United Healthcare's Paradox

[GraceUnderPressure]

I hate, hate, hate dealing with insurance. Lord help us all when the govt finishes taking over healthcare - it's the only bureaucracy that surpasses the insurance paper chase.

 

Anyway, so here's the challenge: United Healthcare has their IVIG policy available online

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Drug%20Policies/IVIG_policy.pdf

 

On page 1, they state "Immune globulin is PROVEN for the following:" which is followed by a list that goes on to page 2 where they have "Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (streptococcal infections induce exacerbation of symptoms in some children with obsessive-compulsive and tic disorders)" included on that list.

 

BUT (and here's the part where our coverage is being denied) if you go further on to page 15 of this document, they list diagnosis codes that are "Proven" and then those that are "Unproven" -- and the list of "Proven" codes has NOTHING that applies to PANDAS while the list of "Unproven" has most of the codes normally submitted.

 

The only thing I can think now before I have to try a letter of appeal (I so do not have time for this crap - my life is falling apart while I am playing their "guess which code we'll cover it under" game) is to try it under one of the Sydenham chorea diagnostic codes maybe? Or is it possible that my DH's Human Resources dept might be able to help? Anyone had any luck with either of those?

[MomWithOCDSon]

Grace --

 

Sorry I don't have any actual advice to share, but boy, can I commisserate!!

 

I just filed a complaint against United Healthcare with my state insurance board, as well as an in-house complaint with their own "Compliance" department.

 

I had heard from some others on the forum here, many months back, that they had a lot of success with United Healthcare. So when my company switched to United from BCBS this past January, I had high hopes and moderate expectations. They managed to dash all of those in less than 8 months. It's a long story and likely of no interest to anyone else here, but suffice it to say that after having gotten precertifications for therapy treatments for DS's OCD, those folks STILL dragged and dragged and dragged their feet on processing the claims, let alone paying them. More than sixty days after they processed the claims, I'm still waiting for my reimbursement. On top of which, they've now decided that, after 18 sessions, DS should be "cured" of his OCD and they're refusing to approve any further precertifications for sessions until the therapist has been made subject to some "review board." Because everybody knows that OCD is curable within 6 months, right?!?! So our therapist must be some sort of shyster, bilking us and the insurance company out of hundreds of dollars! Yeesh!

 

I mentioned our troubles to a friend of mine who's an HR specialist for a local company; she says that United Healthcare -- at least in our area -- has a horrific reputation of disputing most claims and delaying payment as long as possible. I wished I'd known beforehand, as I might have been in a position to sway my small company's decision in that regard. Now that I DO know, I will be steering clear in the future!

 

Long primal scream here on behalf of you and all the rest of us confronted with troubles courtesy of our broken health insurance system!

[GraceUnderPressure]

Thank you so much for your commiseration, Nancy! There have been so many past raves, I was starting to wonder if I was the only one who has been less than happy with UHC. I have heard much worse from these wretched companies, but when you're expecting better than what you've had before and you end up with worse, it's all the more frustrating.

 

My DH had a possibly life threatening clot in his carotid artery back in January & UHC would not even approve the scan to check it initially. The dr was really ticked (hmm, between Tourette's & Lyme I don't think I want to use that word anymore - let's just say the dr was very irate) & told my DH to go get it done anyway because he guaranteed they were going to cover it. DH heard him reaming somebody from UHC on the phone as he left to get it done. They agreed to cover it. Turned out that he did have a tear that had developed a clot & luckily it affected his vision rather than his brain so that he had a warning it was there - he spent a week in the hospital on blood thinners.

 

We're supposed to get him re-scanned this month to see how it's healing & I don't even want to try to deal with it until we've resolved this (plus with a possible $25K bill looming on the horizon, we can't afford it even if they do cover it). We're going to see an LLMD in Oct. & we're wondering if we'll be able to afford the treatment. We were never rich, but we used to have a small margin to cushion us from the unexpected. These past few years have eaten up virtually all of it. If we succeed in getting ds functional, he's going to have to pay his own way thru college. Still, that's a better prospect than not succeeding.

