Guest guest Posted December 8, 2001 Report Share Posted December 8, 2001 Well, I am wondering if I am really ever going to get this surgery. First of all, I got laid off, so have to spend a fortune on COBRA, but to top that off, even though I got an approval letter from Cleveland Medical Mutual, today I got a denial from the Toledo, OH office, because they say I can get the services within network and I requested out of network (requested with Dr. Hess). Now, I pay through the nose for the insurance I have and specifically got this because they said I could go out of network and only the HMO required that I stay in network. I even have a breakdown of what they will pay in/out of network. I know I will have to pay more for out of network, so why are they giving me a hard time about this? Now I have to appeal this and go through all of that stress. I have heard that Medical Mutual wants people to use their Dr. who is at Toledo college (somewhere) probably to get him business, but I also read on line that he didn't seem to know what he was doing a woman who went to him only lost about 30 lbs. I do not want to go to him. I am really DEPRESSED. Carole Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 8, 2001 Report Share Posted December 8, 2001 Carole, Are you sure that they are not just saying that you won't get the higher payment of in-network doctor? Maybe they are just informing you that you will pay the out of network percentages--not the in network percentages. Look over the letter again, just in case. Dawn Dr. Hess, Bowling Green, OH BPD/DS 4/27/00 www.duodenalswitch.com 267 to 165 5' 4 " size 22 to size 10 have made size goal no more high blood pressure, sore feet, or dieting! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 8, 2001 Report Share Posted December 8, 2001 In a message dated 12/08/2001 3:35:59 PM Central Standard Time, MsMystic1@... writes: > Please be advised that utilizing a > provider outside of the netwoirk/first teier or non-contracting may > result in additional financial liability. In the future, for the > most cost-effective use of your insurance benefits, it is necessary > to keep medical care within the provider network if at all possible. > Carole, These are the words that make me suspect they are just talking about what level of payment, not whether you can have surgery with this doc. Dawn Dr. Hess, Bowling Green, OH BPD/DS 4/27/00 www.duodenalswitch.com 267 to 165 5' 4 " size 22 to size 10 have made size goal no more high blood pressure, sore feet, or dieting! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 8, 2001 Report Share Posted December 8, 2001 > Carole, > > Are you sure that they are not just saying that you won't get the higher > payment of in-network doctor? Maybe they are just informing you that you > will pay the out of network percentages--not the in network percentages. > Look over the letter again, just in case. > > Dawn > Dawn, The letter says " The Care Management Dept. of Medical Mutual has received a request for out-of-network care for the above referenced patient at or by: Dr. S. Oakley for the following days of service: 12/18/01 to discharge. It has been determined that the requested services can be provided within the network. Therefore your request for out-of-network services(s) is/are denied. Please be advised that utilizing a provider outside of the netwoirk/first teier or non-contracting may result in additional financial liability. In the future, for the most cost-effective use of your insurance benefits, it is necessary to keep medical care within the provider network if at all possible. The subscriber or provider can submit an oral or written request for an expedited or standard appeal. Expedited requests are granted for services that are ongoing or imminent. The appeal should include any relevant information to the reconsideration of the denial. The appeal must be initiated within ninety (90)days from the date of this letter. Please attach a copy of this letter to all appeal requests. " So - what I did was send them the original approval letter (which was submitted by Dr. Oakley, also) and a copy of the information I was given by my employer for the plan I bought (which just showed less being paid for out of network) and copy of my card which shows the type of insurance I bought, plus a letter explaining that I was told that only if I was in an HMO would I be required to stay in network, but that if I wanted to go out of network, I could do so without a referral and just have to pay the difference. I also cc: to the Ohio Dept of Insurance. I also posted a complaint on the Ohio Dept of Insurance website. I hope they over-turn this and do it fast. According to them, if you fax and ask for expedited, they will make a determination within one day. I just think this sucks because now I have to wait all weekend and it has just made me so down. Carole > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 8, 2001 Report Share Posted December 8, 2001 Carole, I understand your frustration, but it sounds like you're taking the appropriate steps to resolve this issue to your satisfaction! Don't give up and keep us updated! *hugs* Anita > > > > The letter says " The Care Management Dept. of Medical Mutual has > received a request for out-of-network care for the above referenced > patient at or by: Dr. S. Oakley for the following days of > service: 12/18/01 to discharge. > It has been determined that the requested services can be provided > within the network. Therefore your request for out-of-network > services(s) is/are denied. Please be advised that utilizing a > provider outside of the netwoirk/first teier or non-contracting may > result in additional financial liability. In the future, for the > most cost-effective use of your insurance benefits, it is necessary > to keep medical care within the provider network if at all possible. > > The subscriber or provider can submit an oral or written request for > an expedited or standard appeal. Expedited requests are granted for > services that are ongoing or imminent. The appeal should include any > relevant information to the reconsideration of the denial. The > appeal must be initiated within ninety (90)days from the date of this > letter. Please attach a copy of this letter to all appeal requests. " > > So - what I did was send them the original approval letter (which was > submitted by Dr. Oakley, also) and a copy of the information I was > given by my employer for the plan I bought (which just showed less > being paid for out of network) and copy of my card which shows the > type of insurance I bought, plus a letter explaining that I was told > that only if I was in an HMO would I be required to stay in network, > but that if I wanted to go out of network, I could do so without a > referral and just have to pay the difference. I also cc: to the > Ohio Dept of Insurance. I also posted a complaint on the Ohio Dept > of Insurance