Anyone know a good lawyer in PA?

[tpotter]

Yes, I'm very serious. 2nd level appeal, they actually made up diagnoses (didn't even examine my children before they "created" 4 diagnoses that they didn't have. They conveniently left off pieces of information that was advantageous to denying us, and they even messed around with what the doctor said. They also keep having surgeons, etc. review for immunologists, and apparently an "employee" of BCBS was a voting member on our committee (I asked for the names of the doctors who were on the committee.) They gave me the names of the 2 "medical directors" (a surgeon and a psychiatrist), but didn't give me the name of the "employee." I'm not sure what they mean by an "employee." Do you think they actually meant that they took a janitor or something to make up the 3rd voting member?

 

I spent 6 hours yesterday writing up a response to what they wrote, but it's very obvious that BCBS still won't approve. I repoted it to the state insurance commission, and have been told by them not to send in any more information. There are 20 complaints ahead of me, they don't make medical decisions, and besides, BCBS hasn't bothered to respond to their request for information. When she's ready to get my side, she'll ask for it.

 

Anyone else having the same experience with BCBS, and want to go into a class action suit? We even have a dx of Immune Deficiency, and my guys are really, really sick!

 

I wonder if this has anything to do with the healthcare changes that just went into effect.

[EAMom]

I'm not sure what they mean by an "employee." Do you think they actually meant that they took a janitor or something to make up the 3rd voting member?

 

 

Okay, the vision of that did make me laugh!

 

(Don't know a lawyer...sorry).

[peglem]

Yes, I'm very serious. 2nd level appeal, they actually made up diagnoses (didn't even examine my children before they "created" 4 diagnoses that they didn't have. They conveniently left off pieces of information that was advantageous to denying us, and they even messed around with what the doctor said. They also keep having surgeons, etc. review for immunologists, and apparently an "employee" of BCBS was a voting member on our committee (I asked for the names of the doctors who were on the committee.) They gave me the names of the 2 "medical directors" (a surgeon and a psychiatrist), but didn't give me the name of the "employee." I'm not sure what they mean by an "employee." Do you think they actually meant that they took a janitor or something to make up the 3rd voting member?

 

I spent 6 hours yesterday writing up a response to what they wrote, but it's very obvious that BCBS still won't approve. I repoted it to the state insurance commission, and have been told by them not to send in any more information. There are 20 complaints ahead of me, they don't make medical decisions, and besides, BCBS hasn't bothered to respond to their request for information. When she's ready to get my side, she'll ask for it.

 

Anyone else having the same experience with BCBS, and want to go into a class action suit? We even have a dx of Immune Deficiency, and my guys are really, really sick!

 

I wonder if this has anything to do with the healthcare changes that just went into effect.

I would think a janitor would have made a more compassionate, wiser decision.

[tpotter]

I would think a janitor would have made a more compassionate, wiser decision.

 

 

You're probably right! But, I still think it's interesting that she gave me the names of the other doctors that she mentioned...just not the "employee."

[NancyD]

I am considering doing the same if our next request for IVIg gets denied again. I have appealed twice so far. Unfortunately, we have different insurance and live in MA. I am looking for an attorney who specializes in healthcare law. Our insurance company used to cover IVIg for PANDAS and we switched to them in 2008 from BCBS after appealing them 3 times, but HPHC changed their guidelines in Feb...after my daughter had great success with the infusions and they covered them 100% for 18 months. The process is so frustrating!

[smartyjones]

are you familiar with an organization called, i think, "the council of parent attorneys and advocates" -- i believe in Baltimore? i don't know too much about it, came across it in an article about kids with lyme and school issues. it's one of those things on my list to find out more about when i have time. . .

 

try a google and then let me know if you can't find it and i can get more info.

 

 

[forjpj]

You have probably already looked at this but just in case you haven't...look at patientadvocate.org. Probably just more of the same, but not sure!!

 

Sarah

[MomWithOCDSon]

I wonder if this has anything to do with the healthcare changes that just went into effect.

 

1. BCBS stinks, IMHO. I have nothing good to say about the way in which they handle claims. We have them, too (in Illinois), and every year, I beg my small employer to change companies.

 

2. I would think the recent changes (i.e., Mental Health Parity Bill) would have nothing to do with this particular situation, as nothing in your claim would have anything to do with mental illness, on top of which, now what we can actually THANK that bill for is the fact that any therapy, psych visits, etc. our children attend is covered to the same extent and in the same way as their visits to the pediatrician, the allergist, the immunologist, etc.

[tpotter]

2. I would think the recent changes (i.e., Mental Health Parity Bill) would have nothing to do with this particular situation, as nothing in your claim would have anything to do with mental illness, on top of which, now what we can actually THANK that bill for is the fact that any therapy, psych visits, etc. our children attend is covered to the same extent and in the same way as their visits to the pediatrician, the allergist, the immunologist, etc.

 

 

Actually, thanks to BCBS' desire to "create" diagnoses for my boys (without examining them...hmmm...is that even legal?) they are diagnosed with "psychiatric illness" (my response was it is NEUROPSYCHIATRIC, but they don't care.

 

I'm also ready to report the doctors who "created" diagnoses for the insurance company to our state licensure board. If they're going to just "go along" with what BCBS is demanding (e.g. refusal to pay on all accounts), and then create stuff to try to get out of it, they have to be responsible.

 

I will also check out the advocates that one of you guys sent.

 

Thanks for all the suggestions.

[Fixit]

just asked hubby as we used to live there...

his sales territory included pa, nj, ct, ny, de

he said you will probalbly have a hard time as most of the pharmacueitcals are in pa...

just like i cant' get a lymes doc in ga since cdc is here....

[tpotter]

OK guys...I just found out what "employee" of BCBS means. She came from a part of the company called: "Infomatics." The person telling me that has no clue what it is, and can't explain why it's ok to use a non-medical person to make a medical decision!

 

I asked for a copy of the policy, and also asked her to find out what the h... "infomatics" is (I didn't use the "h" word...I just needed to put it here!)

 

This is completely insane.

[kimballot]

OK guys...I just found out what "employee" of BCBS means. She came from a part of the company called: "Infomatics." The person telling me that has no clue what it is, and can't explain why it's ok to use a non-medical person to make a medical decision!

 

I asked for a copy of the policy, and also asked her to find out what the h... "infomatics" is (I didn't use the "h" word...I just needed to put it here!)

 

This is completely insane.

 

 

AHhh... the infomatics person probably did the online research.. probably plugged in the diagnoses and the treatment and looked for articles to substantiate the treatment. The question is... what diagnosis did they plug in? Did they put"immune deficient" and "Auto immune disorder"..... or did they put "psychiatric disorder"??