescriptions needed for you and YOUR baby! Perhaps have them let the new insurance know that they can choose to continue coverage as originally stated or be prepared to cover litigation for endangering your and your baby's health and well-being. (Ok... seriously likely *not* the best approach as you WANT to have a job and coverage -- but given the circumstances, certainly it is tempting!)

Please let us know how things go! If I can help in any way, please contact me at any time at missyj@pregnancy.org.

~Missy

MissyJ's picture

Submitted by MissyJ on

Hi again!

I posted a note requesting help from some of our members that work in the industry. Here is one of the responses:

"Things I can say:

She should do the continuity form for care transition. I have do no idea why the specialist says they don't accept that. It has nothing to with them. It's just Humana stating they will pay this provider in network for X amount of time or X amount of visits.

The fact they do not have her on file may stem back from her employer although most enrollment processes can take 10-14 business days from date it is received from the company.

Prescriptions...pay up front, save receipts, ask pharmacy on refund policy. Most pharmacies will refund 7-10days after fill date if you bring in your insurance info. Otherwise you file straight to the insurance company.

They are not responsible for anything that she hadn't asked herself. Her company may never have forwarded that benefit info for the research they said they did...but I would ask that benefits person why she wasn't told of the out of network situation when she provided the info.

*Information expressed here is my own opinion and does not reflect on positions or opinions of my employer*"

Hope this helps! If you have further questions drop by the thread I launched for you on our "Anything Board."