midjd
Administrator
Your Money Admin
Joined: Dec 18, 2010 14:09:23 GMT -5
Posts: 17,720
|
Post by midjd on Aug 26, 2013 15:03:13 GMT -5
DH's surgeon sent in a preauthorization request for a cadaver knee transplant to our insurer (Anthem) about a month ago. DH fits all the guidelines for this type of surgery and there is no reason he shouldn't be approved. The only issue is timeframe - since we've already hit our maximum OOP for this year, we'd like to have it done before December. DH's surgeon is fine with this and says the sooner the better. The surgeon told us (using somewhat colorful language) to follow up with Anthem, and said that his office would do the same, and that hopefully being nagged from all directions would prompt them to approve it within the next four months. He also told us that the first few times we called, they'd tell us they never got the doctor's letter, then we'd fax it, they wouldn't get the fax, we'd call again, they'd tell us we sent it to the wrong department, we'd get the surgeon to fax it, they'd tell him they never got it, etc. Anyway - now we have each spent several hours on the phone with Anthem. The first time DH called, they told him they couldn't give him any info because he wasn't the benefit holder. Then when I called, I was told they couldn't give me any info because I wasn't the patient (this made more sense). Every now and then, after going through 10 minutes of robot prompts, we'll just get a message that says "all circuits are busy" and then *click*. Today, after DH was told that they never received anything from his doctor (shocking!), I got a fax number for the precertification department, but the person I talked to did not instill much confidence that this was the place DH should be faxing any medical info. So I guess we're back at square one. Are there any special tricks/secret phone numbers or passwords/etc. or is this just a matter of going through each of the various phone trees until we want to scream? I reached that point a couple of days ago, but DH might still have some stamina left.
|
|
973beachbum
Senior Associate
Politics Admin
Joined: Dec 17, 2010 16:12:13 GMT -5
Posts: 10,501
|
Post by 973beachbum on Aug 26, 2013 15:08:05 GMT -5
DH's surgeon sent in a preauthorization request for a cadaver knee transplant to our insurer (Anthem) about a month ago. DH fits all the guidelines for this type of surgery and there is no reason he shouldn't be approved. The only issue is timeframe - since we've already hit our maximum OOP for this year, we'd like to have it done before December. DH's surgeon is fine with this and says the sooner the better. The surgeon told us (using somewhat colorful language) to follow up with Anthem, and said that his office would do the same, and that hopefully being nagged from all directions would prompt them to approve it within the next four months. He also told us that the first few times we called, they'd tell us they never got the doctor's letter, then we'd fax it, they wouldn't get the fax, we'd call again, they'd tell us we sent it to the wrong department, we'd get the surgeon to fax it, they'd tell him they never got it, etc. Anyway - now we have each spent several hours on the phone with Anthem. The first time DH called, they told him they couldn't give him any info because he wasn't the benefit holder. Then when I called, I was told they couldn't give me any info because I wasn't the patient (this made more sense). Every now and then, after going through 10 minutes of robot prompts, we'll just get a message that says "all circuits are busy" and then *click*. Today, after DH was told that they never received anything from his doctor (shocking!), I got a fax number for the precertification department, but the person I talked to did not instill much confidence that this was the place DH should be faxing any medical info. So I guess we're back at square one. Are there any special tricks/secret phone numbers or passwords/etc. or is this just a matter of going through each of the various phone trees until we want to scream? I reached that point a couple of days ago, but DH might still have some stamina left. Next time you speak to a live person tell them that when you were talking to the insurance commissioners office for your state to file a complaint they told you you needed the name and address for the person you were talking to, so they need to spell their name for you. I promise you you will get a supervisor on the phone to help you.
|
|
midjd
Administrator
Your Money Admin
Joined: Dec 18, 2010 14:09:23 GMT -5
Posts: 17,720
|
Post by midjd on Aug 26, 2013 15:21:02 GMT -5
Haha! I may have to try that.
Since I do have a physical address for the preauth department, I was wondering if sending the letter registered/return receipt would do any good? Or will someone sign for it and then send it into the void?
I deal with a similar "we never got it" when trying to get loan modification documents to any of the Big 5 banks, and we've come up with a good workaround (scanning everything and emailing to the bank's local attorney with read receipt) - seems like there has to be something similar here, but I'm not sure what.
|
|
NomoreDramaQ1015
Community Leader
Joined: Dec 20, 2010 14:26:32 GMT -5
Posts: 48,070
|
Post by NomoreDramaQ1015 on Aug 26, 2013 15:25:44 GMT -5
The first time DH called, they told him they couldn't give him any info because he wasn't the benefit holder. Then when I called, I was told they couldn't give me any info because I wasn't the patient (this made more sense).
