Good news from UHC

[peglem]

Some of you may know that I have an upcoming appt. with Dr. Latimer in January. I just got a letter from UHC that they will cover the office visits with her at regular, in network rates!!!! This is because Allie was referred by a local rheumatologist who said he does not have the expertise to treat...so, they don't have an in network provider who can provide the needed expertise. Yea!

[nevergiveup]

Hey peglem, Thats great. They covered my dd's too, except a regular in network rate is 80.00 and Dr L charges 480 for intial panda visit. Unless she is willing to waive her charges??? I believe her office will file your insurance but require pmt in full at visit. Unless you can prenegotiate a reduced rate with her which some docs due depending on financial need. Dr L does an extremely thorough neuro exam with an extended amt of time reviewing the medical history. Our appt have taken up to 3 hours at times. (With her present the whole time). No doc can survive on 80 for 3 hours. This is what are medical system has brought us to same pmt for every case whether difficult or not. Many docs are moving their practices this way. Pay up front TRUE cost of their time and take what you get from insur as reimbursement. Our managed care system does not take into account or compensate for the truly difficult cases. Peglem, does UHC pay IVIG or PEX for a diagnosis of PANDAS.

[peglem]

Hey peglem, Thats great. They covered my dd's too, except a regular in network rate is 80.00 and Dr L charges 480 for intial panda visit. Unless she is willing to waive her charges??? I believe her office will file your insurance but require pmt in full at visit. Unless you can prenegotiate a reduced rate with her which some docs due depending on financial need. Dr L does an extremely thorough neuro exam with an extended amt of time reviewing the medical history. Our appt have taken up to 3 hours at times. (With her present the whole time). No doc can survive on 80 for 3 hours. This is what are medical system has brought us to same pmt for every case whether difficult or not. Many docs are moving their practices this way. Pay up front TRUE cost of their time and take what you get from insur as reimbursement. Our managed care system does not take into account or compensate for the truly difficult cases. Peglem, does UHC pay IVIG or PEX for a diagnosis of PANDAS.

My daughter has seconday insurance from the state that should pick up all remaining cost....so I am blessed there!

I have not tried submitting for PEX or IVIG- but UHC does have this document that says IVIG has been proven effective in treating PANDAS:

https://www.unitedhealthcareonline.com/b2c/...ulin_(IVIG).htm

 

from there, bolding mine

Coverage Rationale

Immune globulin is PROVEN for the following:

 

Autoimmune Diseases

# Autoimmune uveitis

# Dermatomyositis and Polymyositis

# Autoimmune Diabetes mellitus (Antibodies against islet cell antigens, including glutamic acid decarboxylase II, are implicated in the autoimmune pathogenesis of insulin dependent (type 1) diabetes mellitus.)

# Fetomaternal alloimmune thrombocytopenia

# Graves ophthalmopathy

# Immune thrombocytopenic purpura (ITP)

# Severe rheumatoid arthritis

 

Infectious and Infection-related Diseases

# Bacterial infections in lymphoproliferative disease

# Cytomegalovirus (CMV) induced pneumonitis in solid organ transplants

# Enteroviral meningoencephalitis

# Kawasaki disease

# Neonatal sepsis

# Rotaviral enterocolitis

# Staphylococcal toxic shock

 

Miscellaneous Uses

# Delayed-pressure urticaria

# Prevention of acute humoral rejection in renal transplantation

# Treatment of acute humoral rejection in renal transplantation*

# Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (streptococcal infections induce exacerbation of symptoms in some children with obsessive-compulsive and tic disorders)

# Prevention of infection and acute graft vs. host disease (GVHD) after bone marrow transplantation

# Severe, persistent, high-dose, steroid-dependent asthma

# Toxic epidermal necrolysis and Stevens-Johnson syndrome

*Clinical evidence supporting the use of IVIG for the treatment of acute humoral rejection in renal transplantation is limited. UnitedHealthcare will continue to review clinical evidence surrounding IVIG and treatment of acute humoral rejection in renal transplantation and may modify this conclusion at a later date based upon the evolution of the published clinical evidence.

