INSURANCE COVERAGE

[luvmydogs53]

Hi,  I am still trying to deal with the news ( 11 days) of having an AN. I do want to thank John, Matti, & Lynn for thier helpful words. Each day I get more depressed than the day before. It might be the work I have ahead of me. My newest problem is how to contact these different places I have read about on this sight ( MEI, House) If my insurance is not accepted how can I challange it? I am sure others have had this problem. Thanks

[JHager]

Hello!

I had the same problem with my insurance when my son had to go out-of-network for treatment of his seizure condition.  Although it took awhile, the insurance company did finally approve his treatment.

Here's a few helpful things:

1) STAY CALM!  Remember, the insurance company is in this to make a profit - the more they pay out, the less they make!  You are just a voice on the phone.  If you can stay calm, and even friendly, you smooth the way.

2) The first person you talk to at the insurance company will almost certainly NOT be empowered to make this decision.  If that person is not able to help, request a supervisor.  For subsequent phone calls, always request that same supervisor.

3) Send a detailed fax about your condition.  AN is a relatively rare thing, so the insurance company may not have much experience in its treatment.  Mention the expertise of House for surgery, and Barrow, or Stanford, or Pittsburgh, etc., for radiosurgery.

4) Find out what the process is for appealing a decision should your treatment not be approved.  Follow it to the letter, providing as much detail as possible.  Find out if there's a neurosurgeon or radiosurgeon in-plan and speak to them.  A good doc will give you the names of other docs to get  second opinion.

5) Talk to the folks at House - they deal with this issue all the time, and can help communicate with your insurance.  (That is, if you choose the surgery route.)

6) Talk to an attorney.  Most insurance companies are used to hollow statements like "I'm calling my lawyer!".  However, when the insurance company is actually contacted by an attorney, the gears can often become magically unstuck.

7) Be persistent!  This is your health, and your insurance is there to assist you in maintaining it.

Document everything: every phone call, name, time, response, etc.

9) REMAIN CALM!

Remember, the squeeky wheel gets the oil - if you remain silent, they'll ignore you.

Hopefully, you won't have to much more than present your case well.  But if that doesn't work (as it didn't for me), these are the steps I took to get the  ball rolling.

Good luck!

Josh

[jw]

Hi, there!

I'm sure it is still quite a shock to you, and I can't even begin to know what you're going through.  One day at a time sounds so easy when you're sitting on this side of the fence.  But, remember that many people are diagnosed with this and do get through it ok.  Jake and Linda (see the thread "4 days until surgery") have recently had their surgeries (last week) and are back on the board.  They sound like they are doing well.  There will be a lot of work ahead of you getting things organized, and dealing with insurance companies doesn't make it any easier.  But in the end, when it's behind you, I'm sure that you will feel a great sense of relief and be very happy to have it all behind you.  Somehow, you'll end up stronger for having gone through it.  Until then, work towards tomorrow. 

[kristin]

i'm sorry that you are getting more and more depressed. have faith, k? there are a lot of people here that know what you're going through and are here to help!

i work in medical billing and still the insurance thing can be a little cloudy. i guess the first question is: what kind of insurance do you have? do they cover surgery? how do they treat surgeries out of network? find out what kind of criteria they have and get letters from all your docs..primary care physician, neurosurgeons, neurotolaryngologists, otolaryngologist.  EVERYONE! recommending you to have surgery/fsr/gamma knife (whatever you choose...wherever you want to have it done) have the place of service you choose send a letter. dr. brackmann sent a letter to my insurance for example. don't be afraid to get a little emotional on the phone either...never hurts! this is your brain! remember, chances are the people on the other end of the line have no idea how rare an AN is or how important it is to have the best possible care. this isn't knee surgery we're talking about!

i would read the fine print, call and talk to the pre-auth people (they knew me by my first name). GET IT IN WRITING (before surgery)  i lucked out...my insurance covers things out of network as in-network if they have the following criteria: 1) medically necessary; 2) cannot be done in-network; 3) referred by an in-network physician; and 4) pre-approved. i just yesterday (for real...6 months post-op) got my surgery paid correctly. i had to call and call and call until they finally paid correctly.

anyway...i hope this has helped a little bit.

kristin

[okiesandy]

Luv,

I have been fighting insurance for the last six weeks. Even Rita with Dr. Brackannn's office is frustrated. I have contacted our state Insurance Commission and even they say no hope. Policy is explicit. Will only pay as out of network after usual and custommary rates in my state. I was going to watch and wait for a while then had a 6 months MRI an it is cystic and growing. In desperation I contacted Dr. Clinton Medbury III who posts on another forum. He has sent me many, many, many things on Radiation CK and GK. I have an appointment with him in two weeks. From what I am researching and finding out is that I'm really leaning toward that option. Fortunately it is avaiable locally and maybe there was a reason I could not get past square one with the insurance co. 

I really thought there was only one way to attack this AN. That's what all the doctors I have been to said. Then I contacted several people who had had radiosurgery and radiotherapy. Guess what? I changed my mind. There is more than one way to do this.  Hang in there.

[luvmydogs53]

Since my last post about insurance I went to an in network neurosurgeon. It was worse than I ever expected. He was ignorant about AN surgery and was pushing for Gamma Knife. I explianed that I had not even given either one a fair chance because I was trying to gather information. He and his partner had never done any AN surgeries. He was cold and very matter of fact during my visit. He then worte out a prescription for another MRI with contrast in my primary drs name instead of mine. I will not go back to him again. After my MRI I will pay out of pocket for a dr visit on 11-04 with a very knowlegable dr. After we talk I will start with the insurance co.  Thanks for the advice 

[okiesandy]

Sorry about your doctor. I know what you mean about experience or lack of it. I can go see a doctor for a hang nail and he wants to do my AN surgery.  I went to a new neurotologist and had told him before the visit  I would be having surgery at HEI. All I needed from him was to be able to treat a nonsurgical intemittent hearing loss in my only hearing ear. I really had to be almost nasty to get him to pay attention to my other problem.

Be very careful of anyone that wants to cut into your head.  I have been told by  doctor that it is a simple surgery and not to worry. I would be back to work in 4 weeks max. Oh yeah! One patient of his is still in ICU a week later. I am meeting with a radiation oncologist today and will see what he has to say  If that little nagging feeling comes into play in his office I will to to another. I would sure rather take my chances with radiation than go to some guy that has only done 50 or a 100 spread out over a lot of years.