Re: Insurance woes

[Guest guest]

Well,

This year I have United insurance- a plan Dr. G is on, and they will pay

if we go to Dr. G's office in person. (When we started with Dr. G we had

Aetna- a plan he was not on.) As far as I know, most if not all,

insurance plans will not cover " phone consultations " so that entire

expense is not covered. And unfortunately, since I don't live local to

Dr. G, our help comes via fax, email and phone. This is unfair, but it

is not Dr. G's fault. This is MANAGED care.

One thing to keep in mind, your state should have regulations to protect

you from HMOs. In Texas, if you can " prove " that your plan does not

have a local doctor to treat your child, the plan has to pay for one

that can treat your child. PPOs operate slightly differently. And

self-insured plans also have different rules.

You know you always have the appeal process, but this is a real pain.

If you can get to the face-to-face meeting with a panel to hear your

side, and if you come to the meeting very prepared to fight, you often

win. Insurance companies use the tactic of " saying no " as many times as

legally possible (without even listening to your argument) to wear you

down so you will give up and not make it to the face-to-face meeting.

You need to have a very good understanding of how your insurance is

administered and be prepared to fight, not just pay. It is very helpful

to get a HR rep on your side to help with the process, but this too

requires work to find someone who is skilled and willing to really help.

We have all made the choice- fight or pay- it depends on what it is

worth to you. Sometimes it is easier to pay.

Sincerely,

Plano, TX

Who is involved in the appeal process as we speak!

missy starr wrote:

>

> I was totally shocked and I am still in shock to know that I have went

> through the process of filling out all of the paper work in order to

> get an appointment with Dr. G and then to be told he cannot see me

> because of my insurance coverage. I am a military spouse and it

> really is ashame that many of us have to sit my on the sidelines

> because we do not possess the right insurance needed to see Dr. G. I

> had no problem purchasing the 3 tickets needed to get there but for 2

> kids to be seen would cost me both my arms and legs. When will Dr. G

> be open to an insurance such as Tricare if ever?

>

> Thanks

>

> Msadvo

>

>

[Guest guest]

((((((((((Dearest Judi))))))))))...golly, I wish I could help! You're

always in my heart & in my prayers, kiddo.

Much Love...

Tess

[Guest guest]

<PRE>kinda like my insurance, now they won't pay for any pt on my feet, won't

pay

for any yeast infection treatments. why?? because i used them too much. my dr

says they can't discriminate against me because of my disease. but they have.

i hope you find a good set of dr's you can agree with. i did that switch last

year except for my rheumi!!! i get my medicare in june. if i still get it.

haven't heard from them yet since they asked for my explaination on monies i

earned. (sick pay from work) hope the new plan works better for you. at least

they stopped it before you had over $8000 in pt bills!!! kathy in il

[Guest guest]

Judi,

Sorry to hear of your insurance troubles. I'm enrolled in a PPO

administered by BC/BS. It is not restrictive, like an HMO. I can go to any

doctor or facility I like. The difference is, if I choose to go to a doctor

or facility " out of network " my co-pay is higher. Also, I can be responsible

for the difference between the insurance company's " allowed amount " and the

doctor's or facility's actual " charged amount. " That difference, in some

cases can be quite significant. Some doctors will write off the difference

to keep a regular patient.

Do you know what insurance company is administering your new PPO? I bet you

can still continue to use the facility and the doctor you now have, you may

have to pay more out of pocket. And you are on the right track, try to get

your doctors and hospital to enroll in the PPO. The more doctors and

facilities a PPO offers the better for the plan.

Let us know how things work out!

Suzanne

[ ] Insurance woes

> OK, guys, I'm really upset now. I just got a letter from our

> insurance company, telling me I was " terminated " (Arnold, how could

> you?) on December 31! When I called them they said, yes, I was

> terminated, but reinstated under the PPO plan effective Jan. 1, so

> now I can only use their approved providers. They'll send me a book

> which I " should receive in 7-10 working days. " I asked if my current

> physicians were included, and neither the primary doctor, rheumy (no

> loss there) or the local hospital are included!!

>

> The rheumy was no great loss, but I was just beginning to enjoy my

> hydro therapy sessions at the hospital, and had the first one

> yesterday, so now I have to quit them until I get the book. I like

> my pcp, and will ask him if he can request inclusion in the plan, but

> it is not likely as he is currently paid by the hospital, and they

> are not recognized by the ppo plan. Sheesh. I'm so upset I can

> hardly type, and my hands and wrists hurt so I have to do it slowly.

>

> Does anyone know of a good rheumy in either Indianapolis or

> Cincinnati? Of course, they will have to be part of the elite group,

> but I would appreciate some names if anyone has them. The odd thing

> is, Ron can continue to use any physician he wants to, because he is

> on Medicare.

