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Thread: Well oiled machine

  1. #1

    Well oiled machine

    *** THIS IS A RANT, PLEASE LEAVE NOW, DO NOT READ BELOW, IT'S JUST A BITTER, FRUSTRATED CRIPPLE WHINING ABOUT SHIT HE CAN'T CHANGE... YOU HAVE BEEN WARNED***

    I've been battling with my DME for the past 2 years to get a chair and finally I got them to submit it to insurance, so now of course the insurance company is the obstacle.

    Insurance companies (BCBS of SC in my case) are like well-oiled machines when it comes to completely ignoring you and not letting you talk to anyone about the issue you have.

    A couple months ago an insurance lady I actually got on the phone after only 45 minutes of being transferred and put on hold told me how I could appeal the denial of my titanium upgrade. So I asked my PCP to send the letter appealing the denial. Well eventually they denied the appeal (after telling my doctor that he faxed the appeal to the wrong number, which was the exact number the above lady told me to fax it to), which leads me to today.

    I call BCBS at the number the nice lady in the above paragraph gave me. Turns out it's not her phone number... also not the right department for the appeal, and it's only a voicemail so other than leaving a voicemail (ha! like they're ever going to return that!) all I can do is call the precertifcation department. My afternoon went like this:

    2:15 pm called precert department, entered my member number on the phone, put on hold, someone answered the phone call, "verified my member number" (read wasted time for a couple minutes), then said they could transfer me to the proper department.
    2:25 put on hold again for ten minutes, finally someone answered, "verified" me again and then asked me to hold.... held for fifteen minutes... then they said they could transfer me to the proper department.
    2:40 transferred to another department who listened to my spiel about how I wanted to contest the denial, then said they worked in the "small groups" section and would have to transfer me to the "major groups" department that handled my company's insurance... she kindly does provide me with the phone number for "major groups" in case we get "disconnected"... another fifteen minutes on hold.
    2:55 "major groups" finally answered, but all the sudden they can't hear my phone, I can hear them perfectly clearly, but they can't hear me, so they hang up on me, which sends me to an automated "how'd we do" survey thing... I rate them poorly as I'm on the way back to work and don't have the time to wait on hold again.
    5:00 I call back the "major groups" number, because I know they're open until 6pm based on what they told me before we were "disconnected". I'm put on hold for twenty minutes. After twenty minutes I'm told they need to transfer me. "Where to?" I ask... to the PRECERT DEPARTMENT they say... "what in the holy hell?" I ask, that's where I started this whole ordeal three hours ago. "Well they shouldn't have transferred you" the clearly-starting-to-get-annoyed lady says on the other end. I ask to speak to a manager... she resists... I ask again to speak to a manager... she says it's getting close to six. I ask her name again and say "Erin from the "major group" department, I am requesting to speak to YOUR manager at this time, are you telling me that I cannot speak to your manager." She says no, of course she isn't, but I might have to hold...

    At this point I know where it's going. It's barely more than half an hour before their department closes, all she has to do is put me on hold for half an hour and her day is over. So she does. She puts me on hold around 5:30, and checks in every ten minutes or so to see if I'm still there, asking if I will continue to hold. Then at 6:01 she picks up the phone again and asks if I would like to leave a message because there is no longer a manager in the building and the department is closed... I say "That's what I figured, you'd just put me on hold until 6 pm and tell me there's nothing you can do" and then hang up the phone.

    The whole fucking system is like a well oiled machine, extremely effective in it's singular purpose to confound the patient and prevent them from getting any meaningful information or address any concerns.

    But I've got Erin's name and the department she works in. Unfortunately for her she was the one stuck holding the hot potato at the end of the day, so I'm gonna call her back at 8:00 tomorrow morning and see how long it actually takes to get a manager on the phone... My guess is three hours, but I'll entertain bets.

  2. #2
    That sucks have you considered requesting the address where to send the appeal letter? If I was in your case I would request my pcp send me the appeal letter. Then make several copies of it and never send the original. Send it certified mail so you know they received it and cannot lie. As you have a record it was signed for by usps.

