Problem w/ acceptance of state-funded health plan in diff. state

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Murfy
Murfy Member Posts: 342

I have an Aetna PPO that is self-funded through state of Illinois. I now live in TX. Thus far, all claims have been approved for funding. When my MO filed a claim for Granix recently, his office ladies asked Aetna when funds could be expected. Illinois was ambivalent and told them it depends on legislative appropriation approval and there was no date set. My MO office freaked, called me and said I would have to start paying for my remaining treatments up front (at in-network rates) as Illinois said they couldn't pay (although they approved). One office lady said if I didn't pay up front, I may have to seek my remaining treatment elsewhere.

Sounds like I am supposed to pay for Granix on Monday, but then plan to talk to insurance supervisor and see if office will continue to file claims and allow us to assess insurance status after final treatment in March. Perhaps I could make 'good faith' payments to MO at that time until insurance comes through. If I get nowhere with her, I have appt with MO on Friday and can see if he will intercede.

I have an in-network insurance that has approved all my claims to-date and will, eventually pay these claims. Should I be expected to pay upfront expenses or is this setting a precedent? Is there anything else I can/should do?

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  • Murfy
    Murfy Member Posts: 342
    edited February 2018

    I talked to my MOs insurance staff and thought I had made headway, but apparently not. I have put $1250 on my credit card this week and have chemo scheduled for next week. Had an Aetna supervisor call the office to ask MO to honor insurance, to no avail. That this has happened exactly half way through treatment feels like a shakedown. Don't know what to do except pay off credit card and/or hire an attorney.

  • Murfy
    Murfy Member Posts: 342
    edited February 2018

    Squeaky wheel has prevailed! After many phone calls between me, insurance, and MO, a compromise has been reached. I will only pay for Neupogen shots out of pocket, and doc will continue to file claim for them and all other procedures. After end of cancer treatments, MO will start billing me for payments I can afford until insurance coughs up what they owe. MO will then reimburse me all that I have paid. Mostly WIN-WIN.

    Looking forward to going on Medicare in 3 years!!

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