IVIG approval upon changing insurance companies

[sptcmom]

Hello, DH just switched jobs a couple months ago and we now have Aetna. We made sure to get a cadillac plan but who the heck knows based on all the insurance horror stories I've been reading.

We had a cadillac plan with Empire BCBS and they totally covered IVIG with Dr K for the first time.They covered it 80% which was a huge help.

Now do you think just because BCBS covered it , its in the insurance companies database or information pool if there is any such thing and Aetna should be ok with it too as long as we keep everything the same the codes I mean?

Anyone have any experience with this?

Its too late to get COBRA at this point but DH and I did debate if we should just take COBRA BCBS for the 18 months after the older job was done with. The cost for COBRA was a couple grand a month and just couldn't afford it.

We're also doing Lyme/Bartonella treatments now and thats all out of network. The topnotch LLMDs don't take insurance, the fees, supplements, testing with out of network labs etc etc is all tons of $$ and its very hard right now.

Any advise? info?

Thanks so much

Jodie

[melanie]

Hi Jodi

 

What treatments are you doing for Lyme and bart and who are you using ??also what are you doing witht the IVIG stuff??Im lost and confused .Hows he doing I thought things were good???

 

Melanie

[JAG10]

We have seen coverage for BCBS change from state to state, within state, company to company, person to person and even for the exact same person w/exact same codes and treatment approved the first time and denied the second. Unless you can find that it is specifically covered within your plans governing documents, it's quite the roll of the dice.

 

For our dd10, we have Independence BCBS in PA. (We think) by mistake they covered one day facility fee for Oakbrook, but paid out $4550 which was a nice chunk of the cost. They did not pay the 2nd day facility fee, the cost of the Gammunex or Dr. K's fee. Well, wouldn't you know, Oakbrook isn't letting go of that money even though we paid them in full, up front. We have gotten several different stories out of them from "we need to wait 30 days" to they actually called Indep BCBS to see if it was a mistake and they were going to rescind the payment. Indep BCBS said technically they should not have paid the $4550, but they will not be rescinding the payment. STILL no $$$ from Oakbrook. Now they are saying since we only paid a $900 per day facility fee, that is all they will reimburse us and we STILL haven't even seen that for a May IVIG!!!

 

I do not hold Dr. K responsible for Oakbrook's greediness; a doctor cannot be held responsible for the actions of the facility where they practice. But, we cannot deal with Oakbrook again which will limit what Dr. K can do for our dd.

[wornoutmom]

Aetna has not been good to us. THey are very specific in what they will cover IVIG for. Unless you have immune deficiency (we did not) it will be hard to get it covered imho. If you find something different let me know! We are on 3rd level appeal. You can go to their website and read up on the IVIG coverage - there's like 48 condidtions they cover for. We are thinking of switching over to UHC in January.

[nevergiveup]

You paid in full and they got 4500 from ur insurance company. They cannot keep more than what they billed. They need to reimburse YOU the difference. How much in total did they get for your childs ivig? This should be a big issue, if you feel that oakbrook is greedy, they are making ridiculously high amounts of money on each infusion if they are receiving non insured rates. Why does doc K not help since he is a big client of theirs?

[dcmom]

JAG- I would not give up. Is Oakbrook "in network" for your health ins co? We had to pay up front for pex at Gtown. We paid $26k, and at the time thought we would very likely be denied coverage. Two weeks after the procedure, we were approved, and our insurance co sent US a check for $5k. I called everyone asking where I would get the other $20k. My insurance co told me that since Gtown was "in network" they were required to refund us the difference between what we paid, and the contract fee. They did take their time, but without much work on my part, Gtown did send me a check for the $20k.

 

I think you should call the health advocate, or whoever is appropriate (tpotter may know) in the state of Illinois. Oakbrook "contracted" a rate with you, and there is NO reason they should keep your insurance money. I KNOW it is so hard to fight this and pandas- but I know you will feel vindicated if you can do something about it.