  3. #3
    Quote Originally Posted by nmireles View Post
    That sucks have you considered requesting the address where to send the appeal letter? If I was in your case I would request my pcp send me the appeal letter. Then make several copies of it and never send the original. Send it certified mail so you know they received it and cannot lie. As you have a record it was signed for by usps.
    That's a thought, but then I have to pay actual money to send them a letter. And besides, I wouldn't know who to address it to other than BCBS at this point. If I can get someone to give me to correct person's name to address it to so it gets to the right place, surely that person could also connect me to their voicemail.

    They got the letter and denied the appeal already, my last resort is to request a PM&R doc review it as KLD suggested for me to do in my other thread.

  4. #4
    Was this the form your doctor used to start the appeal?
    Are you still within the appeal time limits listed on the bottom of the form?

    https://web.southcarolinablues.com/U..._rev060418.pdf

    Think of this appeal as a ladder.

    The insured patient appeal is the first step. You were knocked off the ladder. That happens in the majority of first level insurance claim appeals no matter what the condition.

    The PM&R Doctor is the second step. He/she will submit the appeals form along with a letter of medical necessity. He/she will then get called by a BC/BC appeals Doctor who will likely not be a PM&R Doctor. That appeals Doctor, who is paid by BCBS, will likely knock your doctor off the ladder by again denying the claim.

    Your PM&R Doctor should immediately insist on escalating the appeal to a "same specialty" Physician reviewer. This is the third step and should ideally lead to your PM&R SCI doctor talking with their PM&R specialist on the phone. The pitfall in this step is that their PM&R Doctor reviewer may not be PM&R SCI. Your doctor can request to speak with a Doctor in same specialty, same certification if needed.

    Is this awful? Yes.
    Last edited by 2drwhofans; 10-04-2018 at 10:02 AM.

  5. #5
    Quote Originally Posted by 2drwhofans View Post
    Was this the form your doctor used to start the appeal?
    Are you still within the appeal time limits listed on the bottom of the form?

    https://web.southcarolinablues.com/U..._rev060418.pdf

    Think of this appeal as a ladder.

    The insured patient appeal is the first step. You were knocked off the ladder. That happens in the majority of first level insurance claim appeals no matter what the condition.

    The PM&R Doctor is the second step. He/she will submit the appeals form along with a letter of medical necessity. He/she will then get called by a BC/BC appeals Doctor who will likely not be a PM&R Doctor. That appeals Doctor, who is paid by BCBS, will likely knock your doctor off the ladder by again denying the claim.

    Your PM&R Doctor should immediately insist on escalating the appeal to a "same specialty" Physician reviewer. This is the third step and should ideally lead to your PM&R SCI doctor talking with their PM&R specialist on the phone. The pitfall in this step is that their PM&R Doctor reviewer may not be PM&R SCI. Your doctor can request to speak with a Doctor in same specialty, same certification if needed.

    Is this awful? Yes.
    You seem to know infinitely more about this process than I do.

    You say "the PM&R Doctor is the second step" This sounds like I should have a PM&R doc to submit the second step.

    I've seen a PM&R doc a grand total of 1 times in the 11 years since I got out of a rehab hospital, and that was about six years ago. I guess you're saying I should have a PM&R doc submit the letter before I request that it be reviewed by a PM&R doc (I was able to find out that the person who denied the claim for BCBS is some type of PCP type doc [can't remember if it was IM or FM]).

    Jesus Christ, this seems like a lot of work. For me to get in with a PM&R doc in the first place is definitely a multi-month process, and then I'm sure there will be more bullshit. It's already been over two years... I hate to give in, but maybe I should just give them the extra $1600 and be done with it... I mean $1600 definitely hurts my budget, but I have been planning and saving for a much more significant blow to my finances than that for the past couple years that I've been working on getting my chair, and I could afford it at this point.... goddamnbutifidon'thategivinginthough...

    It's kind of shocking to me that some/most/afew of you have PM&R docs that you just... see? Like for appointments and whatnot. The one and only PM&R doc visit I had they gave me a script for baclofen for spams (which my PCP has continued to this day like 5 years later), but otherwise they didn't really DO anything for me...

