Sunday, April 17, 2011

You think I'd crumble? You think I'd lay down and die? Oh no, not I . . .*

A full week of no updates . . . and what do I have to show for it?


Those are the supporting documents that were included in my insurance appeal.  (No, I didn't include 6 packets of blank paper---those ones are just flipped face down due to identifying information).  While I've often alluded to the misery of fighting with insurance, I don't think that I've ever taken the time to really lay the battle out.  Now that our appeal has been finished and sent, I have the presence of mind for some explanation.

I have regular fights debates clarifying conversations with the kind customer service folks over at our insurance company.   Just this week, we had 2 chats:

Monday: I receive 3 denials of claims for pediatrician visits (I tend to save up receipts and then send a bunch at once).  Upon calling and talking to the rep, I explain that I don't think it's possible that we haven't met our deductible for Maya.  He says "well, remember, the amount is not based on how much the doctor bills, it's based on how much we pay out."  I fumble with receipts, sigh, and ask why her vaccinations weren't covered, since the form says "Vaccinations are only included until the patient's 19th birthday."  At this point we realize that all of the claims were processed under my name instead of Maya's, and we have the exact same exchange that I have at some point during Every Single Call to the company:

Him:  Well, ma'am, the doctors office must have made an error in filling out the forms.
Me: Actually, I fill out the forms.  And at this point, I could do them in my sleep.  Are you able to pull up an electronic copy on your computer and verify that there's not a mistake on the forms?
Him: Hold on one second (click clack clickety clack).  Hmmmm.  (click clack clickety clack) Well, ma'am it seems like everything is in order here.  I'm going to just go ahead and reprocess them for you.
Me:  Ok, great.  (eyes rolling until they nearly touch my brain)  Thanks so much for your help.

Tuesday:  While cleaning off my desk (sorting through papers for the appeal) I find an older denial for 2 pediatrician visits.  This time the reason for the denial is "The treatment was given in an inappropriate or invalid place of service"  (yes, that's a direct quote).  And the call went like this:

Me: I'm calling because I think these claims may have been processed incorrectly.
Insurance: Well, ma'am, I'm seeing that they were denied because the service was provided in an "incorrect or inappropriate location".
Me: Well, they were pediatrician appointments. In the pediatrician's office. I'm not sure where else we could have met with him.
(then we looped directly into the conversation quoted above)

Anyway, this appeal was not about these smaller denials---it's about 79 (so far) denials for Maya's feeding therapy.  Maya gets private feeding therapy twice a week, which is invaluable to the development of her muscles and coordination, and is a large part of the reason that she's not still eating jars of baby food (which she was still on until after her 2nd birthday).   To make a 3-month-long-story short, after manymanymany phone calls and re-submissions, we found out that the therapy was being denied because it was being provided by a speech-language pathologist (SLP) . . . to the company, appropriate providers of feeding therapy included pediatricians, GI surgeons, and family practicioners. 

(If I hadn't been in frustrated tears at this point of this particular phone call, I would have burst out laughing.)  For those of you not in-the-know, this is the equivalent of saying "We cover root canals, except if they're done by an oral surgeon.  If you have a root canal done by a manicurist, janitor, or high school principal, we'll totally hook you up."

So my appeal was two fold---providing ample evidence that this treatment is medically necessary and highly beneficial for Maya, and attempting to convince them that an SLP is the most highly qualified provider of this service***.  It was a 45 page appeal, including:  a letter of medical necessity from our pediatrician, a letter of medical necessity from our developmental pediatrician, a letter of medical necessity from our feeding therapist, Maya's first feeding evaluation (at 9 months), Maya's most recent feeding evaluation (at 31 months), a phone call log of all of the discussions that I've had regarding these claims, an Excel spreadsheet of the claims and their pertinent information, 2 documents from 2 different insurance companies that show that they only pay feeding therapy claims to SLPs, 2 research articles that explain why SLPs are the most qualified providers for feeding therapy and explain that their knowledge base is unique and nontransferrable to other types of providers.


It's taken me a few months to gather the appropriate paperwork (we couldn't get a letter from the developmental ped until we had our check-up, which takes a few weeks to schedule, etc).  I didn't realize how much having this thing hanging over me was really affecting me (subconsciously) until it was gone. 

