Context: Requirements for a breast reduction under my plan: 3 letters of support & medical notes needed: 1 from surgeon, 2 from additional physicians, 1 of which must specialize in musculoskeletal disorders. There’s a min amount to be removed (I meet the min). 6 months of conservative treatment must be attempted and documented (been going to chiro for years).
I am on my parents’ insurance, but I’ve been handling 100% of this process. My parent filed for a claims support advocate through his place of work after I told him all of this.
Timeline of events:
Spring 2021: insurance tells me that my surgeon must be forwarded all letters of support from other physicians, and then my surgeons office must submit everything to insurance.
July: I’m denied because insurance claims they didn’t receive ANY letters of support from two additional physicians, other than the operating surgeon.
Late July: I tell insurance that my surgeon submitted notes from chiropractor, and insurance denies ever having those notes. They only tell me that my surgeon submitted something via Navinet, which prompted the denial letter. Insurance tells me to have my two extra physicians fax their notes to insurance directly. I tell insurance that I was told differently before, and insurance doesn’t care. They just tell me to have my doctors fax their notes in.
Early August: All additional notes are faxed in as of Aug 9. I receive confirmation from insurance in writing that the notes were received.
Most of August: I am told to wait because my files is under review. I’m told that someone is looking at it, and that I can expect an answer by the end of August.
End of August: I am told that the amount of time needed to look at my file has changed, and that I’ll now know by the end of September. I ask why- no answer.
9/3: I call Utilization Management & Appeals. I leave messages.
9/7: Appeals calls back, tells me I need to have my doctors fax everything to an ENTIRELY DIFFERENT FAX NUMBER because my files were never received. I tell this rep that my files were received, and that I received written confirmation. She doesn’t care- just tells me to fax everything to this new number.
I call insurance again, and get ahold of someone who works in Escalations. She tells me: 1. The wrong person looked at my file. 2. Nobody was looking at the open part of my file this entire time. 3. She could see that my doctors faxed in extra info as of early August. 4. She packaged all of my doctors notes- surgeon, chiro, and PCP, and sent them in one email to Utilization Management/Appeals. 5. Says she’ll call back 9/9 with an answer re: approval/denial.
9/9: She doesn’t call.
9/9 evening: I get an email from surgeons office saying that they tried scheduling a peer to peer review, but Utilization Management said that notes from two additional physicians other than the operating surgeon were never received. So they can’t schedule a peer to peer.
9/10: I call back, am told she’ll call between 2-3PM. I wait. No call. I call at ~3:10, am told in 20 mins. No call. I call at 3:40, and am transferred to the person who was helping me earlier.
She tells me that I’ve been denied, and that my doctor must schedule a peer to peer review because I’ve been denied. I tell her that my doctor tried to, but Utilization Management (which works with Authorization) said that they never received my files from my chiro or PCP, so a peer to peer can’t be scheduled. I then tell her about the misinformation I was repeatedly given in August, and give reference numbers that relate to each conversation. She tells me that she attaches ALL of this to an email that ALSO has all three of my doctors notes AND a new reference number that relates to my case, and sends it to Utilization Management. I ask for a copy of this email, she says she can’t do that. Instead, she emails me saying that my doctor should schedule a peer to peer review by calling a specific number she provided, and then attached the reference number that correlates to the case she wrote up for me.
I then email my surgeons office that same day, stating that I told this person in Escalations everything (like that Utilization Management HAS the files even though they say they don’t), and that they CAN schedule a peer to peer review, and that if they are given any trouble, to tell Utilization Management to refer to the reference number I forwarded to them, because it refers to everything I told the Escalation representative, who apparently wrote it in an email that she sent to Utilization Management, even though I have no proof of such email besides her word, since she wouldn’t CC me or give me a copy.
IS THIS LEGAL?
Insurance hasn’t even looked at my files for 6 weeks, even though they said they were. I’m told by Escalation rep that my doctor has to schedule a peer to peer review, even though I don’t know why I’ve been denied again (doesn’t insurance HAVE to tell you why you’ve been denied?) Utilization Management conveniently tells my doctor that my files haven’t been received, preventing them from scheduling a peer to peer review. Meanwhile I’m told that Utilization Management absolutely has my files. This DELAYS my medical care SIGNIFICANTLY. Is this legal??
Do I have the right to say that because my case has been grossly neglected for 6 weeks, I am entitled to a fast-tracked process?
What if insurance makes scheduling the peer to peer a nightmare? What if it doesn’t get scheduled for another 4 weeks?