    This same specialty same certification thing seems like I should definitely find an SCI PM&R doc (pretty sure that's a fellowship for PM&R), then BCBS would almost certainly be unable to find an appropriate counter-doc to deny the claim, but I have a fairly good grasp on the landscape in my current area and I'm pretty sure I'd have to travel two to four hours by car to find an SCI trained PM&R doc...

    Also I have never seen the form you posted, nor any other form, I was just told that my claim was denied (by my PCP who submitted the appeal, BCBS hasn't yet bothered to send me anything or call me to tell me the claim was denied and I have never seen any sort of form.

    Christ, I'm so lost in all of this, and out of everyone I would think I should be the best equipped to get this stupidgarbagebullshitfrustratingass job done.

  6. #6
    If you see a PM&R physician who is also board certified in Spinal Cord Medicine, and they submit/sign your letter of medical necessity/appeal, then you can also request that the appeal reviewer be board certified in Spinal Cord Medicine, not just PM&R. Most of those physicians who are board certified in Spinal Cord Medicine are PM&R physicians, but a few are orthopedists, urologists, or neurologists. To sit for the board exam in Spinal Cord Medicine, currently, the physician must have completed a post-residency fellowship in Spinal Cord Medicine.

    (KLD)
    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

  7. #7
    Quote Originally Posted by funklab View Post
    You seem to know infinitely more about this process than I do.

    You say "the PM&R Doctor is the second step" This sounds like I should have a PM&R doc to submit the second step.

    I've seen a PM&R doc a grand total of 1 times in the 11 years since I got out of a rehab hospital, and that was about six years ago. I guess you're saying I should have a PM&R doc submit the letter before I request that it be reviewed by a PM&R doc (I was able to find out that the person who denied the claim for BCBS is some type of PCP type doc [can't remember if it was IM or FM]).

    Jesus Christ, this seems like a lot of work. For me to get in with a PM&R doc in the first place is definitely a multi-month process, and then I'm sure there will be more bullshit. It's already been over two years... I hate to give in, but maybe I should just give them the extra $1600 and be done with it... I mean $1600 definitely hurts my budget, but I have been planning and saving for a much more significant blow to my finances than that for the past couple years that I've been working on getting my chair, and I could afford it at this point.... goddamnbutifidon'thategivinginthough...

    It's kind of shocking to me that some/most/afew of you have PM&R docs that you just... see? Like for appointments and whatnot. The one and only PM&R doc visit I had they gave me a script for baclofen for spams (which my PCP has continued to this day like 5 years later), but otherwise they didn't really DO anything for me...

    This same specialty same certification thing seems like I should definitely find an SCI PM&R doc (pretty sure that's a fellowship for PM&R), then BCBS would almost certainly be unable to find an appropriate counter-doc to deny the claim, but I have a fairly good grasp on the landscape in my current area and I'm pretty sure I'd have to travel two to four hours by car to find an SCI trained PM&R doc...

    Also I have never seen the form you posted, nor any other form, I was just told that my claim was denied (by my PCP who submitted the appeal, BCBS hasn't yet bothered to send me anything or call me to tell me the claim was denied and I have never seen any sort of form.

    Christ, I'm so lost in all of this, and out of everyone I would think I should be the best equipped to get this stupidgarbagebullshitfrustratingass job done.

    BC/BS didn't send you an claim appeal form because they didn't want you to have it.

    Deciding whether to fight insurance companies always comes down to the eternal question: Your money or your time?
    Insurance companies play this game very well and they have all the time in the world.

    Titanium upgrades? A promising treatment for cancer that's considered "experimental" ? It all flows through the same fine sieve.

    I've won some and lost way more than some with BC/BS appeals. I tend to fight the out of network bills more than DME these days.

    My husband's SCI doctor relocated to another state years ago. He hasn't had one since. Getting a new outpatient appointment at our local Rehab Hospital takes 6 months.

    If you don't need the new chair right away, I'd try using the BC/BS SC appeals form and escalating to the second level.
    Otherwise, if the upgrade cost wont cause you long-term financial harm, pay for the Titanium upgrade and enjoy the chair you want sooner.
    Last edited by 2drwhofans; 10-06-2018 at 10:37 AM.

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