Let's start with the backstories that are still untold. They will remain untold. Can't invade the privacy of others but I CAN say THIS:
I HATE HEALTH INSURANCE COMPANIES
NOW CLOSE YOUR EYES AND GLANCE RIGHT TO THE NEXT PARAGRAPH IF WORDS MATTER. WORDS MATTER TO ME, TOO BUT THIS TIME, IT MATTERS MUCH THAT I GET THIS COMPLETE AND UTTER ANGER OUT OF MY SYSTEM. USING MY WORDS JUST LIKE WE COACH OUR KIDS TO DO WHEN WE ARE TEACHING THEM TO SPEAK. I CAN HEAR ENCOURAGEMENT IN MY HEAD. USE YOUR WORDS, AM. C'MON, USE YOUR WORDS. OK. CUPCAKE, YOU ASKED FOR IT.....
I F'ING HATE EVERY F'ING HEALTH INSURANCE COMPANY IN THE ENTIRE F'ING COUNTRY.
OK, I'll admit even a warning to glance past to the next paragraph, that would be THIS paragraph, it was probably a bit on the difficult side to miss those words. Trust me. That sentence. I toned it down. I have plenty of adjectives I wanted to add to really drive the point home. Hit the contact button above and I'll gladly email you the full on inappropriate, disgusting language that's on the cutting room floor. And to anyone whom I may have offended, I sincerely apologize for offending you. But, I have to leave my statement as is. It's my truth.
(Editors note: And the sentence was toned down. Mom didn't like all those F's spelled out in such big letters. Mom's Know Best.)
(Editors note: And the sentence was toned down. Mom didn't like all those F's spelled out in such big letters. Mom's Know Best.)
And before I go any further, I just want to say I have a LOVE/HATE relationship with autocorrect. I NEED it because of the ongoing chemobrain issues whereby I transpose letters. It picks up most of my spelling mishaps. But..... sometimes, it changes little words on my and I re-read my stuff and think, WTF???? I see "on" when it should say "of" or, well, come to think of it, I might see "or," too. Whatever. I do know how to write. Mostly. And when my grammar is atrocious. It's mostly deliberate. Had to get that off my chest.
This is what happened in ONE day. Yesterday. And it consumed an entire day to resolve this stuff. Two of us were involved on separate phone lines working our way through separate mazes of push button hell and when I learn who came up with that F&*^%& system, I could end up doing time in Bedford, JUST sayin'. I may end up in the digs of Jean Harris OR, perhaps Martha Stewart. I'm guessing I'd be able to tell if I found my way to Martha's cell because of some sort of cutesy etchings on those bars?
No procedure, no test, no surgery, no hospital admission, NO NOTHING can be done because a DOCTOR, YOUR doctor actually prescribes it. First, everything needs to be pre-certified by some other supposed doctor at some insurance company nine gazillion miles away. Someone who is working the statistics? Someone who has NO CLUE as to the nuances of what may be happening in your particular case.
Case in point? Prior to yesterdays series of debacles.... back in 2006, I received two letters in the mail from my insurance company. On the same day. Both DATED the same day. The first one was to inform me they very kindly approved my bilateral mastectomy as acceptable treatment for my recently diagnosed invasive carcinoma which as a bonus, included two days at Spa Sloan. (I say that with LOVE. The Integrative Medicine is part of the "all inclusive plan".... I could have scheduled reflexology or a bedside massage, I KID YOU NOT) And in envelope number two? "Ms. AM, you know that biopsy that was performed. The one that actually FOUND the cancer.... We ain't paying for that."
I think I received those letters within 48 hours of my scheduled surgery so I wasn't the most patient person on the planet. Although, soon, I'd have NO CHOICE but to be a patient. When I got through THAT particular push button hell maze, the very first real voice I heard got absolutely no information. I don't think I was rude. Those front line people have really sucky jobs. But I do remember saying something like this, "No offense, but I'm not wasting my time explaining what I am only going to have to RE-explain at least five more times, so I am NOT giving you my name or my ID number or ANYTHING. Please connect me to the people who deny coverage." And I'm fairly certain the next thing I might have heard was something like, "Ma'am, I need to see your records so I can properly......" And I'm absolutely certain the person was cut short and I was likely short tempered.
I'm guessing the next words from my mouth must have traumatized the poor entry level kid. I'm thinking it must have gone along the lines of, "I just found out I have breast cancer and I'm going to have BOTH of my breasts removed in two days. I need to discuss a denial with someone." Using the words "both of my breasts removed" is what I would call a "maximum impact ingenious power play" on my part. Not HIPAA but MIIPP. Close enough. The next person was on the phone in less than two minutes and within five, I had a fax in my hands rescinding the stupid denial. THAT was an insurance success story.
Yesterday, not so much.
