Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 Do you have any numbers to fight with? Something that proves the track record locally is really bad? From: [mailto: ] On Behalf Of dmelzer514 Sent: Saturday, March 14, 2009 9:34 AM To: Subject: Insurance Company I found out yesterday that my insurance company will not cover the referral to Pittsburgh my dr set up. They called to tell me if I wanted to go to Pittsburgh it would cost me an $8,000 out of network deductible plus all the charges above their usual, customary and reasonable charges. Those lovely charges would not go toward the deductible and I would be responsible for them throughout treatment. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 Do you have any numbers to fight with? Something that proves the track record locally is really bad? From: [mailto: ] On Behalf Of dmelzer514 Sent: Saturday, March 14, 2009 9:34 AM To: Subject: Insurance Company I found out yesterday that my insurance company will not cover the referral to Pittsburgh my dr set up. They called to tell me if I wanted to go to Pittsburgh it would cost me an $8,000 out of network deductible plus all the charges above their usual, customary and reasonable charges. Those lovely charges would not go toward the deductible and I would be responsible for them throughout treatment. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 Do you have any numbers to fight with? Something that proves the track record locally is really bad? From: [mailto: ] On Behalf Of dmelzer514 Sent: Saturday, March 14, 2009 9:34 AM To: Subject: Insurance Company I found out yesterday that my insurance company will not cover the referral to Pittsburgh my dr set up. They called to tell me if I wanted to go to Pittsburgh it would cost me an $8,000 out of network deductible plus all the charges above their usual, customary and reasonable charges. Those lovely charges would not go toward the deductible and I would be responsible for them throughout treatment. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 Nope just the examples of how badly I was treated when I was sent there during diagnosis which the insurance Company doesn't care about.DarcySent from my Verizon Wireless BlackBerryFrom: "Anita Oakley" Date: Sat, 14 Mar 2009 09:40:02 -0500To: < >Subject: RE: Insurance Company Do you have any numbers to fight with? Something that proves the track record locally is really bad? From: [mailto: ] On Behalf Of dmelzer514Sent: Saturday, March 14, 2009 9:34 AMTo: Subject: Insurance Company I found out yesterday that my insurance company will not cover the referral to Pittsburgh my dr set up. They called to tell me if I wanted to go to Pittsburgh it would cost me an $8,000 out of network deductible plus all the charges above their usual, customary and reasonable charges. Those lovely charges would not go toward the deductible and I would be responsible for them throughout treatment. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 Nope just the examples of how badly I was treated when I was sent there during diagnosis which the insurance Company doesn't care about.DarcySent from my Verizon Wireless BlackBerryFrom: "Anita Oakley" Date: Sat, 14 Mar 2009 09:40:02 -0500To: < >Subject: RE: Insurance Company Do you have any numbers to fight with? Something that proves the track record locally is really bad? From: [mailto: ] On Behalf Of dmelzer514Sent: Saturday, March 14, 2009 9:34 AMTo: Subject: Insurance Company I found out yesterday that my insurance company will not cover the referral to Pittsburgh my dr set up. They called to tell me if I wanted to go to Pittsburgh it would cost me an $8,000 out of network deductible plus all the charges above their usual, customary and reasonable charges. Those lovely charges would not go toward the deductible and I would be responsible for them throughout treatment. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 If it were me, I’d avoid any kind of lying. Insurance companies won’t hesitate to go after you for fraud. Can you do something shy of quitting your job? If your managers are so understanding and helpful, can you get them to cut your hours to 30 a week? You’d qualify for your husband’s insurance, still be making ¾ of what you are now, and deal with a different insurance company. Nita From: [mailto: ] On Behalf Of dmelzer514@... Sent: Saturday, March 14, 2009 9:44 AM To: Subject: Re: Insurance Company Nope just the examples of how badly I was treated when I was sent there during diagnosis which the insurance Company doesn't care about. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 If it were me, I’d avoid any kind of lying. Insurance companies won’t hesitate to go after you for fraud. Can you do something shy of quitting your job? If your managers are so understanding and helpful, can you get them to cut your hours to 30 a week? You’d qualify for your husband’s insurance, still be making ¾ of what you are now, and deal with a different insurance company. Nita From: [mailto: ] On Behalf Of dmelzer514@... Sent: Saturday, March 14, 2009 9:44 AM To: Subject: Re: Insurance Company Nope just the examples of how badly I was treated when I was sent there during diagnosis which the insurance Company doesn't care about. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 If it were me, I’d avoid any kind of lying. Insurance companies won’t hesitate to go after you for fraud. Can you do something shy of quitting your job? If your managers are so understanding and helpful, can you get them to cut your hours to 30 a week? You’d qualify for your husband’s insurance, still be making ¾ of what you are now, and deal with a different insurance company. Nita From: [mailto: ] On Behalf Of dmelzer514@... Sent: Saturday, March 14, 2009 9:44 AM To: Subject: Re: Insurance Company Nope just the examples of how badly I was treated when I was sent there during diagnosis which the insurance Company doesn't care about. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 It's nice to have the option of going onto your husband's insurance. Is it possible to sit down with the two insurance companies and both employers and negotiate some sort of deal? If you dropped your hours below 32/week would you be able to go to Pittsburgh on your husbands insurance? or would they throw up road blocks as well? Ian I found out yesterday that my insurance company will not cover the referral to Pittsburgh my dr set up. They called to tell me if I wanted to go to Pittsburgh it would cost me an $8,000 out of network deductible plus all the charges above their usual, customary and reasonable charges. Those lovely charges would not go toward the deductible and I would be responsible for them throughout treatment. They then said I have to go to the Cleveland Clinic and if I go to Cleveland they will consider it in the network and it will be free. My dr's office argued with them and I argued with them and got nowhere. There is not a transplant hospital in my insurance network but apparently they have negotiated something with Cleveland. So now I have to choose:1. Give up vacations and sporting events and all the fun things in life so that I will have the money to go to Pittsburgh - and most likely still end up with money trouble.2. Agree to go like a lamb to the slaughter and return to the Cleveland Clinic where I am certain I would die if I had to have major surgery. That place is a horrible hell hole of incompetence and arrogance. 3. Make my local dr. mad and just ignore his request to go to a transplant hospital completely. This is the one I'm leaning toward. I would let there office set everything up and then just cancel it so they would think I went. I might be able to pull this off because Cleveland doesn't like to waste their time with the little community dr's so they won't keep him updated. 4. Quit my job so that I can get on my husband's insurance. I can't be on his insurance if I work 32 hours a week outside the home for a company that has health insurance. Obviously quitting is a very bad plan in this economy. 5. Have the owners at work lie for me (which they would do in a heartbeat. The one lied for me all the time when I wanted to skip tests in grad school to go to concerts - he wrote letters for my prof's that I was going to be out of town on business). Have them tell my husband's employer I've had my hours cut and no longer qualify for insurance. I just can't get caught working full time or I would have to repay all the claims. None of these scenarios seem good. I do not feel safe going back to Cleveland. I completely understand the possible ramifications of not going but I think my odds are better with no treatment then being treated by the Cleveland Clinic. I am certain that hospital would kill me, torment me and drive me crazy in the process. Has anyone ever won one of these battles with an insurance company? Did you just give in and go to a bad hospital or end up spending every dime you had on medical care?Thanks,Darcy -- Ian Cribb P.Eng. (6... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 I thought I was going to have a similar issue. My insurance plan covered transplants, but we had no “network” hospital that did them. They came through with “network” coverage the day of my final pre-transplant visit. It is a money game. You might be able to contact the insurance company and ask if Pittsburg would agree to the same terms if they would allow them in your network. I know that there are companies that negotiate transplant claims. The one my employer used was Interlink. It basically gave them network prices because most transplant centers accept Interlink’s discounts. It got my employer (who is self insured) a discount of about 20%. As far as the “plus all the charges above their usual, customary and reasonable charges”, this could be a Pandora’s box. There is no standard for usual, customary