$#@%! Insurance Companies

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Chovy

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I am just about to lose it. I am a patient of Dr. Hilgers at the Pope Paul VI institute and am scheduled to have a diagnostic laparoscopy tomorrow. I had one a few years ago and they found that I had severe pelvic adhesions which had been causing me pain for about 12 years and (TMI INFORMATION ALERT!!!) had wrapped around my ovary, adhered it to my back and had also infiltrated my rectum. They did surgery at that time and removed the adhesions.

Lately I’ve been having the same problems as I had before (pain in my side, no ovulation and near-constant diarrhea) and Dr. Hilgers suggested the laparoscopy. I called our new insurance a month ago to find out how this would need preapproval, etc… They told me no pre-certification was necessary and based on what I was telling them, there should be no problem.

So… this morning I get a call from the hospital, and the insurance has denied coverage for the entire thing. I need to bring a check for $6100 if I want to have the procedure done at all TOMORROW MORNING! I have just had it. My husband has moved to Philadelphia, and is flying home today to be here for the surgery. Dr. Hilgers’ surgeries book up 6 months or so in advance and I don’t have that much time to wait for the insurance to hear my appeal (it’s a 60 day appeal process.)

Sorry for the vent- it’s just amazing to me that if you don’t want to get pregnant, the insurance companies will pay for absolutely anything, but if you have a real medical problem that may also be preventing you from getting pregnant, nothing is covered.
 
It’s also noteworthy that they have no problem lying to you about your coverage either.

May I ask which insurance company this is?
 
My husband’s company is self-insured, but they are an insurance company- Western & Southern.
 
Interesting. I have heard of similar things happening with Blue Cross. 😦

The bureaucrats at insurance companies have no business deciding what is medically necessary and what isn’t.
 
Have you tried calling the insurance company back? I think a lot of times these things just automatically get denied just in case we might just accept it and go away.

It sounds to me that since your having other medical issues (diarrhea etc. ) the fact that your trying to get pg should be irrelevant. It should be covered as a treatment for the symptoms that your having, maybe your doc needs to intervene with the insurance company and explain that to them.

You can always appeal. I know that doesn’t help you tomorrow, though.

I HATE insurance companies too, I know how ya feel. :mad:
 
I’m SOOO sorry this is happening to you! I’m saying a prayer for you right now :). Insurance companies can be a real pain. My own family has had trouble with them over the past couple of years with regards to mental health stuff and chiropractic care, which are both high needs in my family. I hope a miracle happens and no matter what, God is in control :).
 
Try to get your Dr. involved. My ob/gyn told me (when I was pregnant in 04 and we were talking abou the whole universal insurance thing being debated for the presidential elections) that she was fighting with an insurance company for one of her patients that needed a proceedure done b/c the patient had a condition that caused her to constantly bleed (and need blood transfusions weekly). The insurance company would not cover the surgery b/c not “all of the options had been exhausted”. To think, they could have probably saved more money by allowing the surgery than letting the poor woman bleed and need transfusions weekly.
 
I know you probably want to crawl under the covers and cry in utter frustration…but you don’t have the luxury of that today…

Get on the phone and DEMAND to talk to a supervisor, administrator, underwriter–whomever, whatever it takes and make it clear beyond a doubt that you’re not going away or letting them off the hook until you get the answer you’re after. (I wish I could help you with this–I LOVE going after obstinate insurers and have had to do so many times with my son’s surgeries)

Enlist the help of the folks @ Creighton, Hilgers, wherever. They will probably have some resources you could tap into. Don’t give up or let the appointment lapse. Fight for this one–it sounds like it’s worth the effort and so are you!! Good luck!! You CAN do this.
 
Chovy,
I work in health insurance…for a major hospital. I know how frustrating that can be. Does your insurance have a contract with that hopsital or doctor. If so, it is the doctor and facilities job to obtain the authorization from the insurance company. Here is what I suggest:
  1. Find out from the doctor’s office if they received any form of approval from your insurance company for the procedure. This should have been done by the doctor’s staff.
  2. If they did, ask for a copy of the referral or pre-certification and contact the hospital with that information.
  3. If they did not, ask for their help. It is their job.
You are right about the insurance companies. Before I converted to the RCC, I had a bi-tubal ligation and it will cost me close to $7,000 to have it reversed but the insurance covered all of my sisters fertilization treatment (we work for the same hospital). The insurance won’t pay for a reversal for me. It is very frustrating.

If you would like me to help you and intervene with the insurance company or need more specific details, just email me!!

Pax
 
Thanks everybody. I tried talking with the supervisor and got nowhere except frustrated. My emotional state is rather weak right now due to other unrelated issues but I did talk with the Doctor’s office and they are willing to negotiate a fee and will still file with insurance. They just finally got to talk with the insurance this week to try to get precertified because DH has a new job and along with it new insurance.