Over a YEAR ago. Yes, I said a year ago, there was an episode. For the sake of the conversation, let's just say that a test had to be performed. A very, very expensive test and there was only one lab that could perform this test. AND, the lab happened to be in network with the insurance company. And it was agreed by all the test was likely necessary. Three doctors insisted it was absolutely necessary. And, time was of the essence and this was all playing out between Christmas 2010 and New Year's 2011. Try to get a doctor that week..... and try to expect anyone at an insurance company to actually apply any sort of logic to what was truly a life threatening situation.
The test was performed on January 2. 2011. The lab contacts the insurance company who MISINFORMS them, "You are not a network provider under this insurance policy." Ok. Into my pocket for lots and lots and LOTS of money. Misstep Number One. Had the lab been given proper information, everyone would have been on the phone on January 2nd working this out. Three weeks of arguing and I ultimately find out they ARE a network provider and as such, I should have only paid the "contract" rate which snagged me a refund. I saved LOTS. It only cost "lots and lots." By the time all of this played out, they now had to make a "backward review" regarding the need for this test. Because the results were in, and everything had stabilized, the insurance company gets to Monday morning quarterback and say, "not medically necessary." Appeals are made with full medical documentation. DENY. DENY.
Under NYS law, I have 45 days following a final adverse determination to make a complaint and request an independent review. I made my appeal on day 43 or 44 depending upon when the clock starts and stops. Does the day of the letter count as day one or is it the day AFTER the letter? No matter. The appeal was made before Day 45. That was one year ago. I've made a number of calls and it was still under review.
In an odd twist, the same test had to be repeated after the first one was deemed "not medically necessary." This time however, the test was performed out of town by an out of network provider. They followed procedure to the letter. Test was approved. Two follow up tests were also approved. I paid up front and would be reimbursed because all of the stupid rules were followed. Yay, me. Go through phone maze hell to make sure everyone is on the same page. Mission Accomplished. That bill was submitted about three months ago.
Recently, a determination was made that further follow up testing should be done. In other words, Round Three. It is accepted medical protocol. The insurance company is contacted. Lab is in network. "Your insurance is cancelled as of December 31st." HUH??? Over the past couple of weeks, paperwork was straightened out and this is all thanks to the fact that there are now three insurance companies in NYS. They all merged. The merged records can't be accessed when the number on the card is called. Those records aren't in THEIR computers. Two weeks to get that resolved. Coverage is approved. By the time the appointment is scheduled, the approval is no longer valid. And now we are at today.... and if you made it this far..... gee whiz thanks..... but THIS is what happened today.
The appointment was scheduled but the lab had to redo the pre certification. Shortly afterwards the lab called to say, "Your insurance is cancelled as of February 29th." Appointment was cancelled. Two hours for one person to go back and forth with the insurance company and dial no less than seven different phone numbers, get disconnected a few times upon transfer attempts. What happened? The insurance reverted back to the "original" ID number from December. ARE YOU KIDDING ME????? Now the lab has to be called back. Is the slot still available on Wednesday? As of this writing, there is no answer. FIRST, the lab has to call the insurance company back to reattempt the pre certification. THEN, they will reschedule the appointment.
As I was listening to all of this insurance talk, I decided to leave yet another message for the NYS Department of Labor regarding the appeal which is officially one year old. Voice mail. Half an hour later, the mail arrived. First, there is a letter DENYING the coverage that was so carefully pre certified. Now it was my turn to step into phone maze hell since I knew more about that whole process. I very calmly asked, "Can someone explain HOW you are denying a claim for which everything was PRE-APPROVED?" On hold and transferred, a few disconnects and ultimately, "The facility used the wrong code. We have nothing to match it up to." Yo, bitch. Your grammar sucks and you seriously must be kidding me. Call the facility from months ago. The place that is out of town. Explain that I need them to check the diagnosis codes and send me a new bill. They are lovely people and are quite accommodating. I have to call them again tomorrow to see if the person who handles all this code nonsense figured out what must be done to rectify the paperwork.
The better letter? I got my reply from the NYS Department of Labor. When the insurance company approved the second round of tests as medically necessary, I sent this information to be added to the complaint. That delayed things but it bolstered my position that the FIRST round of tests should never have been denied. Why did they approve round two and persist with the denial of round one? Makes NO sense. ANYONE with a brain and even with my friggen chemobrain, I can see that simply flies in the face of any and all logic. And that doesn't even address the fact that the facility was told they were not part of the network for round one which was NOT CORRECT. No doubt part of that "merger" thing and having information in seventeen different places.
I have NO idea what they are looking at but today I was informed that I forfeited my right to an external appeal because I did not follow the 45 day rule. ONE year later.... it took ONE YEAR for some smart ass to look at something and once again, blame me.
