Rads Denied???

That's ridiculous and sub-standard!



Is there a mess up on patient name/ medical number etc..?



Did they medical director give a number to contact him/her at?



I'd call the hospital administrator on call even this weekend, and ask him or her to work with you to facilitate proceeding on Monday or Tuesday.



T.

I checking to see how you were doing and found this note-

We are always having to resubmit claims to our insurance.  When I had my first two children through emergency C-section we were told the anesthesia in both cases was unnecessary-Makes you want to find men (or women) in suits and do something painful to them.

DH called insurance provider and it went through without any more problems.

How are you-other than fed up with red tape?

Bev

excuse me?!?!?!?!  I can't believe what I'm reading...I wish I had an answer for you G.  This is incredible!  Don't tell me...the insurance company is Cigna.

-Your best bet is have the rad doc call the company and demand to discuss the case with doc to doc.

-It may delay your rads because the ins. doc's are known to be unavailable.

-In the meantime call whoever sent you the letter and/or your adjustor and raise hell.  Demand to speak to her supervisor and then to speak to HER supervisior.  Don't let them say they'll call you back, be prepared to be on hold and make them give you a direct call back #.

-If you DO have a case mgr or ins.co nurse, call them,too. 

-In the meantime, you can also call your state insurance commission and let them know or file a complaint with them.

-You can also contact the billing dept for the rad doc and explain the denial and see what they can do to get the billing numbers correct or at least determine if they are incorrect.

-Good luck and let us know, more informed folks may come by with better info.

go online and find out who the ceo is for the company. call his office and ask for a direct review.  you will probably get an admin asst but believe me. they don't ignore calls that go directly to the ceo. it can help get the red tape unwound.

make sure you have you ammunition ready with 2 peer reviewed studies that prove rads is appropriate along with the Nccn information.  Be ready to fax all immmediately and make sure to do with a nice sweet voice that will catch those insurance flies.

So sorry about this.  It is totally insane.  TG, you have been given some great suggestions here.  Hope you do them all. Raise a stink!  Squeaky wheel, etc!!!

Hey G,

Did you have rads the first time around with lumpectomy?  Is this radiation for new primary on the other side?  I know I can only get rads once on my radiated side.  I can't believe rads are denied for a new primary.  That insurance doctor forgot his oath TO DO NO HARM!

My thoughts are a comprehensive detailed letter on your tx to date and your doctor recommendations, along with attached medical research showing why you MUST have rads NOW!!  Maybe Edge can help with this.  I think he'll know where to find the exact documentation you need!! 

Let us know what we can do to help you!!

Love ya G,

Bren

NS, really sorry about this idiocy. You can do an expedited appeal (they have three days to respond). If they deny in three days you can do an expedited appeal to an outside review (check with your state insurance commission for details). You'll need your doctor's help with this. Any substantiating information you submit should be faxed by your doctor's office because if it comes from your doctor they're obliged to read every word. (Whereas if it comes from you they're not - took me a long time to find that out, so now I send them whatever mountains of documentation I want through my onc, whose nurses LOVE to do this to them .)

You can do this NS! And maybe it'll help just a bit if you think of it as a way to make this easier for the next BC Sister coming along behind you. Sigh!

Binney 

Gina, I just saw this.  This is absurd.  Do they think YOU WANT to do this?  I doubt any doctor from the insurance company even read the "request" for rads.  If he/she was a doctor they musta gone to med school in Mexico or took an online course!    No wonder our health care cost is so out of control.  I am stunned! 

I know you are so tired of fighting this crap.  But you can do it and you have definitely been given some great advice.  And YOU WILL get your rads.

Shirley

big hugs, no stroke, deep breath......and isn't it funny, sometimes it's easier to advocate for someone else?  Secret confession here: sometimes I pretend that if I were caring for myself as if I were caring for my niece, who I adore to pieces and would move planets for, well, if I were  advocating for her, what phone calls would I make?  What advocacy approach would I take?  Then things are really clear.  Sometimes it's easier to advocate for ME if I pretend I'm advocating for someone else that I love beyond words.  Kind of screwed up, hope it makes sense.  Otherwise the self-advocacy can make me crazy-screaming-losing-my-s*&*-buckets-of-tears-sobbing-so-it-isn't-pretty upset.  The kind of upset that closes doors, instead of the reasonable persistent education opening doors kind of advocacy that wins me friends that I need in the long run. 

That's what insurance stuff does to me. 

 So I have utmost sympathy for your current situation.  All I can say is, easy-does-it, and no strokes!!

xoxoxoxoxo 

Do you know a lawyer?

If all else fails The threat of legal action actually written from a law

office whose specialty is dealing with Health Insurance Companies may help.  These guys don't do anything without being forced.

In my former job I used to see denial after denial of hospitalizations that were completely insane.  It was practically a given that certain HMO's would reject every hospitalization initially.  Most of the time they wound up eventually approving having to approve them.  They will get away with what they can

in order not to pay.----Nasty-Nasty business.

My sister had to sue Blue Cross to get her young daughter an experimental Cancer treatment for Ocular Melanoma.  Blue cross eventually changed their mind but not before the family had to come up with the money themselves by a fund drive. 

I'm so sorry you have to go through all this additional turmoil and stress

at such a vulnerable time. 

G

I was just telling my husband about this and he said, well remember they told you  you only had 'one chance' at the rads.  ??  I do remember the radiation onc saying something to that effect, but can they be denying for that?  This is a thought if someone else wants to chime in.

g

Abbadoodle,

I didn't know that.  My doc said once.  Thanks for the info!!

Bren

PS - G ... let us know what happens today ... standing by to hear from you!

I'm glad your doctors are all so awesome.

You seriously need to switch insurance.  This is insane.  They have done nothing but screw you time and time again, and you can't live like this.

Good luck at rads tomorrow.