Re: My HMO actually helped me today!

[Guest guest]

Good grief, Steph!  What a saga and how horrible to go thru all the back and

forth.  Good for you for working the phones and advocating for yourself.  And

congrats on trying to conceive!  How exciting!

Kate F

________________________________

From: DeNicola- <stephdenicola@...>

Sent: Thu, October 8, 2009 9:56:21 AM

Subject: [ ] My HMO actually helped me today!

 

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

[Guest guest]

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

--- In , DeNicola- <stephdenicola@...>

wrote:

>

> 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

>

>

>

>

>

[Guest guest]

Congratulations Steph!  Its great that you hung in there through all of that

opposition.

~Connie

From: DeNicola- <stephdenicola@...>

Subject: [ ] My HMO actually helped me today!

Date: Thursday, October 8, 2009, 10:56 AM

 

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

[Guest guest]

Sorry you had to go through that, Steph. So glad you straightened them out!

Not an MD

On Thu, Oct 8, 2009 at 9:56 AM, DeNicola-

<stephdenicola@...> wrote:

> 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