Rich_in_Tampa said:
This is a 55 year old woman, worked and paid for health insurance (plus employer payments) for decades, and basically played by the rules. She's screwed.
Yes, it's a little known fact that the heroic and highly trained clerk at a private health insurance company is often the only thing standing between a typically derelict Doctor and his helpless patient.
Since Rich said "She's screwed...", I was just trying to point out that, in fact, she's NOT screwed. Just about 1/2 hour of time and effort could result in the insurance company making an exception agains their 15 day rule, and agreeing, in advance, to pay for her lifetime's worth of blood thinning injections.
That second comment about the "heroic and highly trained clerk" just further re-inforces to me that MOST people don't realize that it's not the "highly trained clerk" on the other end of the phone who makes the decisions regarding what is or is not covered in the contract nor do they have any power over claim appeals. That's why I pointed out that when sent through the
proper channels, and not by trying to convince a front line customer service rep that the medication is needed, a specialized care coordinator (who is typically an RN or PA) can work directly with a claims manager to walk a special appeal through the process in a relatively quick period of time and resolve this poor patient's situation.
All too often, the doctor's office makes just one phone call to the patient's insurance customer service line, and after being told that the service is not going to be covered, they take that information to the patient and then leave the patient with no hope.
I'm just trying to correct Rich that instead of just telling the patient "it's not covered", and leaving her to think she's "screwed", the doctor's office could go a step further and explain to the patient that oftentimes, a simple appeal filed as per the step by step instructions I mentioned earlier could result in coverage for the injections. A call to the patient's broker or insurance company if there is no broker, to get the correct appeals address and process, is usually the first step in moving forward. Many people just try to send a letter of request in with their billing statement or they try to call customer service, only to find they end up at a dead end.
Time and again, I have helped people who have been trying to appeal a claim for months or even years, to resolve the issue in a matter of days by bringing in the proper people from the insurance company to help out. When a claim appeal gets sent to the wrong dept or through the wrong channels, it can slow the process altogether and just lead to a lot of dead ends that seem like "the runaround", when in actuality, the claim appeal would've been processed much more quickly and timely if it had been sent to the correct address, with all of the correct information included.
I'm not trying to insult anyone here, just trying to point out that the insurance company is not going to deny a claim just for the purpose of being greedy and insensitive. Oftentimes the problem is that the insured just needs a little help going through the proper channels to get it taken care of quickly, and rather easily. The assignment of a care coordinator can be a good start if someone knows that they are going to be in for a lot of upcoming treatment. Most insurance companies have "care coordinators" on staff, and it's not hard to get assigned to one by making a simple request (preferably through a broker if you have one.)