The title sums it up. Four weeks ago our daughter's ENT said she should have a ct scan of sinuses done (this is after 3 rounds of antibiotics for a sinus infection). My daughter is 8 and has a long history of ear/sinus problems/hearing loss.
The ENT says the staff will get approval from United Healthcare (i don't know if it matters, but we pay cobra for the insurance).
We have been waiting for a month now, i all the ENTs office constantly and they have told me that they have submitted paperwork twice and both times got rejected by the insurance. I called the insurance last week who told me it's not true and that the doc's office had not submitted paperwork. Call ENT they said they did, twice. Went to office today and they showed me rejection letters (two of them). I called the insurance today (at this point i am mad), and i got transfered to their radiology dept. Got to talk to a lady who did not have a clue why it was rejected, acknowledged that it was rejected twice, and said i guess the next step is for the ENT to call our in staff doctor and talk (she used a term for this). She said our ENT has three days to make this call but could not tell me if the ENT's office was aware of this.
I am wondering what rights do i have at this point. Is there anywhere I can file a complaint. If yes, is it against United healthcare or cobra?
We pay 1900 a moth for this insurance and we have noticed since my husband lost employment and we started paying for cobra we have gotten rejected for almost everything and for everything has been fighting process. We have even dealt with things like showing up for a doctor appt only to be told they called to verify if we have insurance and they were told we don't. Just to make clear, we have not missed or been late with any monthly payment.
I am mad though. That some no-face insurance doctor will make a decision whether my daughter 'needs' this or not.
Per our ENTs opinion they need to see her sinuses in order to know what to be done next considering she gets sinus infections every 2-3 months.
United healthcare in general is a mess! They deny the refill of my sons meds almost every month, he's taken the same med for almost 2 years!
Welcome to Obamacare. And so it begins. This is the wave of the future.
First, the fact that it's COBRA has nothing to do with whether or not they authorize treatment. You can let go of that complication while dealing with this. COBRA is a law and not an office. It states that you can pay privately for your insurance after loosing group coverage.
I suggest that this is an issue to be handled by your doctor's office. The insurance company has told you what it needs. It sounds to me that the clerk at the doctor's office isn't submitting the correct paper work. I would ask to speak to the head of the billing office and work with that person.
Yes, it makes one angry, very angry but you need to let go of the anger so you can think straight and be proactive. Being angry when you talk with the people in offices will not help you get what you need. They will turn you off.
You cannot change what has happened but you can know that your child needs the CT scan and that the insurance company says to you that she should be able to have it. Now get the doctor's office on the ball to make the call.
After getting the CT scan authorized, call United Healthcare's customer service office and while calm and reasonable ask them why you've been having this difficulty. But focus on the CT scan issue for now.
Last year, my daughter who was 8 yo at the time had 4 sinus infections in 4 months. She was diagnosed with chronic sinusitis and missed 38 days of school last year. Her Pediatrician first referred us to an allergist for testing because allergy issues can lead to sinus infections. When my daughter's allergy testing came back negative they ran blood work to check for an immune deficiency. The Allergist thought this was highly unlikely because generally kids with compromised immune systems have all types of infections (phenomonia and skin infections etc) which my daughter never had. The blood work however showed that she was slightly immune compromised. They gave her another dose of the pnemmoccal vaccine and hasn't had a sinus infection since.
Her pediatrician told me a CAT scan was an option but she preferred not to give one to such a young patient with a growing brain. I was against her having the scan because I too had been diagnosed with chronic sinusitis and had a scan. The scan just showed I had extremely narrow sinus cavities. I think she probably inherited my narrow sinus. FYI... I cured myself by simply using saline spray daily.
Perhaps look at other causes before having your daughter exposed to all the radiation that goes with a scan.
We ended up in billing hell with Blue Cross a few years ago. I ended up having to speak to someone pretty high up the food chain to get it resolved, but in the end, they did resolve it. I'd gather all the information together, and see if the doctor's office would be willing to call UHC WITH you (or on a conference call) so they have to stop pointing fingers at each other. You pay a LOT of money for this insurance, and yes, I do think they hope that if they simply reject every claim, you'll end up going away (either getting another job with some other insurance plan, or be unable to afford next month's premium and drop off the rolls that way). You're going to have to make this happen, if it's going to happen. If you get an unsatisfactory answer from one person, ask for the supervisor. If the supervisor gives you an unsatisfactory answer, ask for their supervisor. I ended up speaking with a Senior VP at Blue Cross, and ultimately had to speak to our attorney about our options before our claim was resolved. But like I said, they did resolve it. Stand your ground and don't give up. Make them cover this.
UHC denied one of our big claims once. It went back and forth for a while, and when I told them that I would be formally appealing the claim, the problem suddenly resolved itself.
The contact info for COBRA related complaints is at the bottom of this page:
http://www.health.ny.gov/health_care/managed_care/complaints
Hope that helps....
This is just a classic SNAFU. Nothing about this is from COBRA (a law that let's you keep your employer's group insurance) or the Affordable Healthcare Act that hasn't gone into effect yet.
DON'T have this procedure done without your insurance company's authorization or they will never pay. Get your ENT to talk with the insurance's doctor and get this cleared up. You need to deal with United Healthcare, since COBRA is not a place or people.