website. > I hope they over-turn this and do it fast. According to them, if you > fax and ask for expedited, they will make a determination within one > day. > I just think this sucks because now I have to wait all weekend and it > has just made me so down. > Carole > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 9, 2001 Report Share Posted December 9, 2001 Carol, I am so sorry. I do understand what you are going through. I am beginning to feel some of your stress. I have worked for the same company for 7 1/2 years. I told my employer I wanted to have surgery in January because I wanted to not inconvenience him during the holiday season. Now he is not scheduling me enough hours to keep my insurance. Which I have had no problems with for the last 7 years or so. When I asked him about it, he said I would have to beg for hours from my co-workers. The funny thing is he thinks that I have to have 96 hours a month but after calling my benefits department they confirmed that it is only 80 hours. I have 54 so far this month and I feel I will make the quota. But my boss told me that if they did not have enough hours for me he would have to lay me off. I should have just had the surgery in Dec., and said to hell with trying to accomodate my employer. I hope that you get all your problems worked out and I hope that mine don't get as complicated as yours. I will know more in a few weeks as I am scheduled for surgery January 9,2002. Good Luck!! M. --- MsMystic1@... wrote: > Well, I am wondering if I am really ever going to > get this surgery. First of > all, I got laid off, so have to spend a fortune on > COBRA, but to top that > off, even though I got an approval letter from > Cleveland Medical Mutual, > today I got a denial from the Toledo, OH office, > because they say I can get > the services within network and I requested out of > network (requested with > Dr. Hess). Now, I pay through the nose for the > insurance I have and > specifically got this because they said I could go > out of network and only > the HMO required that I stay in network. I even > have a breakdown of what > they will pay in/out of network. I know I will have > to pay more for out of > network, so why are they giving me a hard time about > this? Now I have to > appeal this and go through all of that stress. > I have heard that Medical Mutual wants people to use > their Dr. who is at > Toledo college (somewhere) probably to get him > business, but I also read on > line that he didn't seem to know what he was doing a > woman who went to him > only lost about 30 lbs. I do not want to go to him. > I am really DEPRESSED. > Carole > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 10, 2001 Report Share Posted December 10, 2001 Hi Carole, I hope you get an answer on this today. Bravo on jumping right back at them with your appeal! Since I've written employee benefits information for 10 years, I've seen my fair share of insurance-speak. That said, when I read the following (emphasis CAPS added): >It has been determined that the requested services can be >provided within the network. Therefore your request for >out-of-network services(s) is/are denied. Please be advised >that utilizing a provider outside of the netwoirk/first teier >or non-contracting may result in ADDITIONAL FINANCIAL LIABILITY. >In the future, for the most cost-effective use of your insurance >benefits, it is necessary to keep medical care within the >provider network if at all possible. I don't think they are denying you benefits outright. Many network plans will pay in-network rates for out-of-network providers ONLY if they do not have that particular type of specialist in-network. So, from reading what they said, I think what they are saying is " we have an in-network specialist, therefore if you go to this out-of-network provider your benefits will not be paid at in-network rates, rather out-of-network rates. " The lower rate causing you to have more out- of-pocket expenses, hence the " additional financial liability. " Hope this makes sense. Good luck! I hope you get it, I'm pulling for you. a fellow COBRA-rates victim > Well, I am wondering if I am really ever going to get this surgery. First of > all, I got laid off, so have to spend a fortune on COBRA, but to top that > off, even though I got an approval letter from Cleveland Medical Mutual, > today I got a denial from the Toledo, OH office, because they say I can get > the services within network and I requested out of network (requested with > Dr. Hess). Now, I pay through the nose for the insurance I have and > specifically got this because they said I could go out of network and only > the HMO required that I stay in network. I even have a breakdown of what > they will pay in/out of network. I know I will have to pay more for out of > network, so why are they giving me a hard time about this? Now I have to > appeal this and go through all of that stress. > I have heard that Medical Mutual wants people to use their Dr. who is at > Toledo college (somewhere) probably to get him business, but I also read on > line that he didn't seem to know what he was doing a woman who went to him > only lost about 30 lbs. I do not want to go to him. > I am really DEPRESSED. > Carole Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 10, 2001 Report Share Posted December 10, 2001 Hi , What is it with these employers?!? It's the holidays for pete's sake. Did they all take a giant Scrooge pill before Thanksgiving or something?!?! Good luck on your quest for enough hours. I hope your co-workers will give you what you need to make your 80 hours. > > Well, I am wondering if I am really ever going to > > get this surgery. First of > > all, I got laid off, so have to spend a fortune on > > COBRA, but to top that > > off, even though I got an approval letter from > > Cleveland Medical Mutual, > > today I got a denial from the Toledo, OH office, > > because they say I can get > > the services within network and I requested out of > > network (requested with > > Dr. Hess). Now, I pay through the nose for the > > insurance I have and > > specifically got this because they said I could go > > out of network and only > > the HMO required that I stay in network. I even > > have a breakdown of what > > they will pay in/out of network. I know I will have > > to pay more for out of > > network, so why are they giving me a hard time about > > this? Now I have to > > appeal this and go through all of that stress. > > I have heard that Medical Mutual wants people to use > > their Dr. who is at > > Toledo college (somewhere) probably to get him > > business, but I also read on > > line that he didn't seem to know what he was doing a > > woman who went to him > > only lost about 30 lbs. I do not want to go to him. > > I am really DEPRESSED. > > Carole > > > > > -------------------------------------------------------------------- -- > > Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.