Why Insurance Companies are so Scary!

[Guest guest]

I have been busy researching for the insurance appeal for my son at 's. I

come to find out that apparently less than 25% of the population will ever

appeal or pursue a denial of coverage. Now I can understand that statistic if

it's a few hundred dollars, but apparently people even in my situation where

there is huge financial risk will not pursue a denial because they just don't

know how or what to do. So insurance companies bank on that statistic when they

deny coverage such as in our situation.

So here's the really scary (and unbelievable) part.......Insurance companies use

specific " guidelines " which come in the form of software packages where they

essentially go through a bunch of check boxes to determine coverage. After many

emails back and forth with Blue Cross, one of the senior reps finally sends me

two different documents that were supposedly used as guidelines in my son's

case.

One is titled " other psychiatric disorders " and the other is " ADD and Disruptive

Behavior Disorders. " Okay, so he could fall under the first category, but

absolutely NOT under the second, but here's the clincher.........I find the

website for the company that issues these guidelines and they have 15 " guideline

groups " to choose from, including the above mentioned. Which guideline group did

Blue Cross *not* use as criteria??? " Anxiety Disorders " which specifically

includes OCD in that group. Yes, he has Tourette's, but Tourette's is a common

co-morbid condition of OCD and they are saying that the TS falls under the

" disruptive behaviors " disorder, which is complete BS because I looked it up.

They reviewers at Blue Cross (supposedly psychiatrists) either have very few

brain cells in their heads and/or they purposely avoided using the " Anxiety

Disorders " Guideline Group because they knew it would make my son eligible for

continued coverage. But wait, there's more......

The specific reasons for denial on the letter: " Based on the clinical provided

you did not meet medical necessity criteria for continued treatment at this

level of care based on the following: you were not reported as being an imminent

danger to self or others, you were not reported as being aggressive or

threatening, and there were no reports of psychosis or mania. "

Really?? Well he's been at 's for 2 months and his case is reviewed by Blue

Cross on a weekly basis. In other words, Blue Cross has reviewed his case 8

times before denying it supposedly using the same criteria all along, including

when he was admitted. So according to what they're their " criteria " supposedly

is he never should have been approved for admittance in the first place. I

highly doubt they approved him for admittance and continued approving him 8

times over out of the goodness of their heart!!

Furthermore, being an imminent danger to self or others and being aggressive or

threatening are *inpatient* criteria, NOT residential, and there is a

difference. All I can say is there will be many heads rolling by the time I'm

done with all of this!!