 

We had UHC almost a decade ago (my DH's company changes almost every year) & never had a problem - we did like them back then - but all of our healthcare issues were so straightforward then so I guess that was the difference. I think I will go ahead & contact someone with my DH's HR dept to see if they can possibly help. I doubt it, but don't see how it could hurt.

[LNN]

We had UHC for a year - HATED them. They balked at covering a $48 annual lab ordered by my OBGYN because the doc sent me to a local lab (that works with every other insurance plan I've ever had) instead of Quest. They would've covered the same lab test if I'd used Quest. Who the heck thinks they need to make sure a particular lab co. is covered? Shouldn't it be based on the test itself? Even if I had to pay the lab directly and then had UHC reimburse me if they didn't have a working relationship with that lab - that's how my current insurance handles Igenex. I pay Igenex and they reimburse me. I told UHC I'd send in the $48 but they'd never ever have my business again.

 

I checked all my paperwork from when we did Pex, which was covered by our insurance co. (NOT UHC) But there are no diagnostic codes anywhere. I do recall the admin at Dr L's office spending an hour on the phone with insurance the day prior to pex, trying to guess the magic code. Somehow, they got it resolved and we got pre-certified. Maybe someone at your doctor's office could call Dr L's staff and have a similar conversation? Doesn't guarantee success, but it would be a conversation between two people who work with insurance billing all the time and they might be able to share wisdom you and I don't have. Only a thought.

[dcmom]

Every insurance plan has different plans for different employers.

 

We have United Health Care- and although I HATE insurance companies- we have been pretty lucky.

 

My kids have both been on daily antibiotics for 2 years, lyme protocol of multi antibiotics for several months, had iv steroids in the hospital and at home, and both had PEX. It has ALL been covered.

 

They did initially deny pex, we had to appeal, but they covered it. We ended up approved at the last and final appeal, and we did enlist the help of the neurologist and dh's HR dept.

 

In the end, however, DH's company is large, and they are self-insured, which means they pay all of the costs, UHC just administers the plan. Maybe this is the reason that we were approved in the end, I think if we lost that appeal, DH's company would have the option to override the denial and approve it- I think it has been done in rare cases before.

 

Good luck- I would push, push, push. In the final week: myself, DH and his HR president called UHC every day (we were somewhat fortunate in the fact that the HR president himself, had recently been diagnosed with a neurological disorder and I think he was receiving IVIG.). Our doctor also was on the phone with them several times, and wrote a letter of medical necessity, stating that any delay in this treatment was seriously jeopardizing my daughter's health and safety.

[Christianmom]

Sixteen years ago, when my son was born, my husband's work was self-insured and went out of business. My son's delivery and subsequent "failure to thrive" illness were not covered. We ended up responsible for the entire bill--about $6,000 back then. I begged mercy with the hospital staff explaining that we had no idea that the company was going out of business and had thought we actually had good insurance. We were also at an all-time low financially, which I explained to them. I had to speak with the head of the department in charge of billing, but she was very sympathetic. She reduced our bill I think by about 40% and allowed us to pay it in reasonable monthly payments. We joked when we paid the last bill that we finally owned our son, as many years had passed. I didn't get involved with the hospital until I was sure my husband's company was never going to pay. It was my last resort. But at least it was a lot better than paying the whole bill.

[peglem]

We've had UHC for years through Hub's work and its been great, until this year. They are not covering a lot of things that they used to, or covering them at a lower amount, leaving more for us to pay. My Hub works for a large company that self insures and UHC administer's their plan. We failed to read the fine print (probably) when we re-upped at the end of last year. We opted to keep the same plan we'd had-but there must have been some changes. They still cover IVIG, its just the new problems (like ER care) that saddles us with huge bills. CRAZY!!!!!