>

> Help!

>

> Judi

>

>

>

[Guest guest]

Hi Jenna,

We have union insurance that is affiliated with BCBS. They

origionally paid us out-of-network benefits(50%). We appealled the

claim and fought for it to be covered in-network(80%) and they

approved it. We had the out-of-network option, but our main point

was that we didn't have an in-network option. These were our reasons.

1. It was prescribed by my son's pediatric neurosurgeon, who

specializes in Plagiocephaly and has had good results with the DOC

Band.

2. Our insurance was not in-network with Cranial Tech(who we used)

or any other company that made orthotic helmets. So we didn't have a

choice to pick someone in-network.

3. The DOC Band(and the Starband) is FDA approved to treat

plagiocephaly.

4. As stated by our ped. neuro., untreated plagio can cause

persistent facial asymmetry, which can affect mandibular mechanics,

jaw function and orbital alignment. Additional complications may

include middle ear infections, migraine headache, TMJ and vision

problems.

5. Since the only other course of treatment is surgery, we feel that

a non-evasive/non-surgical approach using a cranial remolding othosis

is the best and most cost effective course of treatment.

I think if you really push the point that they could not provide you

with someone in-network, they have to pay you something. Good luck,

I hope this was helpful. You can email me at TyJake@... if

you have any questions.

(mom to Jake 1yr and Tyler 3yrs)

--- In Plagiocephaly , " jzrodell " <jzrodell@h...>

wrote:

> Hi,

>

> Bridgette has been wearing her band for 2 1/2 months now. She was

> banded on April 3, at the age of 12 1/2 months. At first we were

> delighted with her progress, we noticed great results in the first

> month. After that, her growth slowed dramtically, and we have

> essentially not seen any discernable changes in the past 1 1/2

> months. I'm disappointed, but it's not unexpected, considering her

> age when we started.

>

> My insurance claim was denied b/c I used an out-of-network

provider.

> I'm on Blue Cross Blue Shield's new " Basic " plan for the federal

> government, which basically restricts all coverage to their network

> of docs. The only problem is that there is no network provider for

> the DOC band in our area. Has anyone else had a similar

situation?

> I've been doing some research, but so far have only seen appeals

> based on medical necessity. Any advice would be greatly

appreciated!

>

> Thanks in advance for your help,

> Jenna, mom to Bridgette, 15 months, DOC bandit

[Guest guest]

Jenna,

Something to keep in mind - Cranial Technologies are not " in

network " for ANY insurance companies, but sometimes the orthotists

for other bands are. We're currently trying to straighten this out

with our insurance company as well. Good luck!

Kerri

Mom to (DOC banded 5/9/03)

--- In Plagiocephaly , " jzrodell " <jzrodell@h...>

wrote:

> Hi,

>

> Bridgette has been wearing her band for 2 1/2 months now. She was

> banded on April 3, at the age of 12 1/2 months. At first we were

> delighted with her progress, we noticed great results in the first

> month. After that, her growth slowed dramtically, and we have

> essentially not seen any discernable changes in the past 1 1/2

> months. I'm disappointed, but it's not unexpected, considering

her

> age when we started.

>

> My insurance claim was denied b/c I used an out-of-network

provider.

> I'm on Blue Cross Blue Shield's new " Basic " plan for the federal

> government, which basically restricts all coverage to their

network

> of docs. The only problem is that there is no network provider

for

> the DOC band in our area. Has anyone else had a similar

situation?

> I've been doing some research, but so far have only seen appeals

> based on medical necessity. Any advice would be greatly

appreciated!

>

> Thanks in advance for your help,

> Jenna, mom to Bridgette, 15 months, DOC bandit

[Guest guest]

Jenna,

With the DOC band, if there is not another facility within 50 miles,

than you can fight it being in-network...Also, if your insurance

company does not have any other ortho in-network, than this is the

only facility that you can use and you can justify it that way. Hope

his helps. Best of luck!

Randi

mom to Drew almost 7 months DOC band 4-28

> > Hi,

> >

> > Bridgette has been wearing her band for 2 1/2 months now. She

was

> > banded on April 3, at the age of 12 1/2 months. At first we were

> > delighted with her progress, we noticed great results in the

first

> > month. After that, her growth slowed dramtically, and we have

> > essentially not seen any discernable changes in the past 1 1/2

> > months. I'm disappointed, but it's not unexpected, considering

> her

> > age when we started.

> >

> > My insurance claim was denied b/c I used an out-of-network

> provider.

