advise please

[Guest guest]

Hi gang,

Well, the insurance company got my appeal stuff on the 15th (Private

Health Care Systems= PHCS). I have gotten two stories from 5 different

people. My denial letter stated not covered, but verbally I was told

that I (Dr R) did not prove medical necessity. Now after several phone

calls, I have been told that this company denies everyone on the

pre-cert, first time out.....hmmmmmm.

Today I called, and got a " different " person, this kid told me, that the

appeal still had not been evaluated. So, I asked what the procedure for

appeal was. He told me that it was reviewed by a person who looks at

all the documentation and makes a determination. So I asked, " Is the

person making the decision a medically qualified person? " He tells me

" no " then I ask for the name of the person making this decision and he

tells me that he can not divulge that

info......!@#$%^ & *()#$%^ & *()#$%^ & *(. So I thought, by someone's

direction here on the group, to call back and ask for the

receptionist.... lol....I got him again...lol... I just hung up....

Dilemna:...... Should I push the issue w/ the insurance company now?

(they told me last Thursday that a decision should be made w/in 7-10

days.) Or do I wait, and risk not getting the info about the person

making the decision on this. One lady a few days ago, told my hubby

that " it would not be approved " and that " she had never seen one

approved in her opinion and was a waste of our time " .... I called back

and spoke w/ her supervisor... and I let them have it... Told them I

wanted facts not opinion and certainly not an attitude.

Any info would be helpful at this point.

Thanx in advance

Joannie

Irving, Tx.