Re: Navigating Insurance Denials

[Guest guest]

Sorry for the many posts but as it turns out, we put a call into our HR rep.

from my husband's employer and he was great. He called Lifewise and the

insurance does cover the band. They want to know why we were told it was not.

But they only cover it at out of network rates (50%). I'm ok with that. We can

attempt to get in-network rates (80%) by submitting paperwork from the provider

(i.e. Cranial Technologies) which the insurance says they have not done. My

ped. has submitted everything she can to them. Since we were told by their

insurance " expert " it was not covered we assumed it would be a hard fight. They

didn't give us the option of submitting the paperwork so nothing has been done.

The caveat is, to get this covered we have to get this all taken care of before

initiating treatment. Unfortunately, we are scheduled tomorrow for the DSi and

the next available appt. is not for another 2 weeks. So my question to you all

is, should we risk this not getting resolved in the morning with a few

faxes/emails and possible approval prior to the appt. or should we delay

treatment 2 weeks? I don't want to wait much longer as putting it closer to his

5 month mark will put the band coming back in 2 weeks instead of 1. So if you

were in my situation, what would you do? I'm really disappointed in Cranial

Tech. right now. Has anyone had this experience with them? I should've jumped

on this last week when something didn't sound right after hearing from Cranial

Tech. I'm kicking myself now.

Lori

mom to 3 little angels

>

> Hello, I am pretty new to this board and have been following some of the

threads for a couple of weeks now. I'm hoping someone can help or at least

offer some general guidance. We have Lifewise insurance of Arizona(not a very

common insurance) and were flat out denied coverage of the doc band. Not sure

what the reasoning was, they told us at the cranial technologies office that

they are usually good about negotiating with the insurance companies but they

had no luck. They told us even if we had Blue Cross we'd have no luck either.

We were going to switch but I guess it makes no difference.

>

> So does this mean I need to start the appeal process or is it pretty much a

lost cause? Where do I begin? We have not received a denial letter yet. I

have looked over some of the letters in the files section and it's a bit

overwhelming with all the medical data, citations etc. It sucks that we have

such crummy insurance and my husband is even a Dr! Go figure. We've already

paid close to $4,000 out of pocket for a normal non-complicated delivery and

prenatal care. We'd like to at least try to get some coverage. Especially if

there is a possibility that we'll need 2 bands. I don't understand because for

everything else, they've said they would cover 80% as long as we met our

dectible of $1,500. I don't see how this is any different for other orthotic

medical devices. Is plagiocephaly so rare that they just don't understand what

it is or how it's treated? I'm so frustrated...What does it mean to have

insurance anymore?

>

[Guest guest]

I fully believe that the insurance companies don't know how to handle the bands. We got the run around for two weeks from ours. First, told it would be full covered, then was an exclusion, and then covered only by Hanger. This was with multiple phone calls from us and our provider. So, don't be so sure that you have the final answer yet. Ask CT to submit the paperwork anyway and see what follows.

Your baby is still quite young so I think that delaying treatment for 2 weeks shouldn't make a huge difference in the results. Now, if your baby was approaching a year, then I might say to proceed without the insurance. I was told that 4 to 8 months was the ideal time to get the baby banded. You are well within that. Good luck. I hope that you really do have coverage.

, mom to , 23 months

STARband grad

Re: Navigating Insurance Denials

Sorry for the many posts but as it turns out, we put a call into our HR rep. from my husband's employer and he was great. He called Lifewise and the insurance does cover the band. They want to know why we were told it was not. But they only cover it at out of network rates (50%). I'm ok with that. We can attempt to get in-network rates (80%) by submitting paperwork from the provider (i.e. Cranial Technologies) which the insurance says they have not done. My ped. has submitted everything she can to them. Since we were told by their insurance "expert" it was not covered we assumed it would be a hard fight. They didn't give us the option of submitting the paperwork so nothing has been done. The caveat is, to get this covered we have to get this all taken care of before initiating treatment. Unfortunately, we are scheduled tomorrow for the DSi and the next available appt. is not for another 2 weeks. So my question to you all is, should we risk this not getting resolved in the morning with a few faxes/emails and possible approval prior to the appt. or should we delay treatment 2 weeks? I don't want to wait much longer as putting it closer to his 5 month mark will put the band coming back in 2 weeks instead of 1. So if you were in my situation, what would you do? I'm really disappointed in Cranial Tech. right now. Has anyone had this experience with them? I should've jumped on this last week when something didn't sound right after hearing from Cranial Tech. I'm kicking myself now. Lorimom to 3 little angels>> Hello, I am pretty new to this board and have been following some of the threads for a couple of weeks now. I'm hoping someone can help or at least offer some general guidance. We have Lifewise insurance of Arizona(not a very common insurance) and were flat out denied coverage of the doc band. Not sure what the reasoning was, they told us at the cranial technologies office that they are usually good about negotiating with the insurance companies but they had no luck. They told us even if we had Blue Cross we'd have no luck either. We were going to switch but I guess it makes no difference. > > So does this mean I need to start the appeal process or is it pretty much a lost cause? Where do I begin? We have not received a denial letter yet. I have looked over some of the letters in the files section and it's a bit overwhelming with all the medical data, citations etc. It sucks that we have such crummy insurance and my husband is even a Dr! Go figure. We've already paid close to $4,000 out of pocket for a normal non-complicated delivery and prenatal care. We'd like to at least try to get some coverage. Especially if there is a possibility that we'll need 2 bands. I don't understand because for everything else, they've said they would cover 80% as long as we met our dectible of $1,500. I don't see how this is any different for other orthotic medical devices. Is plagiocephaly so rare that they just don't understand what it is or how it's treated? I'm so frustrated...What does it mean to have insurance anymore?>