I actually took out a calendar and counted the days. I have copies of everything including confirmation of my online submission. All timely. Several thousand dollars is riding on this external appeal and complaint against OXFORD INSURANCE COMPANY and one of their OUTSOURCED pre certification companies. "In accordance with the law, the company issued a final adverse determination notice on ..... notice provide you with right to file External Appeal....... time allowed by law has now expired....... unable to resolve questions of medical necessity. SUCH ISSUES CAN ONLY BE DECIDED IN A COURT OF LAW."
And the kicker: "We regret that we cannot be of assistance to you." And to that I say, "By the time I'm done, everyone is going to regret far more than that. You can take that to the bank.... and get me my money back while you're there."
First of all, no one is seriously ill. These ongoing tests are precautionary AND MEDICALLY NECESSARY according to several doctors and in accordance with all accepted medical protocol. Second of all. They picked the WRONG BITCH on the WRONG DAY OF THE WEEK. My state assemblyman lives around the corner. I'm still deciding if I should ring his bell or just contact the media. I'm tired. I have no more fight left in me for this bullshit. But, there's lots of money on the table and it belongs to me. It is rightfully mine. And I know this is the game they play. Wear you down and wear you down until you finally go away.
I'm not going anywhere. Like I said. Wrong Bitch. Wrong Day. And after all of this. NOTHING is RESOLVED. Two of us will be at it again tomorrow. Time to zip it....I'm ready to rile myself up all over again.............
Over a YEAR ago. Yes, I said a year ago, there was an episode. For the sake of the conversation, let's just say that a test had to be performed. A very, very expensive test and there was only one lab that could perform this test. AND, the lab happened to be in network with the insurance company. And it was agreed by all the test was likely necessary. Three doctors insisted it was absolutely necessary. And, time was of the essence and this was all playing out between Christmas 2010 and New Year's 2011. Try to get a doctor that week..... and try to expect anyone at an insurance company to actually apply any sort of logic to what was truly a life threatening situation.
The test was performed on January 2. 2011. The lab contacts the insurance company who MISINFORMS them, "You are not a network provider under this insurance policy." Ok. Into my pocket for lots and lots and LOTS of money. Misstep Number One. Had the lab been given proper information, everyone would have been on the phone on January 2nd working this out. Three weeks of arguing and I ultimately find out they ARE a network provider and as such, I should have only paid the "contract" rate which snagged me a refund. I saved LOTS. It only cost "lots and lots." By the time all of this played out, they now had to make a "backward review" regarding the need for this test. Because the results were in, and everything had stabilized, the insurance company gets to Monday morning quarterback and say, "not medically necessary." Appeals are made with full medical documentation. DENY. DENY.
Under NYS law, I have 45 days following a final adverse determination to make a complaint and request an independent review. I made my appeal on day 43 or 44 depending upon when the clock starts and stops. Does the day of the letter count as day one or is it the day AFTER the letter? No matter. The appeal was made before Day 45. That was one year ago. I've made a number of calls and it was still under review.
In an odd twist, the same test had to be repeated after the first one was deemed "not medically necessary." This time however, the test was performed out of town by an out of network provider. They followed procedure to the letter. Test was approved. Two follow up tests were also approved. I paid up front and would be reimbursed because all of the stupid rules were followed. Yay, me. Go through phone maze hell to make sure everyone is on the same page. Mission Accomplished. That bill was submitted about three months ago.
Recently, a determination was made that further follow up testing should be done. In other words, Round Three. It is accepted medical protocol. The insurance company is contacted. Lab is in network. "Your insurance is cancelled as of December 31st." HUH??? Over the past couple of weeks, paperwork was straightened out and this is all thanks to the fact that there are now three insurance companies in NYS. They all merged. The merged records can't be accessed when the number on the card is called. Those records aren't in THEIR computers. Two weeks to get that resolved. Coverage is approved. By the time the appointment is scheduled, the approval is no longer valid. And now we are at today.... and if you made it this far..... gee whiz thanks..... but THIS is what happened today.
The appointment was scheduled but the lab had to redo the pre certification. Shortly afterwards the lab called to say, "Your insurance is cancelled as of February 29th." Appointment was cancelled. Two hours for one person to go back and forth with the insurance company and dial no less than seven different phone numbers, get disconnected a few times upon transfer attempts. What happened? The insurance reverted back to the "original" ID number from December. ARE YOU KIDDING ME????? Now the lab has to be called back. Is the slot still available on Wednesday? As of this writing, there is no answer. FIRST, the lab has to call the insurance company back to reattempt the pre certification. THEN, they will reschedule the appointment.
