Re: Insurance Denying Payment for Remicade Treatments

[Guest guest]

vanessa,

i am new here and have not had to formally appeal treatment, but gosh, i am

sorry to hear you have to go thru this.

i hope others will have specific advice,but can't you and you rheum write an

appeal saying the remicade is medically necessary because all other meds cannot

control the necrosis and other aspects of autoimmunity.

like one of the senators or was it phil donahue said, we need to take insurance

companies out of the health care system, they want to keep the money instead of

getting people necessary treatment.

take care,

marg

>

> Hi Everyone,

>

> I tend to lurk more than post because being a single mom with a full-time job,

combined with the fatigue of RA, doesn't give me a lot of free time. But I

could use some of the wonderful insight that this group has right now.

>

> After going back and forth with the clinic where I get my infusions several

times, my insurance company, Empire Blue Cross, has denied the claims for my

Remicade infusions. The person I got on the phone said that the doctor

reviewing the claims said it was not " medically necessary. "

>

> I was diagnosed with RA in November 1999. I started on Plaquinil and NSAIDs.

After a few years, my flare ups started getting closer together, so I the

doctors added Methotrexate. Finally, last year, after adding Prednisone long

term rather than just sporadically during flare ups, my rheumatologist decided

that I needed a biologic to control the RA. Part of the decision was due to the

fact that I'd developed avascular necrosis in my right hip, so I was going to

have to ween off Prednisone.

>

> I'm sure to all of you, that last paragraph sounded like a typical disease and

treatment progression. So I have no idea why the idiots at my insurance company

can't see that.

>

> If any of you have gone through something similar with your own insurance, can

you let me know how you appealed it. I really need to find a way to fight this,

because there are already over $20,000 in charges that have been denied. If I

don't win the appeal, I'll have to file bankruptcy. At least I'm poor enough

that I still qualify for a full discharge bankruptcy, but I'd rather not have to

do that. I've worked too hard to get my credit score into the " excellent "

range.

>

[Guest guest]

--

i'm surprised your insurance denied you, typically they won't even give

infusions without prior authorization, but it's so typical insurance doesn't

want to pay. you absolutely need a letter from your rheumy, saying the remicade

is medically necessary. Tell him/her about the denial and your possible

bankrupcy because of it, i'm sure they will help you. this is just another

infuriating example of people in this country being penalized for being sick. it

is absolutely pitiful. I wish there was more advice i could give to you, but

talk with rheumy first and see what happens. Fight for this though. Good luck to

you,

Jen P

From: <vanessalp@...>

Subject: [ ] Insurance Denying Payment for Remicade Treatments

Date: Friday, March 27, 2009, 5:06 PM

Hi Everyone,

I tend to lurk more than post because being a single mom with a full-time job,

combined with the fatigue of RA, doesn't give me a lot of free time. But I could

use some of the wonderful insight that this group has right now.

After going back and forth with the clinic where I get my infusions several

times, my insurance company, Empire Blue Cross, has denied the claims for my

Remicade infusions. The person I got on the phone said that the doctor reviewing

the claims said it was not " medically necessary. "

I was diagnosed with RA in November 1999. I started on Plaquinil and NSAIDs.

After a few years, my flare ups started getting closer together, so I the

doctors added Methotrexate. Finally, last year, after adding Prednisone long

term rather than just sporadically during flare ups, my rheumatologist decided

that I needed a biologic to control the RA. Part of the decision was due to the

fact that I'd developed avascular necrosis in my right hip, so I was going to

have to ween off Prednisone.

I'm sure to all of you, that last paragraph sounded like a typical disease and

treatment progression. So I have no idea why the idiots at my insurance company

can't see that.

If any of you have gone through something similar with your own insurance, can

you let me know how you appealed it. I really need to find a way to fight this,

because there are already over $20,000 in charges that have been denied. If I

don't win the appeal, I'll have to file bankruptcy. At least I'm poor enough

that I still qualify for a full discharge bankruptcy, but I'd rather not have to

do that. I've worked too hard to get my credit score into the " excellent " range.

[Guest guest]

Sorry you are going through this. The person at the insurance company probably

doesn't even have any medical knowledge. I hope you win your case. I am really

mad for you!

>

> Hi Everyone,

>

> I tend to lurk more than post because being a single mom with a full-time job,

combined with the fatigue of RA, doesn't give me a lot of free time. But I

could use some of the wonderful insight that this group has right now.

