My HMO actually helped me today!

October 8, 2009

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

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