[thereishope]

I'm happy for you! Good to know UHC does something. I have so many issues with them. They don't cover any speech services/therapy unless you have a speech disorder as a result of an accident so my son's only speech therapy is through the school district. I think that's horrible that they deem it is okay for a child to go through life without being understood or have difficulty communicating. They also have awful mental health benefits for seeing psychologists and psychiatrists.

[peglem]

I'm VERY blessed to have the secondary insurance from the state, I know that, but not so blessed for my daughter to have the kinds of problems that qualify her for it! I'm eligible for all those therapies through the state insurance, but, frankly, they haven't been too effective and gains from them have been lost to PANDAS. Nowadays, I can't even find a speech therapy provider to work with my daughter!

I do use UHC's mental health program for one of my older daughters. It pays a little...but, "ouch" on those copays! When I see the bills- my copay is higher than what the insurance pays.

[thereishope]

I have a different plan. I have to pay EVERYTHING until I reach my high deductible. Though preventative care is covered 100%. But then UHC keeps harassing me to fill out a questionnaire now that my son is no longer seeing the psychologist. I refuse to fill it out. There's a sentence on there that allows UHC to access your child's records from the therapist and speak directly to the therapist about your child!No way would I allow that.

 

UHC also didn't have a child psychologist even listen in my area. Or maybe not one specializing in the behaviors I was looking for. Can't remember. I went to one they listed and had a bad experience. i finally went to one at Cinci Childrens' .None at that hospital were covered by UHC.

 

We have bad insurance because my husband's job is a small company without too many employees.

[tantrums]

Just be careful that you know all of the details. I was SO excited to hear my insurance BCBS tell me that they would pay for me to go to the Chiari Institute in Long Island after I called several times and demanded they pay for someone who would treat me. Then after a second call, another rep explained to me that they would pay in network rate IF the doctor would call them and request to be considered in network for this case. They will do this if there is a condition which requires specialty care that no one else in your area can treat.

BUT - if the doctor you want to see won't accept the in network rate (and in doing so they cannot bill for the difference) you are out of luck TCI wouldn't accept that for me. I found another NS who will treat my Chiari but also doesn't accept ANY insurance. I haven't broached this subject with him yet - although he MAY be more willing since he also does a lot of charity work.

 

If a specialist isn't accepting insurance at all, in the case of many specialists nowadays - apparently mostly neurologists - then the idea of them having to do EXTRA paperwork and phone calls so that they can accept a lower rate... Doesn't sound likely

 

I don't mean to come here and burst your bubble. I really DO hope it's different for you! But I learned the hard way after getting very excited, making myself an appointment at TCI and hours on the phone.

[peglem]

Both primary (UHC) and secondary insurances have been told repeatedly that this doctor does not take insurance and it will be a reimbursement pay to us. I think as long as they are only reimbursing me as much as they would have to pay in network- it'll probably work. I needed this piece from UHC, before the secondary insurance will look at paying the remainder- so we'll see how it all works out. We did think we would get stuck with the entire bill, and had decided to do it anyway, so we'll deal with whatever happens.

[smartyjones]

peglem - good news! can you try to get something in writing? we recently have a small issue that i think we'll be able to work through b/c the psych didn't send in the proper paper after my insur agreeing to pay him as in-network. i am kicking myself that i don't have anything in writing.

[tantrums]

Well then, if you weren't expecting any reimbursement and your insurance will give you the in network cost that they would pay - then that is fabulous!!

[peglem]

peglem - good news! can you try to get something in writing? we recently have a small issue that i think we'll be able to work through b/c the psych didn't send in the proper paper after my insur agreeing to pay him as in-network. i am kicking myself that i don't have anything in writing.

 

They sent me a letter that I got today- they approved 6 visits-just in case.