Insurance Problems
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  1. #1
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    Default Insurance Problems

    I'm VERY frustrated with our insurance company right now! Alana had a Prometheus test done ($690!) and before we went ahead with it we called the insurance company to make sure it would be covered. They said it would. A few months later we get a bill from Prometheus because the insurance refused to pay saying it was done out of network. We filled out the paperwork for an appeal and included Alana's medical records and a letter from her GI stating why the test was medically necessary. Today I get a letter from the insurance company stating that my appeal was denied because the test could not be deemed medically necessary! WTH?!?

    Is there anything that I can do about this to force the insurance company to pay up? I'm really fed up with them refusing to pay for services just because they can and I feel so helpless in the situation.

  2. #2
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    I am assuming that you don't have a prior authorization in writing or a record of who you spoke to and the date when they told you it would be covered? Can you appeal again? Do you have any leverage in terms of threatening to change companies? Is this an employee insurance company that you could go to the HR department for assistance? Last ditch, I would threaten to get a lawyer.

    Deb ................. DH Norm
    DS Caleb, 13 ...... DS Patrick, 12
    DS Isaiah, 8 ......... DS Thomas, 7

    DD Cherish, 6....... DD Emily, 7\18\13 ....... Ripple, 17
    William, 14 weeks, 4/11/12

  3. #3
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    No, we don't have anything in writing. Alana had a GI appointment at the hospital, she ordered the test, and my husband called the insurance company from work (they won't speak to me because I'm not on the policy....) while we waited to get approval before having the lab done there. The box I was given from the nurse (that the blood was to be mailed out in) was apparently time sensitive so we wanted to do it that day if possible.

    This is actually our second appeal because they conveniently never got the first one...somehow. They told us we could appeal the appeal decision but I don't have any new information to give them so I figure it will get denied again.

    Our insurance is through my husband's employer, but sadly my employer has the same company (BCBS). No way we can find a better company without finding a different job I suppose.

    I love the idea of getting a lawyer but I can't afford to pay for one. If I could I'd just buck up and pay the lab bill.

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    Posting Addict wishing4agirl's Avatar
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    I'm not help. My DH always handles the insurance issues. We had a problem with them not paying for Dakota's therapies when he was little. My DH went to his Union and the Union head honcho took it upon himself to look into it. The insurance company then conveniently started paying. It is so frustrating when they don't pay for things they should be. Hopefully something can get worked out so they pay it.

  5. #5
    Posting Addict CamelNoodle's Avatar
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    I would just appeal it again. I think part of the standard operating procedure is to deny procedures. Many people don't bother to fight.

    I would include the letter from your doctor saying it was medically necessary, a signed statement from your husband saying I spoke to BCBS on date X, approximately time Y, and they said this:
    That would be new information....

    Try try again.
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    We already gave them that information but I will appeal again. Hubby's also going to try HR to see if they can help. I'm too irritated to give up at this point. It just makes me sick that it is standard practice to deny procedures. That test was an important piece of the puzzle for her.

    Speaking of which....she has started having stomach issues again. She has also complained of being dizzy, to the point of having to stop what she is doing and sit down. I'm not sure if she is truly dizzy or possibly lightheaded. Anyone know if that is related to Crohn's disease?

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    My top guesses for the dizziness or lightheadedness would be anemia, low blood pressure, low blood sugar. The doctor could easily check for those. You can test out the blood sugar yourself by giving her a juice box and seeing if the dizziness goes away.

    Deb ................. DH Norm
    DS Caleb, 13 ...... DS Patrick, 12
    DS Isaiah, 8 ......... DS Thomas, 7

    DD Cherish, 6....... DD Emily, 7\18\13 ....... Ripple, 17
    William, 14 weeks, 4/11/12

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    Eating/drinking doesn't seem to help. Nothing seems to help really. If she continues to complain I suppose I'll call the Pedi and see if she'll order some blood tests.

    On a positive note, Madi survived her sleep study! lol She was quite dramatic through the "hooking up" process but the tech was great and very patient with her. I thought she seemed to sleep pretty good that night (don't they always do better when tested? lol) but the tech said she was pretty restless the second half of the night. She hasn't seen Madi have a restless night of sleep! Anyway, we'll get the results in about 2 weeks. I just have a gut feeling that everything will come back within normal limits but we'll see. Aren't some kids just rough sleepers?

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