Your DH needs to call and have them send him a form stating you can talk to the insurance company for him. You should fill one out too for good measure.
|
|
973beachbum
Senior Associate
Politics Admin
Joined: Dec 17, 2010 16:12:13 GMT -5
Posts: 10,501
|
Post by 973beachbum on Aug 26, 2013 15:27:39 GMT -5
When I worked for a insurance company I was the heath care coordinator. It was my job to decide if that surgery was covered under the plan. I always told people to mail everything to "my name personal and confidential". those letters would always make it to my inbox unopened. Sending it certified return receipt requested isn't a bad idea though. As big as we were we still knew who was in the mail room to know it made it in the building. We took insurance commissioner complaints and congressmen type letters very seriously. I have to say though that although people may not have liked my answers a lot of the time no one could ever say I dodged them or gave them the run around. who knows maybe they still get letters adderssed me.
|
|
|
Post by The Walk of the Penguin Mich on Aug 26, 2013 15:30:31 GMT -5
Does your employer have an Anthem representative?
i would up with something similar a couple years ago when. Got hit with a $30,000 bill for my emergency gall bladder surgery. Insurance company claimed that the hospital had not gotten prior authorization, despite the fact that thy had n authorization number approving the surgery from the insurance company!
We went round and round until I finally called my employer's local contact. It took another month or so, but they finally paid up.
|
|
midjd
Administrator
Your Money Admin
Joined: Dec 18, 2010 14:09:23 GMT -5
Posts: 17,720
|
Post by midjd on Aug 26, 2013 15:52:24 GMT -5
Thank you all for the suggestions! I'm clueless when it comes to insurance, so this is very helpful. I need to find out if we have an Anthem rep - I'm guessing my specific agency doesn't, but the state might. Beachbum, I wish you worked for Anthem. I need to find their version of you! OK, another question - would the fact that we've met our deductible/max OOP affect in any way their willingness to authorize the treatment before 12/31/12? (In my cynical mind I can see them sitting on it and approving in January so they at least get another $8K out of us.) Which is their prerogative, and from a financial standpoint it makes sense, but DH needs a new knee like yesterday. He has 2.5mm of cartilage left and they won't do the surgery without a cartilage graft (which also requires preauthorization) if it dips below 2mm.
|
|
Pants
Junior Associate
Joined: Dec 27, 2010 19:26:44 GMT -5
Posts: 7,579
|
Post by Pants on Aug 26, 2013 15:53:04 GMT -5
Mid - 1) The insurance commissioner is your friend. Not like an actual friend, but they get attention. 2) Write an email to the CEO or call his/her voicemail. At our company, there's a special team of claims reps who deal with problems that are brought to the CEO's attention. Many companies have something similar.
Good luck!
|
|
sheilaincali
Senior Member
Joined: Dec 19, 2010 17:55:24 GMT -5
Posts: 4,131
|
Post by sheilaincali on Aug 26, 2013 15:54:41 GMT -5
First- ask them to carefully spell their name and their job title as it is part of your paperwork for the complaint you plan to levy against them. Complaint technically could mean anything from complaining to us, to telling your mayor, to what have you but they don't need to know what type of complaint you plan to levy. Feel free to mention that you learned the art of careful documentation in law school.
Second- ask to speak to their supervisor. If that person gives you the run around keep asking for the next supervisor up the line.
|
|
Pants
Junior Associate
Joined: Dec 27, 2010 19:26:44 GMT -5
Posts: 7,579
|
Post by Pants on Aug 26, 2013 15:55:10 GMT -5
Thank you all for the suggestions! I'm clueless when it comes to insurance, so this is very helpful. I need to find out if we have an Anthem rep - I'm guessing my specific agency doesn't, but the state might. Beachbum, I wish you worked for Anthem. I need to find their version of you! OK, another question - would the fact that we've met our deductible/max OOP affect in any way their willingness to authorize the treatment before 12/31/12? (In my cynical mind I can see them sitting on it and approving in January so they at least get another $8K out of us.) Which is their prerogative, and from a financial standpoint it makes sense, but DH needs a new knee like yesterday. He has 2.5mm of cartilage left and they won't do the surgery without a cartilage graft (which also requires preauthorization) if it dips below 2mm. Of course they would. They also might hope you switch providers in the new calendar year and they don't have to pay. Stay on it and don't let them pull shennanigans on you.