>

> After going back and forth with the clinic where I get my infusions several

times, my insurance company, Empire Blue Cross, has denied the claims for my

Remicade infusions. The person I got on the phone said that the doctor

reviewing the claims said it was not " medically necessary. "

>

> I was diagnosed with RA in November 1999. I started on Plaquinil and NSAIDs.

After a few years, my flare ups started getting closer together, so I the

doctors added Methotrexate. Finally, last year, after adding Prednisone long

term rather than just sporadically during flare ups, my rheumatologist decided

that I needed a biologic to control the RA. Part of the decision was due to the

fact that I'd developed avascular necrosis in my right hip, so I was going to

have to ween off Prednisone.

>

> I'm sure to all of you, that last paragraph sounded like a typical disease and

treatment progression. So I have no idea why the idiots at my insurance company

can't see that.

>

> If any of you have gone through something similar with your own insurance, can

you let me know how you appealed it. I really need to find a way to fight this,

because there are already over $20,000 in charges that have been denied. If I

don't win the appeal, I'll have to file bankruptcy. At least I'm poor enough

that I still qualify for a full discharge bankruptcy, but I'd rather not have to

do that. I've worked too hard to get my credit score into the " excellent "

range.

>

[Guest guest]

Sorry that you are going through this, .

Did Empire Blue Cross authorize and/or pay for any of the Remicade

infusions you have had?

You can ask your rheumatologist to help you appeal. Obviously, he

believes Remicade is medically necessary for you.

You can also call Centocor's AccessOne® at 1-888-ACCESS-1 (222-3771)

and see if they have any ideas.

Not an MD

On Fri, Mar 27, 2009 at 4:06 PM, <vanessalp@...> wrote:

> Hi Everyone,

>

> I tend to lurk more than post because being a single mom with a full-time

> job, combined with the fatigue of RA, doesn't give me a lot of free time.

> But I could use some of the wonderful insight that this group has right now.

>

> After going back and forth with the clinic where I get my infusions several

> times, my insurance company, Empire Blue Cross, has denied the claims for my

> Remicade infusions. The person I got on the phone said that the doctor

> reviewing the claims said it was not " medically necessary. "

>

> I was diagnosed with RA in November 1999. I started on Plaquinil and NSAIDs.

> After a few years, my flare ups started getting closer together, so I the

> doctors added Methotrexate. Finally, last year, after adding Prednisone long

> term rather than just sporadically during flare ups, my rheumatologist

> decided that I needed a biologic to control the RA. Part of the decision was

> due to the fact that I'd developed avascular necrosis in my right hip, so I

> was going to have to ween off Prednisone.

>

> I'm sure to all of you, that last paragraph sounded like a typical disease

> and treatment progression. So I have no idea why the idiots at my insurance

> company can't see that.

>

> If any of you have gone through something similar with your own insurance,

> can you let me know how you appealed it. I really need to find a way to

> fight this, because there are already over $20,000 in charges that have been

> denied. If I don't win the appeal, I'll have to file bankruptcy. At least

> I'm poor enough that I still qualify for a full discharge bankruptcy, but

> I'd rather not have to do that. I've worked too hard to get my credit score

> into the " excellent " range.

[Guest guest]

Hi - I've not gone through anything like what you are going through, but

from what I know of insurance companies and doctor's offices, your

Rheumatologist's billing office or the clinic's billing office should be the

ones fighting this dispute for you - they are the ones that got you the approval

to begin with. It is not up to the patient to have to do the fighting for stuff

like this. This is why the doctors and clinics get paid the big bucks. This is

also why employers have human resource people. We provide the information -

insurance card, driver's license - and THEY get the approval and dispute any

rejections. Our job, as patients, is to get well.

It stinks that it's Friday night and you have to " stew " about this all weekend,

but try not to worry. Make your plans to call the doctor or clinic billing

office first thing Monday morning. If you don't get anywhere with them, then

contact your employer's human resource person. They should be able to help you

there. Most of the time it is just a result of some incorrect diagnosis coding

when the insurance company was billed.

Best of luck to you. Let me know how you make out.....Doreen

>

> Hi Everyone,

>

> I tend to lurk more than post because being a single mom with a full-time job,

combined with the fatigue of RA, doesn't give me a lot of free time. But I

could use some of the wonderful insight that this group has right now.