We are still hopeful though that things will eventually get paid but with DH’s encouragement I am going to go ahead and spend the money. DH said my health has to come first. We had this problem before with the old insurance and had to bring a cashier’s check for $11,500 to the hospital with 2 hours notice. My brother always jokes that he would have had more chance of bringing them a leprochaun.
 
Chovy,
I will praying for you and that everything works out according to God’s plan.

Pax
 
Chovy, you are in my prayers. I have similar troubles and have had similar surgeries. I wish my doctors had been as great as Dr. H. at Creighton. I was just commenting to my mom last week how frustrating it was that I couldn’t go to a doctor in my area and be covered by insurance AND get healthy. The insurance will cover a hysterectomy even when “all other avenues” haven’t been exhausted. Ironic, isn’t it?
 
Chovy, I feel for you. I am battling w/my insurance as well. They denied my blood thinner injections recently because “it was not medically necessary”. Boy, I was so mad that I called them and tried to explain to them that I have a blood clotting disorder and almost died last yr. but that didn’t matter to them. So now I have both of my docs writing letters on my behalf that I have a life and death illness and I need these injections to prevent further strokes and clots.

One good thing though, I was persistant and called them 4 times because the first 3 service reps had no idea what they were talking about. I use to bill insurance at a local hospital so I knew the lingo. I finally got someone who knew how I could appeal and have the info faxed over by the Visiting Nurses and doctors STAT instead of waiting for an appeal.

Anyway, you will be in my prayers. Insurance companies only look out for themselves instead of a patient’s well being at times. They should walk in our shoes for a day to see what it’s like to live with health problems.
 
Insurance companies have no clue what is medically necessary, and don’t care if something is life or death. The only issue is how much it costs “right now” not whether preventative care will actually save money later, or whether there is not time to explore options because the patient could die soon. I knew someone whose daughter was hospitalized for anorexia, and the insurance was willing to pay to keep her in the hospital with a feeding tube, but refused to cover real treatment that would actually help her to recover from her anorexia. And this was at a point where the girl nearly died! I have talked to doctors who have had to deal with insurance companies lying to them and to their patients in order to avoid covering necessary procedures. They say at times if feels like it’s almost like trying to deal with the Mafia.

Grr.

Chovy, you are very very very definitely in my prayers!
 
So sorry about the problems! I just got done with trying to get my pap test covered.

I am so sick of ins. that I think we are doing a homebirth.I wanted to cry when I found out that they cover more to prevent pregnancy. Actually I did cry.
 
My insurance doens’t cover more to prevent it. I’m on the pill because I have really bad PMS (I want to kick puppies and punch babies one minute, then I’m a blithering idiot unable to get out of bed the next) They only cover 2 dollars off the only brand that works for me. I have to pay the other 46 every month.
 
Thanks again everybody. I’m home now and resting fairly comfortably though the thought of the money we spent yesterday is still bothering me. As it turns out, my inclinations were correct about what was wrong. Not only are the adhesions back but they couldn’t even get a picture of my right ovary because my tubes and ovaries are all covered in the stuff. Now we will begin the fight to get the removal surgery covered by ins.
 
Glad to hear you are resting comfortably. Try to let the stress go for a few days to recover. Keep the tension out of your abdomen and really rest. Pray for peace for everyone who handles your account.
 
I have two suggestions:
  1. Always document every contact with them. Get the name of the people you speak with and the time and date of the call.
  2. All states have a department of insurance (DOI) that regulates insurance companies. If you live in a state that has an aggressive DOI that might be an avenue to pursue.
 
Island_Oak said:
I know you probably want to crawl under the covers and cry in utter frustration…but you don’t have the luxury of that today…

Get on the phone and DEMAND to talk to a supervisor, administrator, underwriter–whomever, whatever it takes and make it clear beyond a doubt that you’re not going away or letting them off the hook until you get the answer you’re after. (I wish I could help you with this–I LOVE going after obstinate insurers and have had to do so many times with my son’s surgeries)

Enlist the help of the folks @ Creighton, Hilgers, wherever. They will probably have some resources you could tap into. Don’t give up or let the appointment lapse. Fight for this one–it sounds like it’s worth the effort and so are you!! Good luck!! You CAN do this.
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I would do exactly this.

My daughter was set to go in for a cesarean. Humana TriCare decided at the last minute- literally hours before she needed to be at the hospital, after TriCare had the proof- that they were not preapproving it.

As she lived in my home, and I was not going to see her die in childbirth in my house, I took the phone from her and did just what Island Oak described. Man! Those people can hop to when they want to.
 
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