Don't you just LOVE insurance??

Lisa · 05-30-2006, 09:39 PM

Friends,

I suppose we have a love/hate relationship with insurance companies. I certainly couldn't afford treatment without their help. BUT on the other hand, Mel's company recently switched from Aetna PPO, where we could have any treatment/test, to Aetna PSO. We were told it was the same. Yeah, right. I just got 3 letters in the mail DENYING any type of spinal CT. This at a time when I have mets on my spine. They DID, however, approve a PET/CT scan and a brain MRI. Since I have these scans every 3 months, this new approval process worries be just a bit.

I hope nobody else is going through this negative change.

Love and light,

Lisa

StephN · 05-31-2006, 02:37 AM

Dear Lisa -
Just another headache you don't need. I suppose you have tried all the usual avenues to get the spine CT approval - letters from your doc pointing out your situation which is documented in your file.
Sure hope this will change course and once you win the initial battle with the ins people you will get the tests required to keep on top of those mets. Hopefully the new treatment is working against those mets and they will be nonexistent, but you still need to monitor that.
Keep us posted, as you are one of the pros in navigating that system.

mekasan · 05-31-2006, 09:55 PM

Dear Lisa,

I completely empathize with your insurance company woes. I have been fighting my primary insurance since the day I was diagnosed. After my mastectomy, my insurance company sent me a letter stating "insufficient evidence" of cancer and they would not be paying for treatment. You will see from my signature that I am stage 1 with two types of cancer. I sent them another copy of my path and they reversed their opinion, but decided to view my mastectomy as three separate procedures and only cover one. Again I had to bombard them with paperwork and they reversed their decision. Then they stated they would not extend my coverage, and again I got them to reverse.

Now they decided that they will not indicate the balances due on my EOB's so now my secondary (who is willing to pay the remainder of my bills) cannot pay because they do not have an amount to pay. They are not returning my calls. And also, they refuse to approve a surgery although my doctor has written two letters indicating that it is medically necessary and less invasive than the other more costly option. They have not responded. I am having the procedure and will fight them later.

Insurance companies are ridiculous. I am a law student and plan to fight them long after I graduate on behalf of patient like us.

If you have read this far then I must thanks for being my captive audience and permitting me this opportunity to vent.

Sincerely,
Shannon

Lisa · 05-31-2006, 10:42 PM

Go get 'em, attorney Shannon!

Your story is unbelievable. How can you "slip" us the name of the company without actually telling us? My husband is job hunting; I'd sure hate him to move to a company that has your insurance!

Love and light,

Lisa

sarah · 06-01-2006, 04:22 AM

Dear Shannon,
If you'd been in California, the insurance companies couldn't deny any of this. It's unfortuante that different states have different rules. The insurance companies threatened to leave California when the laws were passed to screen for cancer and protect cancer patients - men and women and California said "right, go!!!" of course they didn't leave because California is the 4th or 5th largest eceonomy in the world!!!! Can't lose that. Maybe you need a new governor and senators.
Sarah

madubois63 · 06-01-2006, 05:05 AM

Wow - Shannon, your story is unbelievable. My first thought (before I read you were a law student) was to sue for harassment, distress or something along those lines. I am/was/will be once again a Paralegal (got a real degree). I was working on getting in to law school when I got hit with a relapse. I want to help others that have been where we are too. I have Medicare coverage as my primary and Medicaid (with a spend down/overage/large co-pay) as my secondary. I do not have a HMO - thank God. I can go to any doctor and I don't need referrals or pre-approval. Makes life easier. The only thing, Medicaid requires me to stay in NY state - may be a problem for upcoming treatments, but NY is full of cancer/leukemia treatments options. Good luck with the insurance company and with your law degree!!!

