How to get insurance preapproval?

[7upMom]

What are the steps in getting insurance preapproval when requesting IVIG?

I know you need the codes, but do you just call the insurance company up saying you need a preapproval for a procedure? How long have other people seen this take from their insurance companies? Do they immediately give you an answer , or does it take weeks? Do they expect something in writing?

Just trying to figure out what our steps are, we are headed to IVIG in a little over 2 weeks, so very happy , but if we can later get reimbursed back that would be good. So would like to try to do a preapprov ahead of time

Edited March 27, 2010 by 7upMom

[Worried_Dad]

That's great about the scheduled IVIG! And I don't want to sound discouraging... but I want to be honest about our own experience.

 

We've had 3 rounds of IVIG with Dr. K. Dr. K's secretary furnished us with the diagnosis code and procedure codes ahead of time. In our case, we submitted these to our HR Benefits folks at my employer, who coordinated with our company's health insurance coordinator at BCBS.

 

In all 3 cases, we were told ahead of time that we were pre-approved. Still - per Dr. K's local surgical center policy - we had to pay in full up-front before each IVIG procedure. After IVIG round 1, despite the preapproval, it took almost 9 months to get any money back from the insurance co. I called them weekly and got a different story every week. SO frustrating!!! Could not even engage Health Advocate to dispute the claim, because BCBS just didn't process it, so there was nothing to dispute.

 

I was assured by BCBS that this would not happen again when we were pre-approved for rounds 2 and 3 last summer. In a way, they were truthful: it's been even worse this time. After 9 months - and repeated assurances to our HR Benefits folks that they were "cutting the checks" - we finally saw the claim show up in an Explanation of Benefits. The EOB stated that they were paying $0 for all 4 days of IVIG last summer. Sigh....

 

Our Benefits staff are working with BCBS to try to resolve this, but we have still not seen a reimbursement from the insurance co for this "pre-approved" procedure for IVIG last June and July.

 

My advice would be - if at all possible - get the IVIG done at an in-network local provider that does not require you to pay up-front, and definitely ask for the diagnosis and procedure codes to seek pre-approval. (The service providers might do this for you if they're in-network?) Also, if possible, try to get the service provider to use a generalized diagnosis code for which IVIG is considered "established medical practice" and not code it as PANDAS specifically; seems like most insurance co's will not cover it if it's coded for PANDAS due to the "controversial" nature of that diagnosis.

 

Good luck!

[7upMom]

That would be really frustrating and we are expecting for it not to go easy with the insurance company paying. We also have BC/BS , we have Illinois. Haven't heard the best about BC/BS coming through with payment, but it doesn't hurt to try!!

We are paying up front and doing IVIG with Dr K, but just want to try to get a preauth ahead of time. We aren't going to stress about it too much just will be happy to have him better. Dr K is in network for our insurance and so far with everything thats been going on they have paid very well. We thought about going through our doctor here, she offered to help and follow Dr K protocol, but I think there are so many other things Dr K's expertise in Pandas comes in on that we decided he was the best route for us and we didn't want any oopsy's .

Just trying to figure out the exact steps of getting a preauth? So you had your employer do it? So your codes with Dr K did not work? were all 3 of your ivig's with Dr K?

[Worried_Dad]

Yep, all 3 rounds of IVIG with Dr. K at the Oakbrook Surgical Center. The diagnosis and procedure codes worked for pre-approval - and hopefully they will still work eventually for reimbursement - but the fact that OBSC is out of state and out of network has delayed everything to glacial slowness. (At least, that's the excuse BCBS of MI gives me whenever I call.)

 

If you're in IL and go to OBSC, maybe you'll have a smoother time. Is OBSC in-network for you? Anyway, Dr. K uses a diagnosis code that is for more generalized immune deficiencies, so you have a much better shot at coverage. And you're right - having IVIG done at OBSC under Dr. K's direct supervision is a great way to go. Our son was in major exacerbation during the IVIG procedures, and I don't think we would have gotten through it except for the patience, compassion, and experience of the staff there. They've seen lots of PANDAS kids and understand the special challenges.

 

You're in good hands with Dr. K!!!

 

 

That would be really frustrating and we are expecting for it not to go easy with the insurance company paying. We also have BC/BS , we have Illinois. Haven't heard the best about BC/BS coming through with payment, but it doesn't hurt to try!!

We are paying up front and doing IVIG with Dr K, but just want to try to get a preauth ahead of time. We aren't going to stress about it too much just will be happy to have him better. Dr K is in network for our insurance and so far with everything thats been going on they have paid very well. We thought about going through our doctor here, she offered to help and follow Dr K protocol, but I think there are so many other things Dr K's expertise in Pandas comes in on that we decided he was the best route for us and we didn't want any oopsy's .

Just trying to figure out the exact steps of getting a preauth? So you had your employer do it? So your codes with Dr K did not work? were all 3 of your ivig's with Dr K?

[Iowadawn]

What are the steps in getting insurance preapproval when requesting IVIG?

I know you need the codes, but do you just call the insurance company up saying you need a preapproval for a procedure? How long have other people seen this take from their insurance companies? Do they immediately give you an answer , or does it take weeks? Do they expect something in writing?