COBRA is a law that allows you to elect to continue your employer sponsored health insurance. The law has nothing to do with your actual insurance policy beyond your right to continue the coverage.
I know that some, many, insurance carriers won't approve certain things without a chain of protocol being followed first. For example, if I say my arm hurts, my doctor can't just order an MRI. They would need records of my physical exam, regular x-rays, etc. Your daughter has been under care for quite some time and I would assume that all other tests have been run so that the CT scan is warranted and considered "medically necessary". That's an insurance term.
Insurance carriers have many reasons for denying certain things. It can be as simple as a wrong code being placed on a claim or form. I had a client who was an attorney and for a year kept getting claims denied for something that was clearly covered under her policy. She got fed up with nothing being done through her other broker, so she brought her claims to me. It took me about 5 minutes to figure out what was wrong. Someone had put an infant procedure code on claims for a 55 year old woman and no one ever caught it...not the other broker, not the insurance company, not the doctor's office.
Does the company that your husband's insurance was through have an actual broker? A person that oversees all the submission of paperwork on behalf of the company? If so, they may be able to be an advocate for you and help get to the bottom of it. It sounds like you are really getting the runaround and you could use someone who knows what they are doing to help you out. I specialized in claims resolution and pre-approvals. It would be worth a call to your husband's former company to ask who their broker is or who THEY call for help with things.
I wish you the best. I believe things will work out. If you can get an answer as to why the approval has been denied, at least you'll know what next step to take. There may be just a little piece of the puzzle that's missing. It's been my experience that medical offices and people who work for insurance carriers aren't the best at finding that little puzzle piece.
Hang in there!
P.S. I obtained my insurance license in 2001. I battled with insurance carriers on behalf of my clients regarding claims and pre-approvals well before Obama was even on the radar. This is nothing new.
Just saying.........
I don't mean to sound rude but if my child needed some sort of medical care, my priority would be getting the testing done that the Dr.s deemed necessary and go from there. Work on some sort of Cash pay or payment plan to the Dr. with the understanding that the insurance issues will be worked out one way or another.
At that point.....when you have the necessary testing done.....THEN address all the issues with the insurance company to reimburse you for any out of pocket expenses because the well being of what ever may be going on with your daughter is more important than the he said she said run around that you are getting. Document EVERYTHING including who you talked to and when, all paperwork, etc.
I do agree that you are getting a run around from all sources but the bottom line is getting your daughter healthy.
I'm sorry you are going through this. It is not fun dealing with insurance companies. I've had to appeal decisions myself and I've found when you bombard and continue to bombard them with necessary paperwork and DO NOT GO AWAY they will eventually come around and look at your case..why? Because you are costing them money and time everytime you talk to them, correspond with them, etc. They care about their pocketbook so if you start costing them money... they will resolve your issues just to get you to go away. It works.
I'd call the ENT Billing office and have them handle this situation on their end. You have insurance, apparently some connections aren't crossing right. If you are in-network, and have insurance coverage, you should be able to get this kind of procedure done.
This actually has nothing to do with Obamacare, but is simply a company that would like to save a few bucks at the expense of your DD's health.
If you pay COBRA, likely you will not do that for a long time (most people pay COBRA) only for a few months. So if they deny your claims and make you go through the lengthy appeals process they are basically trying to stall it until you are no longer their problem, ahem - customer.
Health insurance companies suck!
Dealing with our health care system, particularly insurance companies is a nightmare!! It has been a nightmare for a long time, so all of you people who think this is about Obamacare need to get your facts straight!!! It is a ridiculous comment!!!! I have had private health insurance (the same you have) for the past 5 years. I have found them to be decent (I loathe insurance companies)... Not really different from any of your other health insurance options out there. Insurance dictates everything. Cobra is not the group to deal with. I would have your insurance company representative contact your doctors office while you are in the phone (3 way conversation). That way you are witnessing what is going on. I've had to do this before and the insurance company was happy to do it. Best wishes! It should not be this difficult to get the care we need!!
COBRA is a paperwork mess. In our experience it was easier to get thing done and then deal with insurance after. You have to stay on it to get them to finally pay. We've been back and forth for some time for a late night ER visit when my son's ear began bleeding and would not stop and it became apparent it wasn't just a nick just inside, it was by the ear drum. The after hours nurse for our doctor said we needed to go to the ER because it could be a ruptured ear drum or other bad issue.
Paper work goes through different channels than regualar insurance. Doctors offices had dealing with it. We had to sign waivers at our pediatrition just to get the kids taken care of.
I would have the test done and then continue to fight with insurance. You will eventually get it worked out but at least your child gets taken care of.
United health care typically has a two tier internal review process. If your claim/procedure is denied on both levels, then you have recourse in your state's department of insurance, which monitors insurance companies to be sure they follow the law, aren't screwing people over, etc.
In NY, this department is handled by the department of financial services. Www.dfs.ny.gov
Good luck!
In California, we have the Insurance Commissioner and that is where you would file the complaint here. Not sure in your state, but it would be against the health insurance company.
I have to think that is a Cobra problem not a UHC problem. I think that Katrina said it when she said it's a mess. It is. I'm not sure how to help you but I guess stay vigilant and call your ENT to make sure they've called UHC. I would speak to a nurse of the doctor you work with and explain what happened, perhaps the nurse can help you make sure the necessary things are done. Good luck.