It all goes right back to that learned helplessness stuff that I've talked about before.  It's such a downer to have something that you need to do, when you're powerless to get it done.  My to-do list felt insurmountable when I had this deeply subconscious inner dialogue of "Why bother calling that doctor to schedule an appointment?  You haven't even made a dent with the insurance yet."  or "How can you take the time to respond to emails when you should start typing a call log for the appeal?"

So either I would do smaller things on my list and feel guilty about not making appeal progress, or work on the appeal and watch my apartment get messy, take-out get ordered, and a million little things amass on my daily list and fester.

It's so hard to feel powerless.

And I'm so glad that the appeal is done :)

So now the ball is in their court. 

Be sure to stay tuned for a ridiculous update about how it was denied because they are only able to process appeals that are typed in Times New Roman, or postmarked on a Saturday, or whatever.

 ***As an aside, I'm not fully convinced that it actually is their policy that SLPs are not payable---I feel like they may have just been using that as a deterrent in the system to get me to throw up my hands and give up.  They refused to provide me with the policy in writing, telling me that then I could "just commit insurance fraud."  (How?  I'm not sure.)

I realize this makes me sound like a conspiracy theorist, but these people have pushed me right to the edge.  During one call, at 12:27pm the person I had been speaking with said "Ma'am, I'm sorry, I suddenly can't hear you at all---you're breaking up---let me just put you on hold for a minute and then reconnect to see if that helps."  She hung up on me.  When I called back at 12:29 I got a recording: "Thank you for calling.  It is currently our lunch hour.  Please call back after 1:30pm EST.  Thank you." 

Seriously?  It's enough to make anyone go postal.


NCavillones said...

I am just flabbergasted. 45 pages? You are a superstar. Fingers crossed for vindication!

Marie said...

Insurance companies are awful to deal with. Thankfully- I've only had ours deny one thing thus far!

Mary McCormack said...

I love your sense of humor through all of this, not to mention your determination!

Anonymous said...

Insurance is horrifying to deal with, and yours sounds particularly so. I am hugely bothered by the fact that they won't give you a policy in writing. Can they actually Outright opt not to? We had trouble getting one, but they danced around it and blew me off. I still don't really
have anything in writing saying they don't cover tube feeding supplies, but it's true that they aren't covering them. I know the frustration you describe, dealing with people that appear to big the biggest morons ever, and leave you wanting to bang your head against a wall. I am so rooting for you, and am in awe of basically the dissertation you put together. If I ever have to do something like this, maybe I can contract it out to you lol!

Erin B said...

After reading this to my husband, a lawyer, he was pissed. Its hard for him to give advice to someone in a different state but in MT it is incredibly illegal to deny a request for a copy of your policy. He strongly recommended you see a lawyer who knows NY insurance law because you are being treated very, very poorly....repeatedly. This is not something you should have to deal with. I am so sorry that a very busy mom has to WASTE her time with insurance appeals. :(

Dana said...

WagnerThree & Erin B: No, I've recently discovered that they are not legally allowed to just opt out of giving me details regarding my denials, and the relevant parts of the policy, in writing. (Of course, I found this only last week, as I was knee deep in appeal stuff).

I'm really hoping that the appeal will be appropriately reviewed and accepted. If it's denied, then it may be time to involve a lawyer---but I really don't want to because then any money that I might get back would likely go directly towards paying a lawyer's bill . . . so then there's not much of a point to this, anyway. Other than vindication ;)

Bonnie@TheFragileXFiles said...

OMG! That's all I can say.

Cheryl (in Buffalo) said...

I am so sorry that you are going through this...and I totally understand...having also had an unbelievable number of denials for my daughter's specialists! My favorite reason that they have given me to date is...."Denied due to the fact that this service has already been submitted for payment prior". The problem with that denial is that the doctor's office tried to resubmit the visit billing using a different code (which does sometimes help) for a claim that was originally denied....but how can they try to do that if the insurance wil not allow any rebilling? I have learned to go in to doctor's appointments saying "Please use the code for "x" before your regular code, because then the bills have a better chance of being paid....I am sure the doctor's offices don't like it, but I have less phone calls to make....

Anonymous said...

I am banging my head against a wall for you! I've had some denials that also were so ridiculous they would be funny if they weren't so time taxing. Isn't it amazing to think that our lives as parents would be so much easier if people just did the jobs they got paid to do? I raise my glass of wine to you, and chug it down for you as well.