and reasonable. Each insurer develops their list. It may be based on statistics, but it could be a totally unrelated set of statistics. This could impact hospital charges, radiologists, pathologists, surgeons, etc…………… I had a little bit of an advantage. I have worked in the business end of healthcare for over 30 years. There is always a way, but most times it is hidden from the insured. Good luck. From: [mailto: ] On Behalf Of dmelzer514 Sent: Saturday, March 14, 2009 9:34 AM To: Subject: Insurance Company I found out yesterday that my insurance company will not cover the referral to Pittsburgh my dr set up. They called to tell me if I wanted to go to Pittsburgh it would cost me an $8,000 out of network deductible plus all the charges above their usual, customary and reasonable charges. Those lovely charges would not go toward the deductible and I would be responsible for them throughout treatment. They then said I have to go to the Cleveland Clinic and if I go to Cleveland they will consider it in the network and it will be free. My dr's office argued with them and I argued with them and got nowhere. There is not a transplant hospital in my insurance network but apparently they have negotiated something with Cleveland. So now I have to choose: 1. Give up vacations and sporting events and all the fun things in life so that I will have the money to go to Pittsburgh - and most likely still end up with money trouble. 2. Agree to go like a lamb to the slaughter and return to the Cleveland Clinic where I am certain I would die if I had to have major surgery. That place is a horrible hell hole of incompetence and arrogance. 3. Make my local dr. mad and just ignore his request to go to a transplant hospital completely. This is the one I'm leaning toward. I would let there office set everything up and then just cancel it so they would think I went. I might be able to pull this off because Cleveland doesn't like to waste their time with the little community dr's so they won't keep him updated. 4. Quit my job so that I can get on my husband's insurance. I can't be on his insurance if I work 32 hours a week outside the home for a company that has health insurance. Obviously quitting is a very bad plan in this economy. 5. Have the owners at work lie for me (which they would do in a heartbeat. The one lied for me all the time when I wanted to skip tests in grad school to go to concerts - he wrote letters for my prof's that I was going to be out of town on business). Have them tell my husband's employer I've had my hours cut and no longer qualify for insurance. I just can't get caught working full time or I would have to repay all the claims. None of these scenarios seem good. I do not feel safe going back to Cleveland. I completely understand the possible ramifications of not going but I think my odds are better with no treatment then being treated by the Cleveland Clinic. I am certain that hospital would kill me, torment me and drive me crazy in the process. Has anyone ever won one of these battles with an insurance company? Did you just give in and go to a bad hospital or end up spending every dime you had on medical care? Thanks, Darcy Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 Darcy, Hi. I'm so sorry to hear about what you're going through. I'm even more sorry that I don't have any words of wisdom to offer you. I think it all comes down to personal choice and peace of mind. That being said, I would advise you against lying since that would put you in heaps of trouble with anyone who found out and also put those who lied for you in trouble as well. In my opinion, it's always easier to go with the truth. I've been in a situation similar to yours. In my case, I'm no longer able to work, but I'm not married so I had no choice but to go with Social Security. It sounds like you may have a decent back-up option with your husband's policy, so I'd definitely think it's worth looking deeper into that and seeing what things could be worked out. For what it's worth, I battled back and forth with myself about whether to " fight " PSC and deal with hospitals, watching my savings dwindle and all the money I'd saved since I was 16 years old go down the hospital drain, giving up the little luxuries in life, etc. or just handing myself over to PSC and my awful local hospital and have at it. In the end, I decided that my health was worth it and I'm blessed to have a family who helps me out in every way they can. It wasn't an easy decision to come to, but I've never regretted it for a day...maybe for a few minutes when I get a huge hospital bill, but never for a full day! Best of luck to you in whatever you decide! Sandi in VA (er, um, Rochester) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 Darcy, Hi. I'm so sorry to hear about what you're going through. I'm even more sorry that I don't have any words of wisdom to offer you. I think it all comes down to personal choice and