Re: Re: My HMO actually helped me today!

October 8, 2009

Steph!

Bless your heart! You poor thing! But kudos to you for staying on top of your

own healthcare!!! Good for you!!! I'm so sorry about the tears but congrats on

trying to get pregnant!!! I hope that all continues to work out for you in every

way possible!

in SC

From: tiredtaz <tiredtaz@...>

Subject: [ ] Re: My HMO actually helped me today!

Date: Thursday, October 8, 2009, 4:55 PM

Steph,

I'm so sorry you had to go through that horrible incident... But at least

something positive came as a result. Best of luck with your new Rheumy! I really

hope everything works out for you.

Bonnie

>

> Hello everyone,

> I just had an interesting experience with my HMO that I am still

stunned by -- and I know no one will appreciate it as much as you all.

> This month, my office switched HMOs -- from United Healthcare to Anthem

Healthkeepers. I loved UHC because they let me get my Remicade through home

health care and it never cost me a cent in the 5 years I was with UHC. After the

switch to Anthem, I learned that my rheumy was not a participating doc so I

switched to a different rheumy.

> My new rheumy, Dr. M., is great -- although his office staff leaves a

little to be desired. Anthem wouldn't pre-auth my Remicade until I passed a 72

hour TB test. After that, the rheumy decided he would be more comfortable

getting my Remicade in his office instead of at home (I'm trying to get pregnant

so I actually don't mind the additional monitoring).

> Today, Anthem called me to say my Remicade had been approved (yeah). Then

Dr. M's office calls and say it will cost a $20 copay plus 20% of the drug ---

WHAT??? That's at least $500 -- so the office was working with the patient

assistance program.

> So, I flip out and call Anthem. I get a very nice man named Andre. After

crying to him, I cite the pages in my Evidence of Coverage that state I do not

have any coinsurance for infusion. He looks it up, agrees & calls Dr. M's

office. Then I call the pre-auth lady to alert them of the error (she was not

happy I told her she was wrong).

> It turns out, someone (either the rheumy's staff or Anthem) approved

Remicade as an injectable drug -- which would be 20%! After 7 phone calls and

several crying fits, my rheumy's business office just called to say I was right,

the pre-auth was fixed and the infusion center will call me to set up an

appointment.

> The moral of the story -- surprisingly, the HMO isn't always the bad guy

-- especially when you know your rights. Crying doesn't hurt either (the tears

were real, of course, since this drug keeps me functioning) .

>

> Take care,

> Steph in VA

>

> ~~~~~~~~~~~~ ~~~~~~~~~ ~~~~~~~~~ ~~~~~~~~~ ~~~~~~~~~ ~~~~~~

> The 2009 Charlottesville Arthritis Walk was Sat. May 2 at UVA's Stadium

> The Walk raised about $20,000 for research & programs for people with

arthritis!

>

> " Never underestimate the power of a small, dedicated group of people to change

the world -- indeed, it's the only thing that ever has. " (Margaret Mead)

> AmeriCorps Alums -- Still Getting Things Done

>

October 8, 2009

Hi Steph: Way to go!!! Fight for what is right and you did that. So happy you

like your new Rheumy, and your Remicade is paid for. Yeah is right.

I love when I am right too! Tears do work, thankfully. God Bless you and I

hope you get pregnant soon.

My daughter went through hell and finally got pregnant after 11 years of trying

everything. She had a perfect healthy baby girl, and in 3 months she was

pregnant again, naturally, and had another perfect healthy baby girl. Miracles

do happen, and prayers sure do get answered. She was 39 with the first, and 4o

with the second. Love mey 2 babies!!!

Take care, and rest when you can. You so deserved all this good outcome.

Hugs,

Barbara