Out of Network Coverage

[Seal]

Hey,
Has anyone been successful with out of network coverage through an appeal?     My surgery was just thrown into limbo today when I got the word that United Healthcare denied coverage for the operation at SBI since they are out of network.     The "gap" coverage clause is supposed to take effect when local sources are not available for the procedure.    In my case, United is saying that their network has providers and thus deny coverage at the last minute for the scheduled operation next week.     Now in reality, the only reputable endoscopic treatment for  ANs is SBI, and they are out of network.    Since there is no local "in kind" service available, I should be able to get approved for the operation.      Unfortunatly, some brave soul "just doing their job" up the line at United decided to cancel the already approved coverage, putting me in limbo.      What I have found out is that United Healthcare as well as other providers base these decisions on so called "codes" of coverage, and they actually DO NOT have a code in their system for endoscopic treatment.     SBI's office used a code for neurosurgery, and some functionary decided that there is other "neurosurgeons" in their approved list, thus issuing a denial of service to  SBI.    They will not fax this official denial nor e-mail it.   So with snail mail of the USPS, we will not receive the denial notice intime, and m surgery will not happen.

So assuming that I need to appeal, has anyone out there been successful with appeals, specifically regarding SBI?     

TIA,
Steev

[EJTampa]

Hi Steve,
 
While I don't have the information you need on the chance of a successful appeal, I do, at the very least, wish to convey my sympathy for what was just dumped on you at the last minute.  I said it many times, it's the waiting that is the hardest part.  That just plain (4 letter word, starts with s, and is synonymous with stinks)!
 
One suggestion I would have for you is to contact SBI quickly and have them work with your insurance company directly.  I know that won't fix the waiting for the denial letter, but maybe between the two something can be worked out to save your date.
 
Of no comfort to you at all, I'm sure, if you do need to go a more traditional surgical route, you really can come home from the hospital the day after traditional surgery, and function quite well too.  I hope you don't get forced down a path you didn't wish to follow 
 
Ernie

[Seal]

Ernie,

I appreciate your concern and thanks for the support.  I have been denied again on the first appeal of the rejection letter dated March 6th.    This is after United Healthcare gave us the initial approval code number to proceed with the surgery at SBI.     Then seven days later, they decided to reject it and reverse the approval.   They have tried to say that there are two neurosurgeons in my area that can do the job.   Well, one does not actually have any experience with acoustic neuromas and the second is currently not operating and is under investigation for operating twice in two years on the wrong side of patients brains.   Great referal network eh?    In my humble opinion, United Healthcare is run by incompetent, corporate idiots that only care about refering patients back into their own network so that they can pad their yearend bonus that are based on how many are refered back into their network.     I now have to cancel my trip and plans for surgery next week at SBI to fight these idiiots.    They have no compassion and no sensitivity to the patient nor to the family of the patients.    I'm more worried right now that my wife is going to have a nervous breakdown.    When I commit to a project or customer, I do and will stand by my initial word and promise.  These ignorant criminals obviously don't operate under the same value system.        This is just wrong. 

Steve

[sgerrard]

I would definitely contact SBI and ask the doctor there to directly contact the insurance company medical person who is making this determination. A medical professional will have much more influence than you as a patient. UH is unlikely to have anyone actually qualified enough to determine that you can get adequate neurosurgery treatment for your acoustic neuroma from someone in their network - they won't have anyone with that kind of specialized knowledge. A doctor who is qualified to do so can "gently but firmly" explain that to them.

Steve

[Seal]

Thanks for the input Steve.     You and I understand it, but it's getting UH to understand the situation.      Roxy is the contact and front person at SBI, yet they seem to be unwilling to really got to the matt and really push on behalf of the patient.      She even stated that most facilities just give up once they are denied coverage.    They don't want to expend excess time and money fightling a fight with an insurance provider when it is the client. who is the ultimate customer.    We will appeal, but the delay starts all over again.   I have to  get in the que for SBi, and that is assuming that I finally get UH to cover the out of network costs.     I have applied incredible pressure on UH that I can't reallly detail here on line.     Even the V.P.of sales for UH was forced to take our calls yet he did not have any leverage to contribute.      This is just not fair......................and meanwhile I contiunue downhill with more facial numberness, triping and fallng, loss of taste, etc.     I know this will only get worse from here.

[EJTampa]

She even stated that most facilities just give up once they are denied coverage.    They don't want to expend excess time and money fightling a fight with an insurance provider when it is the client. who is the ultimate customer.

Ouch.  That was SBI?  After visiting their extensive and well laid out website, I thought for sure they were world class, or heading that way.  My wife is a nurse, and has to "convince" insurance companies from time to time.  I think I might contact someone "above" Roxy, if possible, and try again.
 
My ENT was fighting with my insurance company to cover an MRI.  They called me 4 hours before my appointment to let me know the Doctor was going "toe-to-toe" with the doctors at the insurance company, but weren't sure there would be a decision in time.  When I got to my appointment, the final arrangements were being made but I got my coverage and had my MRI.
 
I would persue both directions, but it seems like you would have a better chance with SBI on your side instead of just shrugging their shoulders.  Of course there is always a "middle man" such as a lawyer or an "eye on your side" type of news investigative snoop. 
 
I hope you get this resolved in a way that is favorable to you soon,
 
Ernie

[sgerrard]

Another avenue might be to contact the in-network doctor the insurer thinks can handle the case. See if the doctor is willing to assert that he can treat the AN with the same outcome that treatment at SBI would produce, including preservation of nerve function. I remember when Adrian (Samantha n Adrian) was getting surgery in 2007, he had to send his MRI and tests to a local doctor, who took one look and said "no, I can't do this, you need to go to the out-of-network expert." Having an email from the expert also helped.