Just trying to figure out what our steps are, we are headed to IVIG in a little over 2 weeks, so very happy , but if we can later get reimbursed back that would be good. So would like to try to do a preapprov ahead of time

 

7upmom-

 

Call me. I'll try to help.

 

Dawn

[Iowadawn]

Yep, all 3 rounds of IVIG with Dr. K at the Oakbrook Surgical Center. The diagnosis and procedure codes worked for pre-approval - and hopefully they will still work eventually for reimbursement - but the fact that OBSC is out of state and out of network has delayed everything to glacial slowness. (At least, that's the excuse BCBS of MI gives me whenever I call.)

 

If you're in IL and go to OBSC, maybe you'll have a smoother time. Is OBSC in-network for you? Anyway, Dr. K uses a diagnosis code that is for more generalized immune deficiencies, so you have a much better shot at coverage. And you're right - having IVIG done at OBSC under Dr. K's direct supervision is a great way to go. Our son was in major exacerbation during the IVIG procedures, and I don't think we would have gotten through it except for the patience, compassion, and experience of the staff there. They've seen lots of PANDAS kids and understand the special challenges.

 

You're in good hands with Dr. K!!!

 

 

That would be really frustrating and we are expecting for it not to go easy with the insurance company paying. We also have BC/BS , we have Illinois. Haven't heard the best about BC/BS coming through with payment, but it doesn't hurt to try!!

We are paying up front and doing IVIG with Dr K, but just want to try to get a preauth ahead of time. We aren't going to stress about it too much just will be happy to have him better. Dr K is in network for our insurance and so far with everything thats been going on they have paid very well. We thought about going through our doctor here, she offered to help and follow Dr K protocol, but I think there are so many other things Dr K's expertise in Pandas comes in on that we decided he was the best route for us and we didn't want any oopsy's .

Just trying to figure out the exact steps of getting a preauth? So you had your employer do it? So your codes with Dr K did not work? were all 3 of your ivig's with Dr K?

 

Worried Dad-

 

Well--Gol----ly!!! Sounds JUST LIKE OUR EXPERIENCE. Oakbrook ceased being a "Bluecard" provider two days before our son's procedure & this royally screwed up everything. We took 5 months to see the checks!! Our Bluecard dept in Iowa BCBS did go to bat for us and reimbursed at the rate had we had it done in Iowa. They had to get techy guys to work around the confines of their computer system to pull it off. We just kept squeaking. Oakbrook was no help. We got a variety of stories each time we called. It was very frustrating. We were pre-approved. That probably saved us and the fact that we were pre-approved prior to Oakbrook cutting with the national BCBS provider program. We learned alot about how the whole BCBS works in the country. Don't leave the confines of your state or you are at the mercy of the BCBS ASSOCIATION. Never heard about this entity until our experience!

 

We had an autoimmune disease NOS & encephalopathy NOS for dx codes.

 

They are a provider in Illinois. I think 7upMom will come out fine with pre-approvals. -Iowadawn

[Johnsmom]

Worried DAD-

 

So what are the codes? Do you know what they are exactly. When I posted a few weeks agon asking for PANDAS codes, someone replied that there wasnt one. I didnt think that there was but what does Dr K use. Quite frankly, we are so used to insurance paying for jack #!*! so we are not getting our hopes up.

Thanks

johnsmom

 

 

Yep, all 3 rounds of IVIG with Dr. K at the Oakbrook Surgical Center. The diagnosis and procedure codes worked for pre-approval - and hopefully they will still work eventually for reimbursement - but the fact that OBSC is out of state and out of network has delayed everything to glacial slowness. (At least, that's the excuse BCBS of MI gives me whenever I call.)

 

If you're in IL and go to OBSC, maybe you'll have a smoother time. Is OBSC in-network for you? Anyway, Dr. K uses a diagnosis code that is for more generalized immune deficiencies, so you have a much better shot at coverage. And you're right - having IVIG done at OBSC under Dr. K's direct supervision is a great way to go. Our son was in major exacerbation during the IVIG procedures, and I don't think we would have gotten through it except for the patience, compassion, and experience of the staff there. They've seen lots of PANDAS kids and understand the special challenges.

 

You're in good hands with Dr. K!!!

 

 

That would be really frustrating and we are expecting for it not to go easy with the insurance company paying. We also have BC/BS , we have Illinois. Haven't heard the best about BC/BS coming through with payment, but it doesn't hurt to try!!

We are paying up front and doing IVIG with Dr K, but just want to try to get a preauth ahead of time. We aren't going to stress about it too much just will be happy to have him better. Dr K is in network for our insurance and so far with everything thats been going on they have paid very well. We thought about going through our doctor here, she offered to help and follow Dr K protocol, but I think there are so many other things Dr K's expertise in Pandas comes in on that we decided he was the best route for us and we didn't want any oopsy's .

Just trying to figure out the exact steps of getting a preauth? So you had your employer do it? So your codes with Dr K did not work? were all 3 of your ivig's with Dr K?

[Johnsmom]

worried dad

oops. sorry worried dad, just saw your post about the codes. maybe we will get an answer soon..

 

johnsmom