NancyD Posted June 24, 2011 Report Posted June 24, 2011 Has anyone ever appealed (and won) their insurance company over denial of coverage for office visits and lab tests when the MD practices integrative/alternative medicine? My current insurance (HPHC PPO) does not cover office visits or lab tests when the MD does integrative or alternative medicine. BCBS used to cover it 80%. It wasn't so bad when we were only going 4 times per year but with both of us having Lyme and Bartonella, we must see him monthly and that gets pretty expensive. There is such an inequity in our insurance system and I would like to fight this, but I want to be armed with the best possible strategy and documentation. I would like to find out if anyone has appealed and won over this issue? Thanks. Nancy
MichaelTampa Posted June 24, 2011 Report Posted June 24, 2011 Are you talking about an MD who happens to have "integrative" on his card, so everything he does is not covered, or an MD where some things are covered, but when he does "sounds-wacky-procedure-code-such-and-such", it is not covered?
NancyD Posted June 24, 2011 Author Report Posted June 24, 2011 (edited) He's a family physician/ DAN doctor who does a combination of traditional and "alternative" medicine. Nothing mentioned on his card and nothing unusual submitted. Everything submitted is always coded correctly and fairly standard. They won't cover ANYTHING for him. Our previous IGX tests were covered by insurance because they were signed by my internist and my DD's pediatrician. This time our DAN doctor signed them and the reason they were denied was because they were ordered by an integrative/alternative doctor. All the other lab tests they have covered over the past three years went through Labcorp or our local hospital and the claim that was submitted to insurance didn't have the doctor's name on it. So they paid those claims. Edited June 24, 2011 by NancyD
sf_mom Posted June 25, 2011 Report Posted June 25, 2011 (edited) This is just completely outrageous! We too are having our own insurance issues again. Husband's company switched providers and we no longer get a % of coverage for Dr. visits even though we have a PPO. They stipulate around the use of almost every antibiotic prescribed.... I could go on. -Wendy Edited June 25, 2011 by SF Mom
MichaelTampa Posted June 25, 2011 Report Posted June 25, 2011 I'll go with calling it outrageous too. Have they told you that is the reason? If my insurance company told me that, I would be going straight to my state insurance department and filing a formal complaint. Obviously, if they are denying everything from him, in the end, if you press them for a reason for denial, they will ultimately give a reason that is outrageous, and then that is the time to call the authorities.
NancyD Posted June 25, 2011 Author Report Posted June 25, 2011 I agree, Wendy and Michael, it is outrageous!! I heard it from 4 separate people claims people, including a claims supervisor. I like your suggestion, Michael, about going straight to MA state insurance! That's what I will do. Thanks! Nancy I'll go with calling it outrageous too. Have they told you that is the reason? If my insurance company told me that, I would be going straight to my state insurance department and filing a formal complaint. Obviously, if they are denying everything from him, in the end, if you press them for a reason for denial, they will ultimately give a reason that is outrageous, and then that is the time to call the authorities.
sf_mom Posted June 25, 2011 Report Posted June 25, 2011 (edited) Ooops. Accidental double post Edited June 25, 2011 by SF Mom
tpotter Posted June 26, 2011 Report Posted June 26, 2011 Make certain that you have checked your benefits, and see if there's anything you have to "prove" to get certain codes covered. For example, both my DS's have specific immune deficiency, and it is only covered on our insurance if I can prove that they have been getting sick from it (I got school attendance records for the previous 4 years + doctor's notes from just 1/2 a year...8 instances of either strep or staph in 1/2 a year) to prove it. This is what our insurance claims person insinuated that I do (plus that's also what the state insurance commission is going to want to see proven.) Then, if they still refuse you (like they did us, you have all the information you need to fight it (we evenutally won, because of that.) Good luck.
NancyD Posted June 26, 2011 Author Report Posted June 26, 2011 It has nothing to do with diagnostic or treatment codes. I have a pretty good handle on that. My insurance company will not cover ANY tests or office visits for ANY integrative MD. This is what they have told me. Make certain that you have checked your benefits, and see if there's anything you have to "prove" to get certain codes covered. For example, both my DS's have specific immune deficiency, and it is only covered on our insurance if I can prove that they have been getting sick from it (I got school attendance records for the previous 4 years + doctor's notes from just 1/2 a year...8 instances of either strep or staph in 1/2 a year) to prove it. This is what our insurance claims person insinuated that I do (plus that's also what the state insurance commission is going to want to see proven.) Then, if they still refuse you (like they did us, you have all the information you need to fight it (we evenutally won, because of that.) Good luck.
cobbiemommy Posted June 27, 2011 Report Posted June 27, 2011 We are in the end stage of an appeal with BCBS of KS. Don't know which way it will go. We are using Kevin Flynn of Healthcare Advocates to work our case. Our doctor is an M.D. who practices mainstream medicine with some integrative medicine... It got so expensive that we had to switch docs. We are using a different LLMD! Cobbie
NancyD Posted June 28, 2011 Author Report Posted June 28, 2011 Cobbie, Did BCBS of Kansas deny ALL claims for this MD because he was an integrative doctor? That would be interesting because BCBS used to cover my integrative doctor -- the same doctor that I can't get covered now by my current insurance provider. In fact, they even covered my DD's monthly glutathione IV's several years ago. I wonder if each BCBS functions independently. How do you like the insurance advocate you hired? Nancy We are in the end stage of an appeal with BCBS of KS. Don't know which way it will go. We are using Kevin Flynn of Healthcare Advocates to work our case. Our doctor is an M.D. who practices mainstream medicine with some integrative medicine... It got so expensive that we had to switch docs. We are using a different LLMD! Cobbie
sf_mom Posted June 28, 2011 Report Posted June 28, 2011 Nancy, Kevin Flynn is who we used when we were having insurance issues for our twin pregnancy. His guidance was invaluable to us. -Wendy
NancyD Posted June 28, 2011 Author Report Posted June 28, 2011 Wendy, is he local or national? If he's national, can you please email his contact info? Thanks Wendy! Nancy Nancy, Kevin Flynn is who we used when we were having insurance issues for our twin pregnancy. His guidance was invaluable to us. -Wendy
sf_mom Posted June 28, 2011 Report Posted June 28, 2011 He is national. I'd give him a call directly. Number at bottom of page. http://www.healthcareadvocates.com/president.html
NancyD Posted June 28, 2011 Author Report Posted June 28, 2011 Thanks Wendy...I will call him! He is national. I'd give him a call directly. Number at bottom of page. http://www.healthcareadvocates.com/president.html
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