Fun with the Insurance People

[Philip B]

One of the nurses at my cardio docs office and I started down that path many of you have probably traversed this week. The doc wants me to go on a home monitoring machine and believes that my insurance company should pay for it; I tend to agree with him.

Unfortunately, my insurance company defines home testing units for those of us who are on coumadin as a convience item. What a bunch of crap!

When the insurance company rep called me today I asked her if they regarded the monitoring machines diabetics us as a medical necessity or as a convience item. She responded that those kinds of machines are defined as a medical necessity. The rep really didn't want to discuss the fact that there is little difference in a cleint who is faced with using insulin or coumadin for the remainder of his/her life. I got the typical, "I'm only telling you what my supervisor said," line. Needless to say, the supervisor was too busy to talk to me.

The nurse I've been working with told me this is a standard practice with big insurance companies. The insurance people would rather pay the $90-95.00 it costs for me to use our local hospital's lab every seven to ten days than spend the money on a home testing unit. How cost effective is that?

I guess we'll try to scrape together the money to buy one ourselves.

What a bunch of creeps!

-Philip

 

[Kathleen]

Keep trying with the insurance company. You can file an appeal. I found that when I called the insurance company and had them explain the coverage for durable medical equipment an INR machine qualified. The insurance company told me what to do if I was turned down and that was appealing. There are ways around them and if you work with the supplying company they have some insight to the different insurance company policies. Keep trying, don't take no for an answer for something you are entitled to.
Kathleen

 

[geebee]

Please talk to QAS and get the forms. There is one for your doctor to fill out indicating the medical necessity. There are a couple of things that tend to make insurance companies agree to cover it. If your doctor indicates that you need to test weekly (and remind him that if dosage changes take place, weekly testing is necessary). Also, if you indicate you travel regularly and access to a lab is difficult, that helps. You already have a mechanical valve which is the third biggie.

Please don't give up yet - you just need to know the right things for the form.

 

[Philip B]

Two Techs & Six Sticks

Two Techs & Six Sticks

My cardio doc's staff was working on the QAS paperwork today. The nurse who's been coaching me from the time I learned I needed fairly immediate surgery through my recovery and rehab stuff has significant experience with the paperwork and insurance companies. Unfortunately, according to her, my insurance company is one of the most difficult she's had the misfortune to have to deal with. Despite numerous efforts to appeal the company's decision, she's never seen a successful appeal. In fact, she's never received a response to an appeal from my insurance company.

None of this stuff with the denial of the claim makes sense to any of the medical people I've been working with. The ability to do frequent checks and make needed adjustments reduces the financial risk for the insurance company.

I live in a rural mountain community where access to reasonable, affordable health care services is difficult to come by. Depending upon which lab tech I happen to get to draw blood, it typically takes them two to six sticks before they get it right. This is no joke, during the last four weeks since surgery, I had one visit where it took two techs five sticks to get the sample they needed and during another visit it took two techs six sticks to get the sample. The thought of walking into that lab every week is really depressing, but I'll be there again on Friday morning. At some point, I'm going to ask the hospital administrator what kind of qualifications they require when they recruit lab techs.

According to the nurse and the QAS folks, our best bet for an appeal may be to go ahead and get the machine, submit the receipt, prescription, letter of medical necessity, and request reimbursement. We'll give it a try.

-Philip

 

[Ross]

What amazes me even more is that they sure want their premium payments, but they never want to pay anything out. I absolutely hate insurance companies.

 

[catwoman]

Philip:

If I were to visit my PCP's office every week for an INR test, I'd be in the hole for sick time.

My PCP's office hours are 8 a.m. to 4 p.m. My work hours are 8 a.m. to 4 p.m.

His office is about 2 miles south of my office building. I estimate that with travel time, I'd be taking 1 hour off each week X 48 weeks (after 4 weeks vacation). That would be 6 days' sick time. I only get 5 days' sick leave a year. Any unused time/hours carry over to the next year, but only up to 5 days.

Darned glad I have my own INR machine!!!!!!

 

[Rich]

I still go to the hospital lab every month for the old stick in the arm.
It's been close to eleven years and no problem at all.
I am fortunate that the hospital is only about fifteen minutes from home. And they have a special outpatient lab just for people like us, so we don't have to wait for forty people in front of us at the main lab.
The reason I am mentioning this is for older folks on Medicare. If you have it done like I do it is 100% paid for regardless if you go once every week or once a month.
My next door neighbor goes to his pcp's office(ironically at the same hospital I go to), his doctor uses a home testing machine in his office amd charges him $45 a visit, when my neighbor could have it done for nothing.
So if you don't live far away and are on Medicare this might help.

Rich