This is the location for conversations that don't fall anywhere else on FlameFans. Whether its politics, culture, the latest techno stuff or just the best places to travel on the web ... this is your forum.
User avatar
By CCWMichael
#560201 Federal Employee Blue Cross BS sent me a lovely letter this weekend.
My 25 radiation treatments have been denied for payment because they feel IMRT (a typical type of radiation treatment).
"Specifically we determined that IMRT is not consistent with accepted standards of medical practice in the United States".
I am FURIOIUS!
I am sure since my bills are well into 7 figures they are working to minimize their losses.
And, I start my ported chemotherapy the 9th. I am worried they may pull the same fecal matter.
I will contact my medical team to speak with the insurance but beyond that I have no idea what to do.
Stuff like this sends many people to bankruptcy and that is not my goal.
If anyone out there has ideas of what I can do or aquaintaces that can send me some advisement I would greatly appreciate the help.
What the Fudge have we paid our premiums for for so many years!
User avatar
By Jonathan Carone
#560203 My wife is an oncology nurse. She’s worked in both chemo and radiation. She’s had this happen before with patients. Talk to your oncologist and ask him/her if he can do a “peer to peer” with a physician at the insurance company. Usually that is with an oncologist as well. The reason for the denial is usually because the insurance company prefers 3D radiation but your oncologist preferred IMRT because the 3D would’ve hit too many other vital areas. Usually after your doctor shows the insurance doctor your scans and explains his reasoning, things get worked out.
User avatar
By Jonathan Carone
#560204 Also - she said her office always gets a letter for the denial and they end up working to get it approved before the patient even gets a letter. Your doc’s office may already be working to help you out.
By BuryYourDuke
#560210 I’m very very grateful and thankful that we had someone here with an understanding of the situation, and exactly how to help.

Great job Jon.
User avatar
By CCWMichael
#560247
Jonathan Carone wrote:My wife is an oncology nurse. She’s worked in both chemo and radiation. She’s had this happen before with patients. Talk to your oncologist and ask him/her if he can do a “peer to peer” with a physician at the insurance company. Usually that is with an oncologist as well. The reason for the denial is usually because the insurance company prefers 3D radiation but your oncologist preferred IMRT because the 3D would’ve hit too many other vital areas. Usually after your doctor shows the insurance doctor your scans and explains his reasoning, things get worked out.


Jon,

Many thanks to you and your wife. This helps to hear this from outside my circle. I am amazed though that some many denials are common for a standard procedure. I turned over my documents this morning to my medical team and they stated they are looking for some dosimetric planning to determine less probability adjacent organs will be affected by IMRT as opposed to 3D.

Thank you again for helping to ease my anxiety over this.
User avatar
By RubberMallet
#560265 yeah, this is stuff that makes you just throw your hands up say screw it, its time for a new HC system. I've not dealt with a major thing like this, but all the little things that regularly make my blood boil with insurance companies is enough to drive someone mad.
User avatar
By CCWMichael
#560335 WOW!

Insurance is backing me up here.
Opened a letter this morning fron the insurance company stating: "because my provider participates in our network, you are not responsible for these charges". YES!
No I am smart enough to know thw hospital will work this in their favor and have it authorized but I will still take the deductible over what could have been.
AMEN!
User avatar
By CCWMichael
#560361
alabama24 wrote:YES! Glad to hear it.



It would have been nice if they sent this letter with their initial denial but that would involve understanding the patients reaction.
By Rubicon
#560565
Jonathan Carone wrote:My wife is an oncology nurse. She’s worked in both chemo and radiation. She’s had this happen before with patients. Talk to your oncologist and ask him/her if he can do a “peer to peer” with a physician at the insurance company. Usually that is with an oncologist as well. The reason for the denial is usually because the insurance company prefers 3D radiation but your oncologist preferred IMRT because the 3D would’ve hit too many other vital areas. Usually after your doctor shows the insurance doctor your scans and explains his reasoning, things get worked out.


This has been our experience as well, and not just in cases where claims are denied. My wife is fairly young (40), but had major surgery back in 2008 and has to be on high doses of warfarin for the rest of her life. After her surgeries, her doctor wanted her to be on Lovenox (low molecular weight heparin) for about a month before using the significantly cheaper warfarin. When we went to pick up the prescription, we were told, "That will be 2200." We asked if they ran it through insurance, and were told, "No insurance covers this." We laughed and told him we would have to talk to our doctor.

He simply gave us the supply we needed. And did it years later when she was hospitalized again with issues related to her condition. We have found that when patients simply can't pay for needed treatment (deemed essential by the doctor), the doctor has a number of routes for getting around that. You definitely need your doctor in your corner, though.

I'm glad it appears to be working out for you, CCW!