> > I'm on Blue Cross Blue Shield's new " Basic " plan for the federal

> > government, which basically restricts all coverage to their

> network

> > of docs. The only problem is that there is no network provider

> for

> > the DOC band in our area. Has anyone else had a similar

> situation?

> > I've been doing some research, but so far have only seen appeals

> > based on medical necessity. Any advice would be greatly

> appreciated!

> >

> > Thanks in advance for your help,

> > Jenna, mom to Bridgette, 15 months, DOC bandit

[Guest guest]

Excellent post. Thank you so much!

My only woes have been the cost that my dr charges me. His medical

group charges me 86.00 (43.00 an injection) to give the Xolair to me

and my doctor is very careful and will not let me give them to myself

at home. He is the ONLY doctor who gives Xolair within 200 miles and

is NOT in my insurance network.

the co pay of 30.00 a month for 4 injections is not bad at all, but it

really eats my pocket to pay the administration charges.

He IS trying to work out the cost for me. His medical group sets the

prices and billing not him.

Oh by the way...my asthma lately.... ASTHMA? what asthma?

I only neb once a day an sometimes not even then. I do use my advair

twice daily. I used to be on 50 mg of pred a day, pulmicort, atrovent

and xopinex updrafts 3-5 times a day.

Pred? What is pred

Doug

Group founder

Co/owner/moderator

[Guest guest]

Wow...$86? My doc charges BCBS of Alabama $14 every two weeks for my injections

at her office. Suprisingly enough, they pay every penny. Usually the docs

charge higher fees and get beaten down to nothing by BCBS.

uca79iii <uca79iii@...> wrote:

Excellent post. Thank you so much!

My only woes have been the cost that my dr charges me. His medical

group charges me 86.00 (43.00 an injection) to give the Xolair to me

and my doctor is very careful and will not let me give them to myself

at home. He is the ONLY doctor who gives Xolair within 200 miles and

is NOT in my insurance network.

the co pay of 30.00 a month for 4 injections is not bad at all, but it

really eats my pocket to pay the administration charges.

He IS trying to work out the cost for me. His medical group sets the

prices and billing not him.

Oh by the way...my asthma lately.... ASTHMA? what asthma?

I only neb once a day an sometimes not even then. I do use my advair

twice daily. I used to be on 50 mg of pred a day, pulmicort, atrovent

and xopinex updrafts 3-5 times a day.

Pred? What is pred

Doug

Group founder

Co/owner/moderator

[Guest guest]

Thak you Aramo. Good tips for the consumers.

__________________________________________________

[Guest guest]

Doug,

I am so thrilled for you. Everyone will get there eventually. As for the

cost at the doctor, all I can say is...Move closer to me, I'll give them to you

for free!

Pat

__________________________________________________

[Guest guest]

--- In , " G. " <rrgrimes_u3@y...>

wrote:

>

> Wow...$86? My doc charges BCBS of Alabama $14 every two weeks for

my injections at her office. Suprisingly enough, they pay every

penny. Usually the docs charge higher fees and get beaten down to

nothing by BCBS.

>

>

>

My insurance is Highmark BCBS out of Penn. They pay GREAT in network.

My doctor's group is NOT in network with them. Sad, but the one drug

I need the most is only given by one doctor in the area and his group

is OUT of network.

I pay the 12k in premiums for me and my wife.. NOT my employer. It

sure would be nice if these companies and providers would not fight

about coverage. You know, there ARE people out here that NEED HELP

just to breathe! sheesh! Both sides say " oh, the patient is our first

priority "

LOL! Im laughing so loud rignt now i might have an asthma attack (grin)

Doug

[Guest guest]

Doug....

Perhaps if you come and stand beside me some of your

anti-pred will rub off. A bit of a fish out of water

today and not so pleased about it.....this taper is

like getting a root canal!

__________________________________________________________

Find your next car at http://autos..ca

[Guest guest]

>

> Doug....

>

> Perhaps if you come and stand beside me some of your

> anti-pred will rub off. A bit of a fish out of water

> today and not so pleased about it.....this taper is

> like getting a root canal!

>

>

>

>

,

I am sorry you are still having to take pred. I usualy have to go back

on a small dose during the summer when it's hot, usually 5-10 mg a day.

I can handle taking it for a few months out of the year. As a type II

diabetic, Pred makes my blood sugar zzzzzzzzzzzzzzoom up. My family

doc gives me pills to keep my blood sugar down. Before the Xolair, I

took it year round, usually 40-50 mg a day. I believe that taking so

much pred most of my life was a contributor to developing my diabetes

when I turned 50 year before last.

From what I understand (Pat, chime in here) the longer a person is on

Xolair, the more they can cut down on the pred, most of the time even

getting away from it, like me

Doug