..·´¨¨)) -:¦:-
¸.·´ .·´¨¨)) -:¦:-
((¸¸.·´ ¸.·´ -:¦:- -:¦:-
-:¦:- ((¸¸.Maryann -:¦:-´´

tousled1 · 06-01-2006, 05:21 AM

I sympathize with what you are going through. The insurance companies are all "trying to keep health care costs down." Yeah, right!! I did think that if you had a pre-existing condition and the company switched insurance carriers that your pre-existing condition had to be covered.

Lisa · 06-01-2006, 06:49 AM

Kate,

Yes, as long as you have no "gap" in insurance coverage, you cannot be denied. Having said that, they can charge exhorbitant amounts if they choose. I'm not worried about continuous coverage, just the fact that they can change their approval process. With AETNA PPO (not a HMO), I could go to any doc and get any test. Now with AETNA POS (still not a HMO), I must get approval for every test. This is where the request for the spine CT got denied. BUT, yesterday, my clinic called to say that they had pushed for it, and it's now been APPROVED. I guess my clinic loves me, they really love me (to paraphrase Sally Fields)!

Love and light,

Lisa

tousled1 · 06-01-2006, 06:52 AM

Lisa,

Glad your clinic pushed for the test and you got approval from the insurance company. I never heard of a POS. I've heard of PPOs and HMOs but POS is a new one to me. Hope all your tests come back positive.

Tami · 06-01-2006, 07:32 PM

Lisa - I have a POS at work adminstered by PacificCare and it has an HMO component as well as a PPO component. If I use the HMO I need approvals but pay very little out of pocket and if I choose to use the PPO I will need to pay a percentage for all services. Do you have that option? My company switched from Blue Cross POS last October but it was almost identical to the plan I have now. My family doc, radiation onc and breast surgeon are all part of my HMO and my medical onc is part of the PPO. I have an annual out of pocket maximum that I can be charged and that is $3000. This is not treated like a deductible but rather accumulates throughout the year. While doing chemo and herceptin I knew that the most I would need to pay was $3000 and although that was a lot it was a lot better than the more than $100k that treatment ultimately cost. tami

Sherry in WV · 06-02-2006, 09:57 AM

Read your story on Insurance. Yea I hate it too, we owe a lot of money even after medicare and my insurance.

Just remember you can appeal. If you ever need help I will be glad to help you. I am an RN and work for an insurance company.
you may also have an insurance commisioner. In the state of WV we have one and she has helped me many times in disputes with the insurance co, your taxes pay his salary so don't be afraid to use him/her. Your insurance is called point of service and by that they mean you have to have precerts and use docs and facilities that have a contract with them,
Good luck and remember I'll be glad to help you
peace,
Sherry

mekasan · 06-02-2006, 09:37 PM

I want to add that my primary is student insurance called MEGA Life and Health Insurance and my secondary is Medicaid. Because I was diagnosed right after finals of my second year of school, my coverage was extended for the 12 months I took off on medical leave.

I have every intention of sueing, but before this option is available I must go through all the hoops of the grievance process offered by the insurance company. I must first be denied, then complain, write letters, have doctors write letters, etc... until they give me what I want. They have so far. As soon as they don't then I'll have the "injury" required to sue.

Of course, I could try the psych harm route, but that is hard because it is subjective and the insurance company tends to base their denials on "insufficient information" or a misunderstanding of some sort. This suggests that once I or my doctors provide more info they will pay. I truly feel that insurance companies that behave like mine are abusive to patients who are forced to fight for everything. The scam is to deny everything and wait to see if the patient has the time, energy, or knowledge to complains. Because the law is on my side, they usually reverse the denial.

If this behavior is not illegal, it should be. I began my law clerkship this week and have been assigned to the healthcare division. I will be working closely with an attorney who was a trial attorney in healthcare law (i am not sure of which side he was on before, but now he is working for poor clients). I hope to learn more about my rights as a patient.

Thanks for all your responses. The shadows of this disease cast darkness over so many other areas of our lives. We all need to vent sometimes. It is good to know there is a place to be heard.