Dealing with the health insurance phone tree - UPDATE

[The Walk of the Penguin Mich]

MidJD....

Why a cadaver knee transplant rather than a knee replacement?  Is there an advantage to this?

As long as I've been on replacement groups (for all joints) this is the first time I've heard of a cadaver knee transplant.  I wonder if this could be the issue?

[The Walk of the Penguin Mich]

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."

He needs to call then.  He needs to find out what the hold up is.

[midjd]

He needs to call then. He needs to find out what the hold up is.

He has been... he gets a different answer every time. When he called today, they told him that not only did they not have the letter, but they wouldn't process it if they did because the doctor needs to call them first. His doctor says this is BS and he has never run into this with any other insurance company, or with his other interactions with Anthem.

They won't give him a TKR because of his age (29). A cadaver meniscus transplant is approved for patients <50 and can in some cases eliminate the need for a TKR. At the very least, it'll help him until he hits his late 40s and is eligible for TKR. Otherwise, he's going to end up in a wheelchair before 35.

It isn't a very common procedure, and I had expected at least one denial/appeal, but first we have to get someone to actually look at it...

[The Walk of the Penguin Mich]

OK, I understand now.  For some reason, I thought your DH was older.  Yeah, knee replacements in someone his age are not a good thing.  I ran into this issue too (having a joint fail in your 20s) and had salvage surgery as well in order to buy time.

[midjd]

How are you doing now? I have been thinking of you throughout this ordeal. Joint problems are a real bitch.

I only know of one person who has had a cadaver knee implant (one of my sister's gymnast friends) - I think she was 19 or 20 at the time. She is in her mid 30s now and seems to be doing OK - she's never going to be running triathlons, but is still in good shape and able to hike, jog, etc. It's encouraging to see, although I'm not getting my hopes up that he won't need (I keep typing "kneed," LOL) a knee replacement eventually, but it'd be nice to not be in constant pain until he can get one. 

[wvugurl26]

I'm just flabbergasted that it is so damn difficult to get anyone to look at it and that no one seems to know what the process is.

Mine was just a scope and some scraping of the knee cap which hopefully fixes me. It still pushed me over my out of pocket max. In fact the hospital owes me $18. I had it approved in less than a month without me doing a thing besides signing a surgery consent form.

[midjd]

Mine was just a scope and some scraping of the knee cap which hopefully fixes me. It still pushed me over my out of pocket max. In fact the hospital owes me $18. I had it approved in less than a month without me doing a thing besides signing a surgery consent form.

I hope it helps!

DH had something similar last year and I don't remember going through this process for that, either... so maybe it is more related to the transplant issue vs. preauthorization of something routine. I was amazed at the recovery process for the scope, I figured he'd be out of commission for a while, but he was up walking around within a few days...

[shanendoah]

Having worked for 5 years in a pre-authorization department, I completely advocate calling your Office of the Insurance Commissioner. If something like this had happened in our department, my executive director and my medical director would have been looking for someone's head. That said, have your list of dates and contacts with the company in front of you when you call. The OIC will listen to you and help as best they can no matter what, but it is easier for everyone if they have all the information.

So have your:
I called X date, and they told me they couldn't discuss it because DH was the patient
DH called Y date, and he was told they couldn't discuss it because I was the primary on the insurance
MD's office contacted on Z date, given fax number A. Follow up call to the ins co says they never received it.
DH called on L date, given fax number B. This is a bad number
DH called on M date, told they won't look at the case, or letter from MD unless MD calls first. MD claims this is NOT standard procedure

The more specifics you can give them, the easier it is for them to help you.

[shanendoah]

double post - sorry

[midjd]

Thanks, Shane! I wish I'd kept better records at the beginning, but I didn't think it would drag on for five weeks. I do have pretty good records of the calls made since mid-August.

DH got a call back from Anthem a few minutes ago - he said that they spoke to the physician's assistant, gave her the number to call, and that DH needed to check back tomorrow to make sure they'd gotten the letter and everything had gone through.