>

> After going back and forth with the clinic where I get my infusions several

times, my insurance company, Empire Blue Cross, has denied the claims for my

Remicade infusions. The person I got on the phone said that the doctor

reviewing the claims said it was not " medically necessary. "

>

> I was diagnosed with RA in November 1999. I started on Plaquinil and NSAIDs.

After a few years, my flare ups started getting closer together, so I the

doctors added Methotrexate. Finally, last year, after adding Prednisone long

term rather than just sporadically during flare ups, my rheumatologist decided

that I needed a biologic to control the RA. Part of the decision was due to the

fact that I'd developed avascular necrosis in my right hip, so I was going to

have to ween off Prednisone.

>

> I'm sure to all of you, that last paragraph sounded like a typical disease and

treatment progression. So I have no idea why the idiots at my insurance company

can't see that.

>

> If any of you have gone through something similar with your own insurance, can

you let me know how you appealed it. I really need to find a way to fight this,

because there are already over $20,000 in charges that have been denied. If I

don't win the appeal, I'll have to file bankruptcy. At least I'm poor enough

that I still qualify for a full discharge bankruptcy, but I'd rather not have to

do that. I've worked too hard to get my credit score into the " excellent "

range.

>

[Guest guest]

Hello

I work for a healthcare ins company. Here are the steps you want to take.

1). Call the ins company and see why they are denying it exactly. It maybe they

asked the dr office for medical records, did not receive them and are denying

the claim. If this is the case you would only have to contact the dr office to

send the records to them. Depending on your plan, some plans require prior

approval. If this is the case you can find out who was supposed to get the

approval, get copies of the EOBs (explanation of benefits) and tell that

provider that was to get the approval you are not responsible for the bill.

They get to eat those bills. If the provider has an approval number, that

provider will need to contact your ins company and talk with them.

2.) You could ask your doctor to request a peer-to-peer review. The doctor

would call into the ins company to request this. The ins company would setup a

time that your doctor and an ins doctor would chat and discuss why he is

prescribing this treatment. The ins doctor has the ability to approve or deny

the treatment. Don't be afraid to ask your doctor to do this. you pay his

salary by going to him. He is working for you. Put him to work.

3.) You can also appeal. But know that there is usually a time limit from the

DOS (date-of-service) in which you can do this. You would need to write a

letter of appeal (be as detailed as possible), send ALL medical records and

documentation to support your position, and send it in to the appeals dept of

your ins company. I know with our company there is 3 levels of appeals, so if

you are turned down for the first appeal, the letter you receive will tell you

how to go thru the next appeal. Usually each level of the appeals process can

take up to 30 days.

I hope this helps. I too with RA had to jump a couple of hoops to get the

approval for the Enbrel I needed. Even though I work for a healthcare ins

company. But because of my job I knew what to do to get thru those hoops

quickly.

The last words I have for all is READ YOUR PLAN!!!! Every last word. Get a

magnafying glass and read the small print. This is a contract between you and

the ins company. If they are not abiding by it there are steps you can take.

Also, knowing your plan enables you to know before your provider prescribes a

treatment if the ins will cover it, how it will be pd and what hoops you and the

doctor will need to go thru so you can get it. If you don't have a Summary Plan

Description (SPD) then ask your ins company to send you one. They have to. It

is the law. Make sure you tell them you want the detail one. Not the shortened

version they usually send people.

Take charge of your healthcare! That includes your healthcare ins. You deserve

it!

Soft hugs and warm wishes.

in MN

[Guest guest]

I had to fail at two other meds before going on a biologic. Then I had

to be pre-approved by the insurance company. The process took over a

month, and I was on no DMARD in the interim, having had to stop MTX

and Arava because of a too-low white blood cell count. My rheumy at

the time turned it over to one of his fellows, and the fellow said

there were two insurance companies you didn't want to deal with, and

mine was one of them.

I think they make the process so hard that they hope the doctors will

get frustrated and give it up. I stated this theory once when I called

the insurance company, but of course they denied it.

Currently, I pay $50 for a 34-day supply. My insurance company is

making some cost-cutting changes, and I think that soon I'll have to

start paying $100 for a 30-day supply. The bad economy is affecting

lots of things.

Sue

On Mar 28, 2009, at 10:51 AM, Rice wrote:

>

> I hope this helps. I too with RA had to jump a couple of hoops to

> get the approval for the Enbrel I needed. Even though I work for a

> healthcare ins company. But because of my job I knew what to do to

> get thru those hoops quickly.