Help fighting Health Insurace

[Guest]

Hello. I am new to this forum and I am hoping for some help. I was diagnosed with bicuspid aortic valve about 25 years ago. I was good about getting echoes for monitoring for several years but in my "indestructible" youth did not make it a priority and let it go. I've had a great deal of stress the past few years which has caused some minor palpitations, and at 43 now, I am older and wise enough to start being more responsible. About 2 months ago I went and got a checkup and an ekg from my cardio and he naturally ordered a echo and stress test. It's been at least 15 years since my last test and my insurance company is refusing to pay for the test deeming it un necessary. Both my cardio and the hospital where I had my original trans esophageal have long since purged those records and I have no copies. As you all know, it is essential to have these echoes for monitoring and I am at a complete loss how to fight this. My doctor has filed an appeal but nutraceuticals is still balking. I also have what is pretty much known as the worst health insurance across the board. (United Healthcare). Has anyone experienced a similar situation? I suppose I will have to bite the bullet and pay out of my own pocket if it comes to it as its too important not to but I am already pushed to my financial limit. Even with a payment plan it would be very tough. Are there any advocacy groups or courses of actions to try? Sorry for the long post but I am really stressing out over this ( yes I see the irony there)
I'd appreciate any help you could offer me so very much.
Sincerely,
Steph Williams

 

[honeybunny]

I have United Healthcare and they covered everything (over $200k) so I'm puzzled that they are balking. I was out of pocket $5k because I have a high deductible plan. If you do end up paying yourself, make sure the provider knows this because they may have a different charge for self insured patients. Most providers have deeply discounted rates for self-insured patients.

 

[AZ Don]

United health Care paid for my ohs. Doesn't make sense. Make sure your diagnosis is clearly documented and keep calling and escalating until they pay. They used to deny stuff for no reason but when we followed up they always paid.

 

[Bonbet]

Hi, Steph: In 2013 I had UHC coverage and my premium was 990$ per month. They refused to pay for one half of an approx 6K bill from a complete cardio work up at Mayo.
We checked ahead to make sure the specific tests were covered but they balked at the coding where some items were charged to the clinic and some to the hospital even though I remained at the clinic the entire work up. Mayo uses different codes for different tests. I appealed. Fortunately, here in Oregon, there is an insurance consumer advocacy office in the AG's office. They helped me navigate the appeal. Ultimately UHC paid. That took a year. After it was settled they decided to withdraw the authorizitation for procedures that they had previously OK'd so I owed thousands still. Mayo said they are legally able to do that. So Mayo and the AG's office helped me negotiate with UHC and they eventually met their obligation. Then they dropped me from my plan. They could still do that then, but Obamacare started that next year and I found decent coverage because of the provision that insurance companies had to provide coverage despite my pre-existing condition. Whew. It is so important read to your policy and know your rights. The insurance company relies on the fact that most people are not willing to spend the time and frustration appealing their unfair practices. You don't mention where you are from but check with your state government offices for a consumer advocacy office or something similar. State Legislatures have to OK premium increases for Insurance companies operating in their jurisdictions and the Ins. Co.s don't like to get too much attention. Most hospitals, clinics, providers are very cooperative in terms of ensuring that anticipated procedures will be covered - but that does require a significant amount of advance leg and phone work on the patients part. Good luck with your process. Bonbet

 

[MrsBray]

I had a similar problem. I work for a large employer(5000+ employees), and they have a "Patient Advocate" on site, who is an employee of the insurance company. She helped me get procedures and pre-tests covered, as well my choice of surgeon's (which was WAY different that my primary care provider had chosen for me). I came very close to just throwing in the towel and walking away from the cardiologists office several times. it was like, "Why bother? They obviously don't care about me, so why should I?"
In addition, I found an ally in the weirdest place - my dentist's office! The lady at the front desk (so much more than a receptionist!) gave me a lesson on coding and insurance. She said that if a certain procedure is turned down by a certain insurance company, it's probably not coded correctly. The key is to find someone that is very familiar with the coding for your particular carrier and policy type.

And don't give up. If I hadn't fought and argued for my own health, I would have had my surgery in a their-rate facility, preformed by a surgeon who died 3 years prior. Seriously.

DON'T GIVE UP! BE THE SQUEAKY WHEEL! Call every day until they approve your procedures and tests just so you'll stop bothering them.

 

[Dan Zulu]

Definitely Google your state's insurance regulatory agency and see if they can help you. Here in California patients have many appeal rights that don't rely on insurer-funded "appeals." Unfortunately my federal health insurance is not affected by state law so I don't have that advantage. And United is the contractor administering the federal insurance program (Tricare) so I know how difficult United can be.