How Insurance Company's Figure Out What To Pay For?

[goodnuff77]

Sorry I'm just venting. So my insurance paid for the surgery to have a Port a Cath put in, they pay for a visiting home nurse to change the needles in the port. But today I got a letter after a year saying they wont cover the supply cost to use the port anymore. So I got a bill for $1,221.48 and their saying I have to pay $103.68 a week for the needed supplies. How are they able to do this all of a sudden, and why pay for everything else?

[arizona girl]

This just happened to me to. They shifted the cost of my Ivig med to the pharmacy cost center from the medical cost center. There are no caps for out of pocket on pharmacy. So they are shifting the cost back to the patient, by doing this. I'm not sure yet what recourse there is. It may cost me and extra $200 a month and it won't apply to my total out of pocket for the year, so I will have to continue to pay regardless of having met the cap for the year.

Any ideas on what are rights are and if the insurance companies can do this? This is just starting to happen and may effect other forum members.

Edited March 6, 2012 by corina

[janiedelite]

When I've had a dispute with a health insurer, I enlist the doc who ordered the disputed test/med/etc. They can write persuasive letters to the insurance's appeal committee. Also, have them send you this denial and why they are now denying it in writing. You may need to read your contract with your insurance company. Perhaps they're "bending the rules of the contract" a bit to suit their needs and you can dispute them using their own contract.

If all else fails, you always can file an official complaint with your states Insurance Commissioner. This can usually be done online or by phone. Each insurance company has to get licensed in the state they do business and if the state finds out that they're not abiding by their contract, they can be fined. I find that just mentioning calling the insurance commissioner sometimes gets results.

[rubytuesday]

How aggravating for you. I'm so sorry you have to deal with this kind of stuff, especially when you're ill. I've waged appeals to my health care insurance company in the past--most successful, but only if it a covered benefit. With my IV Ig, everything is covered under my medical insurance (I get transfused at hospital). When I switch over to home sub cutaneous Ig, the medication will be under my pharmaceutical benefit (I too will have a co-pay). The home health care will be under my medical benefit and I was thinking that tubing, pumps, needles, supplies are probably considered to be 'durable medical equipment' (under my medical benefit). Are you able to get infused at an ambulatory unit at local hospital rather than home (would it be back under the medical benefit)?

My Ig has to be pre-authorized. Our pharmaceutical manager sends us a formulary but writes that things are always subject to change within the calendar year (and they have, without even forewarning us). I sure hope this doesn't happen to me. It's so scarey.

I have found helpful information on idf.org, and there are other websites whose names escape me at the moment. You might google PI or CVID support groups. I know idf.org has advocates and members that you might bounce this off of. There is an entire section dedicated to insurance issues (and there are telephone contacts available). It seems to me since everybody's insurances are so varying, it does get tricky. Unfortunately, with your illness, you certainly do not need the added stress.

Best wishes that you get this resolved if you can.

[goodnuff77]

Rubytuesday If I had the Iv done at the hospital it would be covered, But They just upped me to 2 bags aday. So the problem is I dont drive and to get to the hospital everyday for 8 hours ( 250 ml's an hour) would be a little much. I have a wife and 2 kids and want to see them. I dont know what to do... Seems like everything lately is going wrong

[rubytuesday]

Rubytuesday If I had the Iv done at the hospital it would be covered, But They just upped me to 2 bags aday. So the problem is I dont drive and to get to the hospital everyday for 8 hours ( 250 ml's an hour) would be a little much. I have a wife and 2 kids and want to see them. I dont know what to do... Seems like everything lately is going wrong

Well that just stinks. I have to drive nearly 2 hours and then spend another 4 to 5 to get the IV Ig at hospital (which is why I'm so anxious to get it subcutaneously). It's going to cost me more (to me) but I will be so glad to have the convenience of my home/in my time. I am supposed to infuse weekly. I hope there is someone in your benefits department who can explain things and listen to what you are saying. I find a lot of billing mistakes that I call my insurance company about. If I don't get anywhere with talking to my benefits coordinator, and/or the insurance plan, I won't pass up the right to appeal. I just feel so badly for the situation you are in. With my plan, if the doctor writes the script for ordering/dispensing this 'equipment', it is considered DME (durable medical equipment). The heparin they use in your port (?) would be considered to be a pharmaceutical. When I used to get my allergy syringes, I would have to pick them up at the pharmacy, sign for them, but they were rung up as prescription (but that was 15 years ago). I guess what I am saying, you cannot get the substance from the bottle into the port without this equipment (which would qualify as medically necessary) since you have the prescription. Perhaps it is the supplier who is not billing or coding this correctly on the bill. You might be persistent in trying to talk to someone there who does the billing. I hope you check out the websites I'd mentioned. Someone there may be more useful than my own experiences. Good luck!