[Guest guest]

---Hi. we are going through the appeal process also. We do have BCBS and were

denied because their doctors deemed it medically unneccessary. I have been

preparing my appeal because from what I understand, most people do initially get

denied. I have gathered letter from our ped, the neurologist, physical

therapist, and the orthotic doctor. We are doing everything that we can.

Definitely persue.

In Plagiocephaly , " loriines " <loriines@...> wrote:

>

> Hello, I am pretty new to this board and have been following some of the

threads for a couple of weeks now. I'm hoping someone can help or at least

offer some general guidance. We have Lifewise insurance of Arizona(not a very

common insurance) and were flat out denied coverage of the doc band. Not sure

what the reasoning was, they told us at the cranial technologies office that

they are usually good about negotiating with the insurance companies but they

had no luck. They told us even if we had Blue Cross we'd have no luck either.

We were going to switch but I guess it makes no difference.

>

> So does this mean I need to start the appeal process or is it pretty much a

lost cause? Where do I begin? We have not received a denial letter yet. I

have looked over some of the letters in the files section and it's a bit

overwhelming with all the medical data, citations etc. It sucks that we have

such crummy insurance and my husband is even a Dr! Go figure. We've already

paid close to $4,000 out of pocket for a normal non-complicated delivery and

prenatal care. We'd like to at least try to get some coverage. Especially if

there is a possibility that we'll need 2 bands. I don't understand because for

everything else, they've said they would cover 80% as long as we met our

dectible of $1,500. I don't see how this is any different for other orthotic

medical devices. Is plagiocephaly so rare that they just don't understand what

it is or how it's treated? I'm so frustrated...What does it mean to have

insurance anymore?

>

[Guest guest]

FYI to everyone appealing out there - Insurers tend to get nervous and

seriously re-examine denials when they are threatened with a bad faith suit by

an insured. There are bad faith statutes in nearly every state. They typically

entitle the insured to attorneys fees and large damage awards, including

unlimited punitive damages. You may want to consult an attorney or check out

your state's insurance code (i.e. Google search: " Illinois Insurance Code " ) and

use the search function (Ctrl " F " ) to look for " bad faith " and/or " first party

bad faith " in the text of the code. The threat of a bad faith action is usually

enough to grab an insurer's attention.

Best of luck!

Jocelyn

ton, Illinois

> >

> > Hello, I am pretty new to this board and have been following some of the

threads for a couple of weeks now. I'm hoping someone can help or at least

offer some general guidance. We have Lifewise insurance of Arizona(not a very

common insurance) and were flat out denied coverage of the doc band. Not sure

what the reasoning was, they told us at the cranial technologies office that

they are usually good about negotiating with the insurance companies but they

had no luck. They told us even if we had Blue Cross we'd have no luck either.

We were going to switch but I guess it makes no difference.

> >

> > So does this mean I need to start the appeal process or is it pretty much a

lost cause? Where do I begin? We have not received a denial letter yet. I

have looked over some of the letters in the files section and it's a bit

overwhelming with all the medical data, citations etc. It sucks that we have

such crummy insurance and my husband is even a Dr! Go figure. We've already

paid close to $4,000 out of pocket for a normal non-complicated delivery and

prenatal care. We'd like to at least try to get some coverage. Especially if

there is a possibility that we'll need 2 bands. I don't understand because for

everything else, they've said they would cover 80% as long as we met our

dectible of $1,500. I don't see how this is any different for other orthotic

medical devices. Is plagiocephaly so rare that they just don't understand what

it is or how it's treated? I'm so frustrated...What does it mean to have

insurance anymore?

> >

>