Scan denied

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weiseguy
weiseguy Member Posts: 5
edited June 2014 in Employment, Insurance, and Other Financial Issues

Insurance is refusing pre-approval of some scans because they did not know my wife was diagnosed, they seem to think this is still in the pre-emptive stage. Shouldn't there be 1 person assigned at some point so you don't have to repeat the same story 7 times? Fortunately we heard our Dr. isn't afraid to get on the phone with them. She's seeing him Wed. to fill him in. Does anybody have a person assigned or does everybody repeat their story over & over & over . . .

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  • Chickadee
    Chickadee Member Posts: 4,467
    edited April 2012

    Im not aware of assigned insurance agents but typically your records are part of a computer system. Can't quite understand the part about insurance not knowing about your wife's health situation, surely they have paid for her testing and Dr visits and have records of that. Sounds a little like some sloppy paperwork between Dr and insurance. Or your coverage is with a poorly run company. So sorry you have this added stress.

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  • MiniMacsMom
    MiniMacsMom Member Posts: 595
    edited April 2012

    Call. Call the ins company and ask to speak to a.supervisor. dont give the starter lady a reason. Just say u want to speak to a supervisor. Get name number and date of.call. ask to be recorded and then ask the supervisor specifically why it was denied. They should be able to give u a specific reason... wrong dx code... not covered... ect. Use that info to go.back to your doc. Our company has different delartments handle different things and only a supervisor can look at all files once. Good luck :)

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  • nancyh
    nancyh Member Posts: 2,644
    edited April 2012

    The prior-auths on my scans get denied all the time and my doctor has to fight it.  It is almost always a battle.  Insurance companies have subcontracted the pre-auth work to 3rd parties called Radiology Benefit Managers (RBMs such as Qualis and MedSolutions) and their primary purpose is to deny scans they deem unnecessary.  If you don't fit into the checklist on their form, they will deny and make it very difficult to overturn even if your doctor does everything correctly.

    Eventually, if you push, it will be overturned, but it sure can be a headache.

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  • Mooleen
    Mooleen Member Posts: 185
    edited April 2012

    When my diagnosis came, my health insurance company assigned a patient navigator to me. She called me on the phone, gave me her number and said, you just take care of you and I will take care of all the details. Wow, i was impressed. She got my claims through and totally paid in 3 weeks.

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  • financegirl
    financegirl Member Posts: 114
    edited April 2012

    I have many friends with the same type insurance I have.  Been told from them that our insurance only authorizes the first PET/CT infusion scan. The wording is ambiguous because it talks about initial diagnostic ones.  Seems once your cancer is deemed gone or in remission, all future ones are then considered diagnostic as well. 

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  • Sue-61
    Sue-61 Member Posts: 599
    edited April 2012

    The best thing you can do is call your insurance company and request a registered nurse who is a certified case manager. I think some companies call them navigators.

    I am a RN, CCM. When I was diagnosed the very first thing I did was call and request an oncology casemanagerr! I had just retired when I got the ugly diagnosis.

    I have read on this site that many people felt their casemanagers were useless but all the ones I worked with were fabulous. Many times a big expensive test will need a pre authorization. MY CCM was great at gathering the info that was needed and presenting it to our medical director for approval.

    I hate jumping through hoops and think this is your best shot. Wishing you my best, Sue

    EDITED TO ADD: my medical records were not electronic at the time.

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  • weiseguy
    weiseguy Member Posts: 5
    edited April 2012

    Thank you EVERYONE! Great info.

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