|
|
973beachbum
Senior Associate
Politics Admin
Joined: Dec 17, 2010 16:12:13 GMT -5
Posts: 10,501
|
Post by 973beachbum on Aug 26, 2013 16:15:02 GMT -5
Thank you all for the suggestions! I'm clueless when it comes to insurance, so this is very helpful. I need to find out if we have an Anthem rep - I'm guessing my specific agency doesn't, but the state might. Beachbum, I wish you worked for Anthem. I need to find their version of you! OK, another question - would the fact that we've met our deductible/max OOP affect in any way their willingness to authorize the treatment before 12/31/12? (In my cynical mind I can see them sitting on it and approving in January so they at least get another $8K out of us.) Which is their prerogative, and from a financial standpoint it makes sense, but DH needs a new knee like yesterday. He has 2.5mm of cartilage left and they won't do the surgery without a cartilage graft (which also requires preauthorization) if it dips below 2mm. The money shouldn't actually have anything to do with it. it is literally based, or should be , based on what the contract says no more no less. It also shouldn't take that long to approve or disapprove. You could also ask for the name and address and phone number for that division's Beachbum, aka the plan's health care cooridnator or the person who handles cases like this. they have to have one. And use the words 'health care coordinator". Personally I HATED when the customer service tried to handle things themselves. They had to speak to me eventually anyway so why piss them off in the mean time?
|
|
shanendoah
Senior Associate
Joined: Dec 18, 2010 19:44:48 GMT -5
Posts: 10,096
Mini-Profile Name Color: 0c3563
|
Post by shanendoah on Aug 26, 2013 16:30:13 GMT -5
No, it has nothing to do with whether or not you have met your out of pocket costs. In fact, the person approving or denying your request should not even have access to your individual financial information. They should only have access to your plan (so they can see if it's covered) and your medical documentation to make sure it appropriate care. But they have no idea whether or not you've met your OOP costs for the year.
|
|
wvugurl26
Distinguished Associate
Joined: Dec 19, 2010 15:25:30 GMT -5
Posts: 21,882
|
Post by wvugurl26 on Aug 26, 2013 16:30:41 GMT -5
I think others have given good advice.
I've never experienced anything like it. My surgeon's office sends in items requesting authorization and it is done. There is no run around, no lost items, etc. Maybe because I'm under a federal blue cross blue shield plan?
My upcoming surgery puts me over the maximum out of pocket for the year. The surgery and all the physical therapy is on them. My drug costs alone eat up the premiums they get. I'd think they would want to deny anything possible for me if we are using that line of logic.
One suggestion, can you complain to to whoever coordinates insurance for state employees? I can file complaints with the group who coordinates health/dental/vision for federal employees.
|
|
wvugurl26
Distinguished Associate
Joined: Dec 19, 2010 15:25:30 GMT -5
Posts: 21,882
|
Post by wvugurl26 on Aug 26, 2013 16:32:19 GMT -5
It should have nothing to do with costs. Why does Anthem's process suck so bad though? If it has nothing to do with costs, then their entire pre-authorization process needs overhauled. They shouldn't always be losing or never getting confidential medical information.
|
|
raeoflyte
Senior Associate
Joined: Feb 3, 2011 15:43:53 GMT -5
Posts: 15,004
|
Post by raeoflyte on Aug 27, 2013 10:30:34 GMT -5
Is there an anthem office that you can reasonably drive to? It was a much smaller scale, but we fought with insurance for 11 months on some of Dh's blood work until he just walked into their office, and had everything fixed in a 30 minute visit.
|
|
midjd
Administrator
Your Money Admin
Joined: Dec 18, 2010 14:09:23 GMT -5
Posts: 17,720
|
Post by midjd on Aug 27, 2013 10:40:49 GMT -5
Good idea, Rae! There is one just a couple of blocks from work... I think I may head over on my lunch break. Maybe having a pregnant-lady-emotional-breakdown in their lobby will get some wheels turning. DH tried to fax the letter in this morning, but - surprise! - the number I was given yesterday does not seem to connect to anything on the other end. I should have known something was up when the CSR just popped out with a fax number without wanting to know my name, SSN, and the name of my first pet...
|
|
midjd
Administrator
Your Money Admin
Joined: Dec 18, 2010 14:09:23 GMT -5
Posts: 17,720
|
Post by midjd on Sept 5, 2013 10:37:32 GMT -5
Still going around and around with Anthem, but found this article interesting (and pretty damn sad): www.indystar.com/article/20130905/NEWS/309040072/Lawsuit-Man-died-when-Anthem-delayed-coverage-surgery-five-monthsIt took them 5 months to approve a pacemaker for a Southern IN man (ironically also a state employee) and he died before the operation could take place. Luckily DH's issue isn't life threatening. I am frustrated enough with this process, I can't even imagine if something happened to him because they sat on their asses for 5 months and couldn't bother to get the paperwork to the right person...
|
|
saveinla
Junior Associate
Joined: Dec 19, 2010 2:00:29 GMT -5
Posts: 5,273
|
Post by saveinla on Sept 5, 2013 11:08:29 GMT -5
Mid,
Check if you have access to "Health Advocate" as part of your benefits. They should be able to talk to your insurance on your behalf and fix the issue. I have used them before when I had issues with one of my bills and was not able to resolve it on my own.
