Fighting Anthem/Blue Cross

kitkit
kitkit Member Posts: 80
edited July 2019 in Employment, Insurance, and Other Financial Issues

Insurance driving me nuts!

I have Anthem Blue Cross PPO. I have lymph node metastasis of lobular carcinoma in axillary and chest nodes plus I had met in T6. My UCLA doctors recommended stereotactic radiotherapy - one blast - to T6. I had it done two weeks ago and pain is gone. I'm also on Ibrance and Letrozole.

Insurance says even after appeals from dr that they won't pay for my targeted radiation to back because their guidelines say I must have failed first at another radiation. Crazy! Why not have the most targeted and efficient...and also less cost to them if I only have one time rather than a dozen.

Any ideas, sisters? Two doctors have sent appeals, and then requested another review (denied, also). Has anyone gotten this type of decision reversed?

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  • DebAL
    DebAL Member Posts: 877
    edited May 2019

    kitkit, I fought this insurance company for a completely different reason but maybe my experience can help you with your next step.

    First, plan on being on the phone for awhile. Call and escalate up until YOU can get your hands on those guidelines...read, try to find a loophole, and write an appeal letter yourself.

    GET THIS.. was told that when the first appeal goes thru that the physician that makes the decision can be ANY physician. Like my oncologist asking for approval from an OBGYN lol!!! Are you kidding me?? Once it is escalated up , a physician from the same service line must review it. Only then did an oncologist review my claim and it was approved. (This was after my oncologist was denied in her appeal. )

    Drs offices cannot get those guidelines for you. But you can, it's your right. Once you read them there may be an angle that you can make the focus in your letter.

    It is time consuming and the last thing you want to be doing when you arent feeling well. But you may have luck.

    I'm sorry you are going through this and although our situations are different I thought maybe my experience would help you.


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  • Falconer
    Falconer Member Posts: 1,192
    edited May 2019

    I am so sorry you’re in this awful situation with the insurance company. The dx is stressful enough and their heartlessness worse...

    I had a major shift when I received the number of my local negotiator from a colleague. I’m a teacher and we are part of a health insurance collective throughblue cross blue shield. I contacted him and shared all of my documentation. He called the insurance company and the next day it was settled.

    Good luck to you. Holding you in the light.

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  • kitkit
    kitkit Member Posts: 80
    edited May 2019

    Thank you for your responses! My first reviewer was an allergist! The second was a trauma surgeon! I don't have evidence that any radiation oncologist has done a review. i am a very persistent person and am continuing to go up the chain. I am working on several parallel angles at the same time and will report back if anything works!

    Take care everyone.

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  • sbelizabeth
    sbelizabeth Member Posts: 2,889
    edited May 2019

    Kitkit, Falconer has a good suggestion. Where do you get your health insurance? An employer? Call their human resources benefit coordinator and explain what's going on, and ask for help negotiating with Anthem. And consider calling California's Insurance Commissioner to file a complaint. This SO pisses me off.

    http://www.insurance.ca.gov/01-consumers/101-help/

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  • edwards750
    edwards750 Member Posts: 3,761
    edited May 2019

    Appeals do work sometimes. I appealed a claim that was classified OON so it would have cost my DH and I over $5k. The hospital(OON) that did his test was the only one in town who could do it so I appealed to BC/BS and won the appeal. Had the neurologist done her job it would have been handled ahead of time. She didn’t so it wasn’t.

    A friend’s husband appealed a denial for coverage 3x before he got the test approved. Squeaky wheel gets the grease. Be patient and persistent.

    Diane

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  • kitkit
    kitkit Member Posts: 80
    edited May 2019

    Thank you,

    I intend to be persistent. Anthem says my next step is to request all the paperwork they've considered. I've done it. They say it won't be sent to me until early June. In this day and age we all know that it could be delivered to be instantly if they wanted to. Perhaps they've figured out that the delay will cause some people to give up. I've got it calendared.

    K

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  • edwards750
    edwards750 Member Posts: 3,761
    edited May 2019

    KitKit - BC/BS told my DH and I it would be 30-60 days before our appeal was decided. It took 2 weeks.

    Diane

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  • kitkit
    kitkit Member Posts: 80
    edited July 2019

    I won my Anthem appeal!!!

    Finally they sent my info to an independent specialist who was a board-certified radiation oncologist. He agreed that the one-time stereotactic radiation to my one T6 met was medically necessary. Anthem kept saying I had to fail first at an entire series of radiation.

    Previously I had two appeals denied by Insurance department hacks; one was a trauma surgeon, the other an allergist. I am convinced that they wanted me to give up. The request for independent review takes more time as I had to attach research papers justifying my treatment. The independent reviewer cited even more research supporting my position in a lengthy two page analysis.

    What I have learned is to do the extra work and get to an independent reviewer who is in the correct field for review. That made the entire difference.

    Good luck to all in my situation

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  • kber
    kber Member Posts: 394
    edited July 2019

    Congratulations! Yes they do count on you giving up. It's part of their cost management / profit model.

    When I was diagnosed, my first call was to my health advocate. The company she works for is actually independent of the insurance company (Aetna in my case) and her job is to help me navigate the insurance complexities that come with a diagnosis like cancer. Well, I drew the lucky straw because my advocate is a bull dog who put the fear of god into them! She's a nurse practitioner experienced in oncology care and from the get go, when we were trying to get a PET scan approved so I could start treatment, she had a take no prisoners approach! She saved me hours of time and more stress that I can imagine.

    I've become a true believer - anyone facing a complex or serious illness should find out if they have a advocate associated with their plan and make that person one of their first calls!

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  • edwards750
    edwards750 Member Posts: 3,761
    edited July 2019

    Way to go both of you ladies. Taking on the insurance companies is no easy task. My husband and appealed a $5000 charge BC/BS denied because the procedure was OON. My husband had to have the procedure and the hospital where it was done was OON. It was the only facility in town that did the procedure. I wrote the appeal and we won. It took some doing but was worth it. The thing is it could have all been avoided but my husband’s doctor at the time fumbled the ball because all she had to do was request an exception with BC/BS which she failed to do. Most incompetent doctor’s office we have ever dealt with.

    Also a friend’s husband appealed to the insurance company 3 times before they won their case. Persistence pays off. A friend who works for doctors said you can win if you are persistent. She’s seen it happen many times.

    Diane

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