peace of mind. That being said, I would advise you against lying since that would put you in heaps of trouble with anyone who found out and also put those who lied for you in trouble as well. In my opinion, it's always easier to go with the truth. I've been in a situation similar to yours. In my case, I'm no longer able to work, but I'm not married so I had no choice but to go with Social Security. It sounds like you may have a decent back-up option with your husband's policy, so I'd definitely think it's worth looking deeper into that and seeing what things could be worked out. For what it's worth, I battled back and forth with myself about whether to " fight " PSC and deal with hospitals, watching my savings dwindle and all the money I'd saved since I was 16 years old go down the hospital drain, giving up the little luxuries in life, etc. or just handing myself over to PSC and my awful local hospital and have at it. In the end, I decided that my health was worth it and I'm blessed to have a family who helps me out in every way they can. It wasn't an easy decision to come to, but I've never regretted it for a day...maybe for a few minutes when I get a huge hospital bill, but never for a full day! Best of luck to you in whatever you decide! Sandi in VA (er, um, Rochester) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 Darcy, I don’t think any of your 5 options as you have them laid out are good. But, Cleveland Clinic does have a good reputation in many area (Sometimes going even par with even Mayo) so is it possible that you had an isolated poor experience or that you can get the care you deserve from them by having candid/productive/civil discussions with them? If that is not productive, then maybe a meeting with a department head or higher would give you some results. I agree with the others that lying shouldn’t be an option. If you get caught doing this it might spell a lot of trouble for you getting a claim through for a transplant in the future and may get you labeled as being an uncooperative patient. Rick From: [mailto: ] On Behalf Of dmelzer514 Sent: Saturday, March 14, 2009 10:34 AM To: Subject: Insurance Company I found out yesterday that my insurance company will not cover the referral to Pittsburgh my dr set up. They called to tell me if I wanted to go to Pittsburgh it would cost me an $8,000 out of network deductible plus all the charges above their usual, customary and reasonable charges. Those lovely charges would not go toward the deductible and I would be responsible for them throughout treatment. They then said I have to go to the Cleveland Clinic and if I go to Cleveland they will consider it in the network and it will be free. My dr's office argued with them and I argued with them and got nowhere. There is not a transplant hospital in my insurance network but apparently they have negotiated something with Cleveland. So now I have to choose: 1. Give up vacations and sporting events and all the fun things in life so that I will have the money to go to Pittsburgh - and most likely still end up with money trouble. 2. Agree to go like a lamb to the slaughter and return to the Cleveland Clinic where I am certain I would die if I had to have major surgery. That place is a horrible hell hole of incompetence and arrogance. 3. Make my local dr. mad and just ignore his request to go to a transplant hospital completely. This is the one I'm leaning toward. I would let there office set everything up and then just cancel it so they would think I went. I might be able to pull this off because Cleveland doesn't like to waste their time with the little community dr's so they won't keep him updated. 4. Quit my job so that I can get on my husband's insurance. I can't be on his insurance if I work 32 hours a week outside the home for a company that has health insurance. Obviously quitting is a very bad plan in this economy. 5. Have the owners at work lie for me (which they would do in a heartbeat. The one lied for me all the time when I wanted to skip tests in grad school to go to concerts - he wrote letters for my prof's that I was going to be out of town on business). Have them tell my husband's employer I've had my hours cut and no longer qualify for insurance. I just can't get caught working full time or I would have to repay all the claims. None of these scenarios seem good. I do not feel safe going back to Cleveland. I completely understand the possible ramifications of not going but I think my odds are better with no treatment then being treated by the Cleveland Clinic. I am certain that hospital would kill me, torment me and drive me crazy in the process. Has anyone ever won one of these battles with an insurance company? Did you just give in and go to a bad hospital or end up spending every dime you had on medical care? Thanks, Darcy Quote Link to comment Share on other sites More sharing options...
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