This is what I see on our website:
Health Advocate:
Provides assistance with clinical and administrative healthcare issues. Available to benefits eligible employees, their spouse/domestic partner, children, and parents/parent-in-laws. Hours: 24 hours a day, 7 days a week
|
|
|
Post by The Walk of the Penguin Mich on Sept 5, 2013 12:03:41 GMT -5
I'm going to second going to your employer's health advocate.
This has got me somewhat concerned since my employer just switched over to Anthem BCBS this year. Right now, the only services I'm using is PT but I do have an orthopod appointment next month.
|
|
Deleted
Joined: Oct 7, 2024 4:31:09 GMT -5
Posts: 0
|
Post by Deleted on Sept 5, 2013 12:10:53 GMT -5
|
|
midjd
Administrator
Your Money Admin
Joined: Dec 18, 2010 14:09:23 GMT -5
Posts: 17,720
|
Post by midjd on Sept 5, 2013 12:19:16 GMT -5
Thanks, Saveinla - that is a good idea. I can't find any info on Anthem's site about member advocates, though (other than the fact that they apparently exist) - no contact info, etc. Any Anthem members know the secret password? DH called them again and now the story is that his doctor needs to call BEFORE sending the preauthorization letter. He requested to speak to a supervisor and she said the same thing. She asked him if there was anything else she could help with and he replied, "Why start now?" I'm about ready to tell his surgeon to go ahead with the surgery and then we'll just dispute the $30K bill when it comes. Easier to request forgiveness than ask permission, right?
|
|
midjd
Administrator
Your Money Admin
Joined: Dec 18, 2010 14:09:23 GMT -5
Posts: 17,720
|
Post by midjd on Sept 5, 2013 12:20:47 GMT -5
I think in other states Anthem is OK... the only even remotely helpful links I've found in my Googling have been for California, Connecticut, etc. Indiana is a black hole. Thanks, Beer! Worth a shot...
|
|
|
Post by The Walk of the Penguin Mich on Sept 5, 2013 12:23:26 GMT -5
I think in other states Anthem is OK... the only even remotely helpful links I've found in my Googling have been for California, Connecticut, etc. Indiana is a black hole. Thanks, Beer! Worth a shot... Did you see anything about KY in your googling?
|
|
|
Post by The Walk of the Penguin Mich on Sept 5, 2013 12:25:05 GMT -5
Thanks, Saveinla - that is a good idea. I can't find any info on Anthem's site about member advocates,
Call your employer's Human Resource department. They are not Anthem employees, but employees of your employer who help navigate the system.
|
|
Deleted
Joined: Oct 7, 2024 4:31:09 GMT -5
Posts: 0
|
Post by Deleted on Sept 5, 2013 12:26:19 GMT -5
|
|
|
Post by The Walk of the Penguin Mich on Sept 5, 2013 12:30:27 GMT -5
Oh wow! Your link shows that Indiana's Anthem is administered out of the same place that Kentucky's is.
|
|
midjd
Administrator
Your Money Admin
Joined: Dec 18, 2010 14:09:23 GMT -5
Posts: 17,720
|
Post by midjd on Sept 5, 2013 12:36:09 GMT -5
Ahh, gotcha. I will call our SPD 800 number and see if we have one (I would hope so, but who knows). I am sending them an online grievance. We'll see if it goes into the same black hole as the faxes.
|
|
midjd
Administrator
Your Money Admin
Joined: Dec 18, 2010 14:09:23 GMT -5
Posts: 17,720
|
Post by midjd on Sept 5, 2013 12:37:16 GMT -5
I'm sorry. If it helps, by the end of this I should have a whole list of phone numbers/contacts for you to try...
|
|
wvugurl26
Distinguished Associate
Joined: Dec 19, 2010 15:25:30 GMT -5
Posts: 21,882
|
Post by wvugurl26 on Sept 5, 2013 12:40:01 GMT -5
File your grievance with Indiana's insurance commissioner. Somehow letters and faxes with the insurance commission do not end up in a black hole.
The whole thing seems wrong to me. I had a series of gel shots and a knee scope authorized with no issues at all.
|
|
midjd
Administrator
Your Money Admin
Joined: Dec 18, 2010 14:09:23 GMT -5
Posts: 17,720
|
Post by midjd on Sept 5, 2013 12:50:08 GMT -5
I think the issue is a little trickier since it's an actual transplant... but still, I agree that it seems wrong. Even if they denied it, I'd understand - it's the "do this, no, do this instead, no, we need this" that is driving me insane.
I spoke to our SPD benefits administrator, who was super nice but told me that Anthem won't tell her anything (even to confirm/deny they have DH's doctor's letter) because of HIPAA restrictions, but "if your spouse calls they may be able to give him more info."
Now on to the insurance commissioner...
|
|