So, a lot happened today. I finally got through to my PCP about what is going on with my treatments and the dressing changes and flushes for this cath. Great news! The letter that I put together and the packet of information worked. The pathologist (who previously felt I did not need any more PLEX) has decided that he now agrees, after looking over all of my data, that it is a good choice and that he is on board with the plan of getting a treatment every two weeks. Yay! That battle is now over.
How did I get him to agree? Honestly, it was a struggle. After fighting over and over to get them to listen to me I went to the Guthy Jackson Charitable Foundation site and downloaded all of their information on NMO. I then put together a list of peer reviewed journal articles on NMO and PLEX and the usefulness of PLEX as a treatment. I then added the information on the clinical trial MAYO is doing and that was my packet. I then drafted a three page letter explaining why I felt I needed the PLEX and it’s use.
And all of my hard work paid off! He agreed. He had been adamantly refusing to give me the treatments and now he is going to give them to me.
But …. The evil insurance greed monster stepped in to ruin my excitement. They don’t want to cover the cost of the treatment so .. we are back to square one fighting with the insurance company. Talk about evil corrupt corporations.
So I did a little research and wanted to share what I found with my followers on here as to what you can do it your insurance denies you treatment.
So I found this useful document that I wanted to share with all of you:
I hope that it will help some of you … me too!
Identify why your claim was denied.There are many reasons insurance companies can deny a claim. The first step is to find out why your claim was denied. Call your doctor, insurance company or hospital as soon as you receive your Statement of Benefits to find out why your claim was denied. Here are some of the common reasons for denial:
- Incomplete or inaccurate insurance information
- Lack of pre-certification or prior authorization
- Non capture of tests or procedures
- Diagnosis and procedure coding errors and omissions
- Past timely filing limits
- Insufficient medical necessity
- Co-Pay, Deductible, Patient Portion amounts
Keep in mind that many denials are recoverable given the proper tools. AARP reports about half of denials that were independently denied were appealed successfully.
You are not the first, and you will not be the last person to have a treatment claim rejected by an insurance company. As long as you’re calm and organized, you should be able to find a way to alleviate, if not resolve your situation.
- Enlist the support of advocates. Doctors, hospitals and even health insurance companies can help to reverse your denial. Many hospitals employ social workers who assist patients in dealing with healthcare insurance companies, or obtaining Medicare and Medicaid benefits for those who qualify. These social workers operate as proxies, to qualify patients for benefits that pay for hospital bills. They are employed by the hospital to help patients capture any and all benefits that may be used to pay their bills. Often they are linked with the charity care department of the hospital, because if patients cannot acquire insurance reimbursement, they may become eligible for charity care to help pay bills. If this resource is available, you will want to introduce yourself and explain your case. You should be polite and engaging. Help them understand the validity of your claim. You will want them in your corner to direct you in submitting the correct paperwork.
While you’re recruiting your forces, get your doctors onboard as well; they will need to plead your case directly to your insurance company. If your claim was denied due to incomplete or inaccurate information, your doctor may simply need to clarify or correct the claim submission. But, if your claim was denied because of insufficient medical necessity or lack of prior authorization, your doctor may need to write a letter of medical necessity. Such a letter specifies your diagnosis, recommended treatment, and the length of treatment time. Essentially, it lets your insurer know exactly how necessary this denied treatment is for your condition. Templates and examples of letters of medical necessity are available online so that you can familiarize yourself with this type of document.
Apply, reapply, re-reapply. It might not make sense to most of us, but insurance companies are trying to spread risk and keep as much money in their organization for as long as possible as they “adjudicate a claim.” Eventually, they have to pay up and add their payment to you, as their loss on their balance sheet. They use auditing software, often called “claim review programs” to sift through millions of submitted claims. Others have dubbed this software “denial engines” because their intent is to lower the amount of money paid to physicians and hospitals. These auditing programs work by finding technical errors in billing codes that all doctors, hospitals and clinics, among others, submit for payment. The programs use data-mining technology and can even be tuned to capture a predetermined percentage of financial return. The program’s algorithms vary by insurer, therefore the odds of denial or approval are not exact. Shown below are examples compiled by the American Medical Association, showing the difference between denial metrics of companies like Aetna AET -0.26%, Cigna CI +0.04%, Humana HUM +1.3%, UnitedHealth Group UNH +0.19% and more.
So it all comes down to getting this all sorted and then I can get in and get going. As for flushing and changing of the port …. On Monday I am to call Interventional Radiology and get an apt. set up to get it checked out…. What fun. Another one hour drive just to get the tubes and what not cleaned!
So tonight I am just relaxing with Cali and Lassie .. and enjoying the new transformers movie 😀 new favorite I think.