Update: Insurance Woes

[Guest guest]

I've gone in circles trying to straighten out our insurance issues.

Isabella's last cast was not fully paid because of a new billing

code LLUMC is using. However, it does appear that our responsibility

($6850.00) has been absorbed by LLUMC. At least that is what I've

been told, but I am not holding my breath on it. I never did receive

word of the procedure being denied. I think LLUMC dropped the ball

on that one and maybe that is why they are absorbing our share. I

really don't know. I can't seem to get the same answer twice.

Everyone tells me something slightly different. I am just going to

have to let this issue go.

On to the next issue:

Blue Shield HMO has been very helpful and so has our doctor and his

assistant, but I am very unhappy with the authorization requestor.

Isabella's next cast is set for October 24th. My husband received a

call from this person on September 22th informing us that Isabella's

next casting had been denied. She stated an appeal had been

submitted and that we would receive a call sometime the week of

October 6th. That was is, so matter of factly with no other

information. I ended up calling her on September 24th to ask more

questions. Of course, I got no where with her and I ended up in

tears. So bad, that I had to go home as I could not perform my job

duties here at work. I was a mess. Esentially I was told that I just

had to wait until the week of October 6th to find out if she would

or wouldn't be casted on October 24th. I couldn't get any answers on

what the next step would be if the appeal was denied. I did mention

their charity program and was about ot ask for their extension when

she cut me off and told me that we would have ot be 300% below

poverty level and essentially destitute in order to qualify, but

that I could apply if I wanted. Now this person works on

authorizations, but she was clearly taking on another job. I was

left with a feeling of hopelessness. Her casts are billed at $20,000

each. There is no way we can afford $20,000 every 4 months! I would

be destitute after one cast! Even though that door was slammed shut

on me, I did call our doctor's assistant in hopes she could help. I

had to explain to her that I cannot wait until October 6th to find

out if we will get a cast or not. I needed to be proactive and have

a plan B. I told her that our only other option would be to go to

SLC. I was shocked at how little she knows about our casting issues,

given she works directly with our doctor. I told her that we could

not go without a cast and that it could possibly take time to get in

to SLC. I told her that if I just patiently waited until October 6th

to do anything, Isabella could possibly end up waiting until

December or even longer for a cast. I had mentioned that I was going

to request her medical records so I could work on getting her an

appointment in SLC just in case the appeal was denied. She tried to

discourage me, but once she realized the time sensitivity of our

medical problems, she realized it would be best to end up with two

appointment dates (SLC & LLUMC) rather than none. At one point she

finally said, the doctor is not going to just leave you, LLUMC will

not close the doors on you. I began to cry and told her that that

was all I needed to hear. Up until that point everyone I spoke to

made no mention as to what our fate would be if the appeal was

denied. I really felt that if Blue Shield denied the appeal, LLUMC

would just kick us out and shut the door. At least, the

authorization person made it sound that way.

The doctor was consulted and an attempt to contact Blue Shield was

made. As I drove home, I received a call from his assistant letting

me know that Isabella's cast would be authorized. Now I can't hold

my breath on it either, until I get an authorization number, but it

appears it is going to work out. I am still going to request her

medical records and contact SLC just in case it all falls apart at

LLUMC. I cannot trust anyone and this point and the only thing I can

do is be proactive and ensure my daughter gets a new cast one way or

the other, whether it be at LLUMC or SLC.

Here is the entire cause of my living hell: LLUMC is now

billing/coding for manipulation of the spine under anesthesia. Blue

Shield views this code as chiropractic and experimental without

scientific proof that it works. They never billed for this on

Isabella's first 5 casts, but I think they are billing this now

because we have the new AMIL frame. She was the first child (in

June) to be casted using the new table. Our billing problems started

in June. Who knows.

The biggest mystery of all to me is that the authorization person

and the doctor's assistant both told me that they are now billing

for this procedure, using this code, because the doctor has never

manipulated Isabella's spine until now. Can that really be true???

Are they qualified to tell me this? As far as I know, Isabella has

been placed in traction for every casting and her spine has been

manipulated at each one. How could it not, we see an improvement in

every in cast x-ray done right after casting. I am so confused and

so frustrated. I hope someone can chime in and tell me about this. I

hope to have a long chat with the doctor if we do get casted with

him. I definitely hope the authorization does pan out, as I've been

told, so Isabella's case can set precedence for the other two

families at LLUMC in this same situation.

I will continue to fight and try to get the best care for our

children at LLUMC, but I will have to work on SLC as a plan B.

Isabella needs a cast soon no matter what anyone says.

I'm sorry if I post is too long or too hard to follow, but that has

been my life for the past month or so. I am going to formally

complain to LLUMC about the way this entire matter has been handled.

I think it's time for me to educate more people at LLUMC our plight

for our children. No one I spoke to knew he is the ONLY doctor is CA

to do this type of procedure. Ignorance is bliss for some isn't it???

Olivia