As I was listening to all of this insurance talk, I decided to leave yet another message for the NYS Department of Labor regarding the appeal which is officially one year old. Voice mail. Half an hour later, the mail arrived. First, there is a letter DENYING the coverage that was so carefully pre certified. Now it was my turn to step into phone maze hell since I knew more about that whole process. I very calmly asked, "Can someone explain HOW you are denying a claim for which everything was PRE-APPROVED?" On hold and transferred, a few disconnects and ultimately, "The facility used the wrong code. We have nothing to match it up to." Yo, bitch. Your grammar sucks and you seriously must be kidding me. Call the facility from months ago. The place that is out of town. Explain that I need them to check the diagnosis codes and send me a new bill. They are lovely people and are quite accommodating. I have to call them again tomorrow to see if the person who handles all this code nonsense figured out what must be done to rectify the paperwork.
The better letter? I got my reply from the NYS Department of Labor. When the insurance company approved the second round of tests as medically necessary, I sent this information to be added to the complaint. That delayed things but it bolstered my position that the FIRST round of tests should never have been denied. Why did they approve round two and persist with the denial of round one? Makes NO sense. ANYONE with a brain and even with my friggen chemobrain, I can see that simply flies in the face of any and all logic. And that doesn't even address the fact that the facility was told they were not part of the network for round one which was NOT CORRECT. No doubt part of that "merger" thing and having information in seventeen different places.
I have NO idea what they are looking at but today I was informed that I forfeited my right to an external appeal because I did not follow the 45 day rule. ONE year later.... it took ONE YEAR for some smart ass to look at something and once again, blame me.
I actually took out a calendar and counted the days. I have copies of everything including confirmation of my online submission. All timely. Several thousand dollars is riding on this external appeal and complaint against OXFORD INSURANCE COMPANY and one of their OUTSOURCED pre certification companies. "In accordance with the law, the company issued a final adverse determination notice on ..... notice provide you with right to file External Appeal....... time allowed by law has now expired....... unable to resolve questions of medical necessity. SUCH ISSUES CAN ONLY BE DECIDED IN A COURT OF LAW."
And the kicker: "We regret that we cannot be of assistance to you." And to that I say, "By the time I'm done, everyone is going to regret far more than that. You can take that to the bank.... and get me my money back while you're there."
First of all, no one is seriously ill. These ongoing tests are precautionary AND MEDICALLY NECESSARY according to several doctors and in accordance with all accepted medical protocol. Second of all. They picked the WRONG BITCH on the WRONG DAY OF THE WEEK. My state assemblyman lives around the corner. I'm still deciding if I should ring his bell or just contact the media. I'm tired. I have no more fight left in me for this bullshit. But, there's lots of money on the table and it belongs to me. It is rightfully mine. And I know this is the game they play. Wear you down and wear you down until you finally go away.
I'm not going anywhere. Like I said. Wrong Bitch. Wrong Day. And after all of this. NOTHING is RESOLVED. Two of us will be at it again tomorrow. Time to zip it....I'm ready to rile myself up all over again.............
Anne Marie:
ReplyDeleteI sincerely feel your pain. I went rounds with the insurance companies when I had my first mastectomy in 1990 and have dealt with them numerous times since. I swear they look for employees with the brains of a gnat - dealing with them is the ultimate frustration. Hang in there - we're all rooting for you!!!
Hi Ellen,
DeleteThanks.... It really means so much to read "we're all rooting for you!!!" I know that sounds so trite but it's true. This may come down to a lawsuit, but I am up for a good fight. And, prior to this chemobrain crap, I was really good at making an argument. Now, I'll just write a timeline and turn it over to an attorney.
AnneMarie
AnneMarie, how awful that you are subjected to this nonsense. I've learned to hate the word "regret." It's overused for everything from insurance and other bureaucracy to hanky-panky. I feel your pain. All I can say is someday it will be over and you will be able to look back on it. I tell myself that over and over. XX
ReplyDeleteI've told my kids dozens and dozens of times, "Regret is a useless emotion." And you are so right..... "we regret to inform you" ... I mean, hell, it doesn't get more ominous than that, right? They may have done me a favor. Given the content of the treatment, I may have a great case. I'm going for it.....
DeleteYou know, the thing that always makes me insane with these kinds of things is that they happen to people who are not in the best position to fight back, who have CANCER, for instance, for god's sake. And yet, one is forced to marshal one's fractured inner resources and do battle for oneself. I hate the battle metaphors applied to our struggles with cancer itself. But they are entirely apt when we have to do battle with the insurance system. Sigh...
ReplyDeleteGo for it, AM. If need be, I'll show up to help you, in my Warrior Princess costume with a bow & quiver, and we can park ourselves on a few doorsteps. THAT should get some attention...!
Ha! You secured yourself a seat at the table in front of the judge. I'll have to find an appropriately complimentary outfit. For anyone who is reading this comment and has not visited Kathi's blog, she just wrote a piece about The PRICE of cancer..... We kinda sync'd up in that period-ish college-ish kinda way.. except without the need for .... never MIND.....
Delete