Insurance has neglected my case, and it comes at the cost of my delayed medical care. Is that legal at all?
submitted by /u/AccomplishedAcadia59
[link] [comments]
Context: Requirements for a breast reduction under my plan: 3 letters of support & medical notes needed: 1 from surgeon, 2 from additional physicians, 1 of which must specialize in musculoskeletal disorders. There’s a min amount to be removed (I meet the min). 6 months of conservative treatment must be attempted and documented (been going to chiro for years). I am on my parents’ insurance, but I’ve been handling 100% of this process. My parent filed for a claims support advocate through his place of work after I told him all of this. Timeline of events: Spring 2021: insurance tells me that my surgeon must be forwarded all letters of support from other physicians, and then my surgeons office must submit everything to insurance. July: I’m denied because insurance claims they didn’t receive ANY letters of support from two additional physicians, other than the operating surgeon. Late July: I tell insurance that my surgeon submitted notes from chiropractor, and insurance denies ever having those notes. They only tell me that my surgeon submitted something via Navinet, which prompted the denial letter. Insurance tells me to have my two extra physicians fax their notes to insurance directly. I tell insurance that I was told differently before, and insurance doesn’t care. They just tell me to have my doctors fax their notes in. Early August: All additional notes are faxed in as of Aug 9. I receive confirmation from insurance in writing that the notes were received. Most of August: I am told to wait because my files is under review. I’m told that someone is looking at it, and that I can expect an answer by the end of August. End of August: I am told that the amount of time needed to look at my file has changed, and that I’ll now know by the end of September. I ask why- no answer. 9/3: I call Utilization Management & Appeals. I leave messages. 9/7: Appeals calls back, tells me I need to have my doctors fax everything to an ENTIRELY DIFFERENT FAX NUMBER because my files were never received. I tell this rep that my files were received, and that I received written confirmation. She doesn’t care- just tells me to fax everything to this new number. I call insurance again, and get ahold of someone who works in Escalations. She tells me: 1. The wrong person looked at my file. 2. Nobody was looking at the open part of my file this entire time. 3. She could see that my doctors faxed in extra info as of early August. 4. She packaged all of my doctors notes- surgeon, chiro, and PCP, and sent them in one email to Utilization Management/Appeals. 5. Says she’ll call back 9/9 with an answer re: approval/denial. 9/9: She doesn’t call. 9/9 evening: I get an email from surgeons office saying that they tried scheduling a peer to peer review, but Utilization Management said that notes from two additional physicians other than the operating surgeon were never received. So they can’t schedule a peer to peer. 9/10: I call back, am told she’ll call between 2-3PM. I wait. No call. I call at ~3:10, am told in 20 mins. No call. I call at 3:40, and am transferred to the person who was helping me earlier. She tells me that I’ve been denied, and that my doctor must schedule a peer to peer review because I’ve been denied. I tell her that my doctor tried to, but Utilization Management (which works with Authorization) said that they never received my files from my chiro or PCP, so a peer to peer can’t be scheduled. I then tell her about the misinformation I was repeatedly given in August, and give reference numbers that relate to each conversation. She tells me that she attaches ALL of this to an email that ALSO has all three of my doctors notes AND a new reference number that relates to my case, and sends it to Utilization Management. I ask for a copy of this email, she says she can’t do that. Instead, she emails me saying that my doctor should schedule a peer to peer review by calling a specific number she provided, and then attached the reference number that correlates to the case she wrote up for me. I then email my surgeons office that same day, stating that I told this person in Escalations everything (like that Utilization Management HAS the files even though they say they don’t), and that they CAN schedule a peer to peer review, and that if they are given any trouble, to tell Utilization Management to refer to the reference number I forwarded to them, because it refers to everything I told the Escalation representative, who apparently wrote it in an email that she sent to Utilization Management, even though I have no proof of such email besides her word, since she wouldn’t CC me or give me a copy. IS THIS LEGAL?
Insurance hasn’t even looked at my files for 6 weeks, even though they said they were. I’m told by Escalation rep that my doctor has to schedule a peer to peer review, even though I don’t know why I’ve been denied again (doesn’t insurance HAVE to tell you why you’ve been denied?) Utilization Management conveniently tells my doctor that my files haven’t been received, preventing them from scheduling a peer to peer review. Meanwhile I’m told that Utilization Management absolutely has my files. This DELAYS my medical care SIGNIFICANTLY. Is this legal??
Do I have the right to say that because my case has been grossly neglected for 6 weeks, I am entitled to a fast-tracked process? What if insurance makes scheduling the peer to peer a nightmare? What if it doesn’t get scheduled for another 4 weeks? Insurance has neglected my case, and it comes at the cost of my delayed medical care. Is that legal at all?
submitted by /u/AccomplishedAcadia59 [link] [comments]Read Morer/HealthInsurance