Games Health Insurance Companies Play?

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GDen
Veteran Member


Date Joined May 2009
Total Posts : 703
   Posted 9/7/2010 2:00 PM (GMT -7)   
My health insurance company seems to have a little game they like to play. It goes like this:

- I talk to them and they say, "Sure, that procedure will be covered 100% regardless of deductible." So I go ahead and pre-authorize.

- My doctor contacts them and my insurance company tells them that they will not cover the procedure until my deductible is met.

- I talk to my insurance company again, raise a little bit of #*%&, and after transferring me to a higher-up they once again say, "Our mistake, that procedure will be covered 100% regardless of deductible."

- I go ahead and get the procedure done.

- My insurance company sends me a statement informing me that they will only cover the procedure after the deductible is met.

Anybody else play this game?
Cimzia, Asacol

Post Edited (GDen) : 9/7/2010 3:32:19 PM (GMT-6)


Nanners
Elite Member


Date Joined Apr 2005
Total Posts : 14995
   Posted 9/7/2010 2:03 PM (GMT -7)   
Did you by any chance write down the name of the supervisor you spoke with? If so, I would contact this person again and repeat what they told you before. Thats just not right. I have an HMO so I don't run into those types of problems luckily. Sorry you had to play this game:(
Gail*Nanners* Co-Moderator for Crohns Disease 
Crohn's Disease for over 34 years. Currently on Asacol, Prilosec, Estrace, Prinivil, Diltiazem, Percoset prn for pain, Zofran, Phenergan, Probiotics, Calcium, Vit D, and Xanax prn. Resections in 2002 & 2005. Also diagnosed w/ Fibromyalgia, Osteoarthritis, & Anxiety. Currently my Crohns is in remission, but my joints are going crazy!
*Every tomorrow has two handles.  We can take hold of it by the handle of anxiety, or by the handle of faith"*

GDen
Veteran Member


Date Joined May 2009
Total Posts : 703
   Posted 9/7/2010 2:12 PM (GMT -7)   
Yep, I have everything written down and the supervisor said it's all also in their computer. I guess from now on I'll make them send me a written copy!

I'm really starting to think it's a game they play, using various tricks to get out of paying their share and only those that fight get what they're actually entitled to.
Cimzia, Asacol

ivy6
Elite Member


Date Joined Sep 2005
Total Posts : 10404
   Posted 9/7/2010 2:30 PM (GMT -7)   
*sigh* You don't need that sort of rubbish... not on top of your illness.
Co-Moderator Crohn's Forum.

Medications for Crohn's ~~ Diet and Nutritional Therapy for Crohn's ~~ Dealing with Abscesses and Fistulae ~~

GDen
Veteran Member


Date Joined May 2009
Total Posts : 703
   Posted 9/7/2010 2:46 PM (GMT -7)   
I'll say! It's just maddening when not only do you have to fight to get healthy, but also have to fight those who are also supposed to be helping you get healthy.
Cimzia, Asacol

Zanne
Veteran Member


Date Joined Apr 2005
Total Posts : 3763
   Posted 9/7/2010 3:09 PM (GMT -7)   
My insurance company's game is to pay for things if I have them done at the doctors office, but not at home. Things like B12 injections. Way cheaper to do at home, but go figure, they will pay for an office visit every 2 weeks, but not for the syringe and B12. Also, they won't pay for my Vit D prescription, but they will pay for other treatments that are way more expensive for bone health. Just crazy stuff. They can't think outside of their formulary, there is no common sense. And then we wonder why the insurance industry is in a mess, its because they can't think!!!

Becky77
Veteran Member


Date Joined Dec 2005
Total Posts : 1768
   Posted 9/7/2010 3:51 PM (GMT -7)   
Where are you Zanne? Vitamin D is cheap...even without insurance. I filled it and they messed up and filled 52 of the capsules and my insurance denied it because they'll only pay for a month at a time, but it was only $15..that's a years worth, so it was cheaper than if I used insurance. I also just filled 3 months of B12 and it was $4 at Walmart. They didn't fill syringes...so I'm having a friend "get" some from her work...hehe!

I hate the bills that get sent to you that should have been written off. It makes me wonder how many people pay these bills without question. Occasionally my GI's office will send me a $50 bill that was leftover after insuance payment and my copay, and all I have to do is call and they write it off. I also get these every once in a while from the hospital. I guess they just see who pays them...some people don't pay attention I guess.
Becky

32 yr old female-dx with Crohn's in '97 after emergency resection and appendectomy, 2nd resection '05, Bilateral pulmonary emboli 10/09
Currently on Humira, Omeprazole, Effexor, Seroquel, Calcium, Vit D
Coumadin stopped 3/15/10!!!!

kelli_C
Regular Member


Date Joined Jul 2009
Total Posts : 130
   Posted 9/7/2010 6:19 PM (GMT -7)   
A lot of people don't realize that doctor's offices and hospitals barter with the insurance for what they'll actually charge and pay. But the patient gets a bill for the amount and is expected to pay full price. It's a bunch of BS.

I don't believe that the insurance companies do this the people on purpose, but I do believe that there's a lot of human error in the biz and each rep's interpretation of your insurance plan is different. I personally don't believe ANYTHING my insurance company tells me unless I've heard it from like 2 or 3 other reps.
UC dx in 1998 (age 18) - proctosigmoiditis - Allergic to Sulfa
1998-2009 Asacol 2/2X daily - very sketchy about taking it...pretty much drug-free for a long time.
Jan 2006 - Crohn's? UC?
Aug 2009 - flare - Mesalamine enemas and 4 Aprisos daily...still a bit sketchy about taking the Apriso once the flare was done
August 2010 - Flaring - Asacol HD and sfRowasa
8/10 - Doc dx me with Crohn's!

GDen
Veteran Member


Date Joined May 2009
Total Posts : 703
   Posted 9/8/2010 6:05 PM (GMT -7)   
Grrrrrrrrrrrrrrr. I made a bunch more phone calls today and got lots of runaround. Somebody give me some prednisone so I can go Hulk and blame it on that.
Cimzia, Asacol

Emoney12
Regular Member


Date Joined Mar 2004
Total Posts : 100
   Posted 9/8/2010 7:52 PM (GMT -7)   
I actually work for a health insurance company and I can bet the customer service is outsourced through a third party. Do you have insurance through your employer? If so you should inform your hr department so they can speak to your companies account rep. Internal management employees at an insurance company have dedicated internal contacts to get these issues resolved. Also you say you have a deductible on your plan. In most cases the deductible needs to be satisfied before any benefits are paid. Some plans only have a deductible that a plies to anything outside a dr office, such as hospital, ambulatory, etc. Some include it for everything, even rx.

GDen
Veteran Member


Date Joined May 2009
Total Posts : 703
   Posted 9/8/2010 8:42 PM (GMT -7)   
According to their policy, this procedure is covered at 100% regardless of deductible. They confirmed that before I had it done (I preauthorized it beforehand). Now after the fact they're trying every trick in the book to get out of paying the whole thing.
Cimzia, Asacol
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