[MomWithOCDSon]

I didn't mention before, also, that UHC refuses to cover DS's Augmentin XR, even the generic variety now available; says that there's an alternative medication available (regular Augmentin or generic amoxi-clav), so they won't even pay a partial component of the XR. So that's been $233/60 tabs, even for the generic and factoring in our pharmacy's "member discount" card!

 

When I called to complain, I asked who makes those decisions and who can I speak to about having that policy reconsidered, etc., since there is a marked difference for DS in taking the time-released variety rather than the standard variety. They wouldn't budge or put me on the phone with anyone. Rather, I was told, I could issue a written query/complaint, and it would be addressed then.

 

BTW, FWIW, my firm is/was (I've recently changed jobs and am now covered by Aetna, effective September 1) a small business with less than 50 employees, so while I paid higher premiums to have the UHC PPO option rather than the HMO, we were still placed within this legal health insurance mumbo-jumbo purgatory that only smaller firms are subject to, apparently. Such as, the insurance company was permitted to essentially ignore the Mental Health Parity Bill and treat mental health claims (like ours for DS's therapy) separately from strictly medical health claims, requiring precertifications for every session, etc.

 

It's a sad state of affairs.

Edited September 2, 2011 by MomWithOCDSon

[GraceUnderPressure]

Ya know, poring thru so many parent's hassles with insurance - as if dealing with this condition isn't purgatory enough - I am thinking what we need is a politician who would be willing & able to legislate something for PANDAS treatment. Does anyone have connections?

[GraceUnderPressure]

Okay, it's 4am over here & I've been on this stupid computer so long that I am hoping I'm not hallucinating, but I just went back to look again at some of the diagnostic codes on UHC's IVIG policy & found them changed rather significantly. (Gee, might they have read this thread?)

 

On the last page of the document it has a POLICY HISTORY/REVISION INFORMATION and the following was just added -

 

Date Action/Description

9/1/2011 Added Flebogamma DIF and Gamunex-C to list of products.

Autoimmune blistering skin diseases revised to proven use.

Revised proven status and evidence for intractable childhood epilepsy to be specific to Lennox Gastaut syndrome.

Updated list of proven ICD-9 codes (added 041.0, 238.79, 242.0, 273.1 279.51, 279.53, 323.81, 337.0, 345.00, 345.01, 345.10, 345.11, 493, 493.01, 493.11, 493.21, 694.0, 694.4, 694.5, 694.60, 694.61, 694.8, 695.13, 695.14, 695.15, 708.5, 708.8, 772.1, 776.7, 995.91, 995.92, 996.8, 996.81, and 996.85, and removed 204.00 and 446.6). Removed all unproven ICD-

9 codes from the policy because standard policy format is to list only proven ICD-9 codes. Approved by the National Pharmacy & Therapeutics Committee on 7/12/2011.

Policy 2010D0035D archived.

 

In theory, it looks like we can now resubmit my ds19's claims under

323.81 Other causes of encephalitis and encephalomylitis

Does that sound right - wouldn't it apply? Or would it not count because they just changed it & his treatments were back in the spring?

[kimballot]

I think encephalitis is a better choice of words and is more specific than endephalopathy. Encephalopathy just means that something is wrong in the brain. Cerebral palsy is an encephalopathy. A brain tumor is an encephalopathy. Encephalitis (inflammation in the brain) is a more specific form of an encephalopathy.

 

Regarding the timing of the code - can UHC give you information about what was covered back in the Spring?

[GraceUnderPressure]

I don't know - they don't seem to be particularly helpful when I contact them. But I will go ahead & call on Tuesday & find out for certain.

 

(I think encephalitis is more appropriate, too - clearly inflammation is a major factor in this condition. I was surprised to learn that encephalopathy is the more common choice)

[T_Mom]

I really appreciate this discussion--having faced similar issues and still in the midst of them.

 

I wonder if the infamous "white paper" will have any bearing on this current situation? --Where is that paper? and I wonder what the hold-up could be?

 

Here we have MULTIPLE professional articles being published in reputable medical journals and we cannot get the EFFECTIVE TREATMENTS covered, even when the outcome is incredibly positive afterwards!!!