Guest guest Posted April 16, 2008 Report Share Posted April 16, 2008 Insurance companies are a PITA. If this is the first denial, I would contact them and have them review it. They have to have someone else in their system review it. You can continue to contest it for several times. Sometimes it works out to your benefit and sometimes not. It all depends on the person reviewing your claim. I had a pet scan rather than an invasive biopsy and my insurance paid everything but the radiologist. How dumb is that? So don't give up yet. Sometimes you have to fight them. I know it's annoying on top of everything else you are going through but it's usually worth it to fight them. I wish you the best. HUGZ, PeggyH > > Hi All, > I was just wondering if anyone's insurance had ever denied a referral > to the Rhuematologist? I have never had trouble in the past, with other > insurance companies, and have always seen a Rheumatologist. Aetna > however not only sat on it for 3 months, but then denied it saying that > my PCP can handle my condition (even though he admitted to me that he > couldn't).I am wondering if it is my Dr.'s fault or if it is just > my 'medical group'. My husband went in with a 'tummy ache' and they > reffered him to a GI specialist and he got approved almost over night. > We have the same insurance, just different Doctors. Should I ditch my > Dr. or is this common? > It really sucks going untreated for so long. I havn't been working and > don't think I can, until I get this under control. > Uggg! > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 16, 2008 Report Share Posted April 16, 2008 I haven't had an issue with this specialty specifically, but I do know that some insurance companies have an unwritten policy to deny all first requests for certain specialties/procedures. It's a " cost-saving " measure, since only a percentage of those denied will then actually appeal. Many people don't realize they have that option and simply accept " No. " As long as you can present a legitimate case, they'll approve it upon appeal. They just don't want to pay for it unless you fight for it. *sigh* I would definitely appeal. And whatever you do, make sure that you're documenting everything! Every conversation you have with the insurance company especially, write down the date, the time, the name of anyone you spoke with, and then take a couple of minutes immediately afterwards to summarize the conversation. Spoke with Jane Doe, requested abc, was told xyz, referred to . After a while, it can be difficult to remember those little details and exactly what the process has involved. If you can instantly refer to your notes and tell someone that you already spoke with so-and-so or submitted that form on such-and-such a date, it may save you a lot of time and energy! And they'll recognize that you're informed and taking this seriously so they'll be less likely to jerk you around. Good luck, let us know what you decide! Love, Judy [ ] Referral Denied! Hi All, I was just wondering if anyone's insurance had ever denied a referral to the Rhuematologist? I have never had trouble in the past, with other insurance companies, and have always seen a Rheumatologist. Aetna however not only sat on it for 3 months, but then denied it saying that my PCP can handle my condition (even though he admitted to me that he couldn't).I am wondering if it is my Dr.'s fault or if it is just my 'medical group'. My husband went in with a 'tummy ache' and they reffered him to a GI specialist and he got approved almost over night. We have the same insurance, just different Doctors. Should I ditch my Dr. or is this common? It really sucks going untreated for so long. I havn't been working and don't think I can, until I get this under control. Uggg! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 17, 2008 Report Share Posted April 17, 2008 i agree with this , by all means appeal the decision, some states like new york also allow for appeals to a state board if you are shot down a second time. there is just no way thaty a regular doctor can trat you for arthritis , especially in the beginning when you dont even know what drugs will be effective for you J Acciarito <jacyone@...> wrote: I haven't had an issue with this specialty specifically, but I do know that some insurance companies have an unwritten policy to deny all first requests for certain specialties/procedures. It's a " cost-saving " measure, since only a percentage of those denied will then actually appeal. Many people don't realize they have that option and simply accept " No. " As long as you can present a legitimate case, they'll approve it upon appeal. They just don't want to pay for it unless you fight for it. *sigh* I would definitely appeal. And whatever you do, make sure that you're documenting everything! Every conversation you have with the insurance company especially, write down the date, the time, the name of anyone you spoke with, and then take a couple of minutes immediately afterwards to summarize the conversation. Spoke with Jane Doe, requested abc, was told xyz, referred to . After a while, it can be difficult to remember those little details and exactly what the process has involved. If you can instantly refer to your notes and tell someone that you already spoke with so-and-so or submitted that form on such-and-such a date, it may save you a lot of time and energy! And they'll recognize that you're informed and taking this seriously so they'll be less likely to jerk you around. Good luck, let us know what you decide! Love, Judy [ ] Referral Denied! Hi All, I was just wondering if anyone's insurance had ever denied a referral to the Rhuematologist? I have never had trouble in the past, with other insurance companies, and have always seen a Rheumatologist. Aetna however not only sat on it for 3 months, but then denied it saying that my PCP can handle my condition (even though he admitted to me that he couldn't).I am wondering if it is my Dr.'s fault or if it is just my 'medical group'. My husband went in with a 'tummy ache' and they reffered him to a GI specialist and he got approved almost over night. We have the same insurance, just different Doctors. Should I ditch my Dr. or is this common? It really sucks going untreated for so long. I havn't been working and don't think I can, until I get this under control. Uggg! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 17, 2008 Report Share Posted April 17, 2008 ps i have Aetna and i am in new york . i have never been denied for treratment by a rheumatologist and i have also had 2 hips replaced and a knee , all under aetna with out much of a hassle at all laurenrosepeters <laurenrosepeters@...> wrote: Hi All, I was just wondering if anyone's insurance had ever denied a referral to the Rhuematologist? I have never had trouble in the past, with other insurance companies, and have always seen a Rheumatologist. Aetna however not only sat on it for 3 months, but then denied it saying that my PCP can handle my condition (even though he admitted to me that he couldn't).I am wondering if it is my Dr.'s fault or if it is just my 'medical group'. My husband went in with a 'tummy ache' and they reffered him to a GI specialist and he got approved almost over night. We have the same insurance, just different Doctors. Should I ditch my Dr. or is this common? It really sucks going untreated for so long. I havn't been working and don't think I can, until I get this under control. Uggg! --------------------------------- Be a better friend, newshound, and know-it-all with Mobile. Try it now. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 17, 2008 Report Share Posted April 17, 2008 I agree as well. And you can always go to the State Board of Insurance. I know with my old insurance, although they were really good about a lot of things, sometimes things got mixed up and entered wrong, causing a denial. Call them, talk to them about the reasons for it, and let them know you want to appeal. Maybe the doc he wanted to refer you to is out of network? Good luck. Tina daytimelover <daytimelover20032000@...> wrote: i agree with this , by all means appeal the decision, some states like new york also allow for appeals to a state board if you are shot down a second time. there is just no way thaty a regular doctor can trat you for arthritis , especially in the beginning when you dont even know what drugs will be effective for you Recent Activity 23 New Members Visit Your Group Health Early Detection Know the symptoms of breast cancer. Meditation and Lovingkindness A Group to share and learn. Drive Traffic Sponsored Search can help increase your site traffic. . --------------------------------- Be a better friend, newshound, and know-it-all with Mobile. Try it now. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 17, 2008 Report Share Posted April 17, 2008 , Appeal the descion. You can ask for a " speedy " appeal in which they have to give you an answer in 30 days. Get a letter from your doctor stating with your current condition why it needs to be followed up by a specialist. I would get as much clinical information as you can and submit your doctors letter along w/ clinical data. (I used to be head of a refferal department for an IPA). 9 out 10 times the person who reviews your refferal for an insurance company is not a doctor, just some person who used to work in customer service. Many times, the people who review refferals don't have medical training. So they are not familar w/ conditions like RA and why it needs to be followed up by a rheumatologist. Many times when it does go to a doctor to review, they are not in that speciality. At my old work an oncologist used to handle reviews for peds and pain management. When you appeal, it goes to a rheumatologist tor review. Most people don't appeal an insurances descion; and from my experience most of the appeals are approved. If your appeal does come back denied...take it to the states medical board. Again in 30 days...you can have your descion and beleive me, most insurances do not want it go that far. The best thing I can tell you is to have a letter written by your PCP why you need to be followed up by an rheumatologist. Get clinical data such as what is RA, what speciality is rheumatology and what conditions do they treat. Get whatever clinical data you can and submit it to them. Like I said, most of the people who review refferals do not have medical training and when you supply clinical on top of a letter from your PCP...they have no choice but to approve your refferal. If you have any questions, please feel free to ask me. This is what I used to do as a living. Best of luck to you. > > Hi All, > I was just wondering if anyone's insurance had ever denied a referral > to the Rhuematologist? I have never had trouble in the past, with other > insurance companies, and have always seen a Rheumatologist. Aetna > however not only sat on it for 3 months, but then denied it saying that > my PCP can handle my condition (even though he admitted to me that he > couldn't).I am wondering if it is my Dr.'s fault or if it is just > my 'medical group'. My husband went in with a 'tummy ache' and they > reffered him to a GI specialist and he got approved almost over night. > We have the same insurance, just different Doctors. Should I ditch my > Dr. or is this common? > It really sucks going untreated for so long. I havn't been working and > don't think I can, until I get this under control. > Uggg! > Quote Link to comment Share on other sites More sharing options...
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