My other advice is to make double sure that everyone has copies of all tests, reports, MRIs, evaluations, and other documents. Make up a set and fax it around to all parties. Make sure everyone has everyone else's phone number, email address, and mailing address. Facilitate in every way you can. Be relentless.

Steve

[Seal]

Hi Ernie,

SBI is not the issue nor the bad guy.   The problem lies with United Heatlhcare and the uninformed dummies that they have on staff that either  approve or deny the out of network requests.     Their job is to maximize profits by keeping patients within their network.   However in this case, SBI is the only place right now in the country with the experience and proven track record in endoscopic removal of acoustic neuromas.   

Steve,  that is an interesting approach.   We already have a statement of urgency from my primary that is getting faxed tomorrow regarding my increasingly serious symptoms.   We have already burned throught four of their options that they have thrown up as local, in network providers.    The best one was the surgeon who is on adminstrative leave for operating twice on the wrong side of two patients skulls in the last two years.     The hospitol was sanctioned as well.   That is a good idea on MRI's to United.    It may not matter, but it can't hurt.     Right now, my job is to EDUCATE the doctors on staff at United Healthcare as to the appropriate options for my particular AN.       

Thanks for your comments guys,
Steve

[sgerrard]

Right now, my job is to EDUCATE the doctors on staff at United Healthcare as to the appropriate options for my particular AN.       

Yes. We know that often our primary care physicians, and even many ENTs, do not know very much about acoustic neuromas. Imagine what the medical person (doctor?) at the insurance company knows about them. They are probably a nurse practitioner, a new resident, or a doctor who was never the sharpest scalpel on the tray. They don't work at a hospital; there is a good chance they have never even heard of an acoustic neuroma.

You want to put them in a position where they have to acknowledge that they are attempting to change your medical treatment, not just assigning you a different doctor. They are not qualified to do that, and will have to recognize that they can't take the responsibility for the consequences of trying to do so. You could sue their pants off if it didn't work out well.

Steve

[allegro17]

Hi Steve,

I am just now reading about this, and, coincidentally, find myself consistantly one step behind you in your AN process.  As I just scheduled my surgery at SBI for 4/28, and am awaiting out-of-network coverage approval from none other than United Healthcare.  Ugh!  I can't believe they are giving you all this trouble!  This is very worrisome, as Roxy/I will attempt to have this procedure covered as an in-network exception.  UGH.  This is making my stomach turn.
I apparently have to wait until 30 days before the date of surgery for this process to officially begin. 
I have had good experiences with UHC in the past and hope for both of our sakes that they see the light. 
Good luck, and keep us updated! 

Best,

Laura

[Seal]

Laura,

You need to take responsibility for this and I mean now.   Do not wait for Roxy to do the leg work, and do not be mislead into thinking that everything will be o.k.   Only you can bring a sense of urgency to the situation.  SBI is not associated with ANY networks.    So if you decide that you want that treatment, then be prepared to either 1) fund it yourself or 2) go through all the pain and struggle to get approved as an out of network exemption.     

After going through the highs and lows of the last week, surgery wil be welcome amusement if and when it finally happens.   

Steve

[suboo73]

Yes. We know that often our primary care physicians, and even many ENTs, do not know very much about acoustic neuromas. Imagine what the medical person (doctor?) at the insurance company knows about them. They are probably a nurse practitioner, a new resident, or a doctor who was never the sharpest scalpel on the tray. They don't work at a hospital; there is a good chance they have never even heard of an acoustic neuroma.

You want to put them in a position where they have to acknowledge that they are attempting to change your medical treatment, not just assigning you a different doctor. They are not qualified to do that, and will have to recognize that they can't take the responsibility for the consequences of trying to do so. You could sue their pants off if it didn't work out well.  Steve

Steve (Seal)  - i have had this experience, plus the one with the wrong codes, plus the appeals -aaaahhhhh - can you see the steam coming out of my ears!!!!!!!!!   
[Steve (May i knit you a hat?) has much wisdom...] 
The insurance companies don't care, just keep putting you off and think that you won't notice, that you'll give up... 
Be relentless, thorough, and keep copies of everything - i agree with all of these things.

I am cheering for you - Go Steve, Go!
Good luck and keep in touch, ok?

Sincerely,
Sue

PS  OMGosh - and have that surgeon on 'administrative leave' operate on my brain, I DON'T THINK SO!

[highlife]

I think that the sad thing about Steve's case is that it probably isn't an MD making the call to refuse payment.  I think he should keep working on Patrick Kennedy and Barack Obama.  Your primary physican should easily be able to substantiate that the two candidates in his network are not adequate.
Steph

[highlife]

And by the way, the state insurance commissioner's office would have gotten a call from me regarding UH's referral to two very inadequate surgeons in their network.
Steph

[Seal]

This program is a large self funded one.    In this case, only the federal government has jurisdiction.... unfortunatly.

Self-insured, employer-sponsored health insurance (ERISA-preempted)
If you work for a large company, there is a chance that the employer is "self-insured".  To determine if your employer is self-insured, speak with your employer. Self-insured companies are not subject to state laws and regulations, which are preempted by the Federal Employee Retirement Income Security Act (ERISA).  ERISA preempted employers are subject to regulation by the Federal Department of Labor's Employee Benefits Security Administration. Complaints about a self- funded health plan should be directed to your companies’ human resource department or contact:
U.S. Department of Labor
Boston Regional Office
J.F.K. Building, Room 575
Boston, MA 02203