I have the complaint to the commissioner drafted and sitting in my Gmail. DH told me not to file until tomorrow. He is a trusting soul.

[Chocolate Lover]

Mid, did you call them on the house phone or cell? You can at least hunt down dates called on cell bills.  It's been so long since I had a regular phone bill I have no idea what kind of calls show on it. 

[midjd]

I made almost all the calls from my cell - so I should be able to get the dates out of my call log. I'm not sure about DH - he's been calling from work, and given the volume of calls they make/receive (car dealership) I'm guessing he used his cell rather than tie up one of their lines, but I'll have to check tonight. Thanks for the reminder!

I've never had a landline, so I'd have no clue what a "real" phone bill looks like either

[Chocolate Lover]

It was the one thing I could think of that hasn't been covered. AND you'll know how long you were given the run around on each call

[The Walk of the Penguin Mich]

How are you doing now? I have been thinking of you throughout this ordeal. Joint problems are a real bitch.

Things have been getting better, I'm 100% more mobile than I was at last year this time but not anywhere near I was when I caught this $%#& infection that caused my year of hell.  

Conventional wisdom says that under normal circumstances, one should be almost at 100% a year after a replacement surgery but there is no data on where you *should* be a year after 4 surgeries in 10 months!  PT and more PT, that's the story of my life these days.

[Nazgul Girl]

   I spent 15 years of my life calling buggers like Anthem.   When you call the pre-auth dept again, if you don't get any satisfaction, ask, " Who's going to step up and take responsiblity for resolving this issue for us ? "   If that doesn't light a fire under anyone, thank them nicely for their "help," and then tell them you want to "escalate" it to the next level.   This will most likely cause some fear in the person at the other end of the phone, since by "escalate" it means that you will be talking with their supervisor.   They will say, " No, I can help you," but pleasantly state that you have spent "25" minutes on the call so far with no resolution, so you need the call to be "escalated."

   Also, make sure you get the employee ID, first name and last initial, and the "record number" or " transaction number" or "log number"  for the call, each and every time you call.   Every big server has a numerical I.D. assigned to the calls that come in, so they can find the records of the call.   If they say they don't do that, ask them how they identify the "notes" that the person who is "helping" you made on the call.

   Many times, an uncaring or unprofessional employee will not bother to make any notes on a call coming in if it spells trouble, so make sure they know that you mean business.

   Keep a phone log with the above info for your records.   Good luck.

[Nazgul Girl]

   Also, I completely agree with everything that shanendoah just posted.   if you combine the advice in the two posts, plus have sit in on the call your Benefits Dept person, possibly with your husband present, so that they  can't duck behind " I can't tell you anything because you're not so-and-so, " hopefully, you will get some results.

   Another possibility is that since this is unusual surgery for a person your husband's age, perhaps the case has been assigned to a case manager, and just the pre-auth is not going to be enough.   If a case manager is involved, find out who she is ( usually they are retired nurses ), and speak to her very politely, asking what kind of documentation your husband's physician needs to submit to prove that this high-level procedure is needed.   The physician may have to write a letter explaining the medical necessity, what treatment modalities have already been attempted and why they failed, and what the outcome and benefit is expected for your husband after the procedure is performed.   The letter will probably need to be supported by medical records.

   A phone call from the doctor to the pre-auth dept. isn't going to do it, in this case, I don't believe.

[lurkyloo]

I've had a fairly good experience with Anthem in CA.  In fact I just got an erroneous bill from the anesthesiologist for $550 (the EOB on the Anthem website had indicated I didn't owe anything) with a special bonus "your payment is overdue, so pay up within 5 days" note on it.  I had to wait on hold for a while to talk to a rep at Anthem but they actually called the anesthesiology office for me while I waited and cleared it up for me.

I do wonder how accidentally on purpose the erroneous bill was.