Insurance Issues

Brenda Brames- I can't speak for the medicaid in your state, but I can for Indiana. I was told the same bullshit stories, won't cover it, wait and see if that is what Crystal really needs, they will pay for one or the other....the end result was that Crystal was getting nothing! I ended up having to completely replace her PT and OT. They were both from the rehab center and I had heard from other families that just weren't as good. I held interviews with available PTs and OTs and hired individual contractors and the difference is just remarkable. They show me everyday exactly how much they care about my daughter and are willing to go to battle for her. Rehab therapists are usually overloaded with paperwork and quotas that they have to meet which stretch them too thin and they then don't have enough time to completely care for their children!! Indiana Medicaid paid for a wheelchair and gait trainer all in the same P/A (prior approval) Sometimes the problem with medicaid is not that they won't approve things is that you just have to submit claims in the right order. Like the stander and the gait trainer: If you have a gait trainer and submit a claim for a stander, they will deny because they say the child can stand in the gait trainer. But flip that: If you have a stander and you submit for a gait trainer, you can say it is for mobility, which the stander can't do for the child. Get it? There is just a lot of red tape involved and a therapist really needs to be familiar with the laws and have the time and be willing to be as thorough as what medicaid requires. Punctuality is a must, while I had been blaming Medicaid for taking such a long time with Crystal’s P/As, come to find out it was the doctor’s office or the therapist who just had not even sent the claim to Medicaid.  Also, I was advised that ever if Medicaid tags a suspended to the claim, instead of turning in the info they requested through that same P/A, send a whole new P/A through, because they have 10 days to respond with an answer or the request will be deemed granted.  Once they suspend a decision, the pressure is off and they can take as long as they want.

Nadine- I would suggest getting a case manager, they should have one for you, they are the ones you can deal with and go to the top, because people are the worst. Also, file a complaint, this is usually with the appeals dept. File as many as you want and cc to the insurance commissioner about their lack of proficiency or whatever. Soon as you get that stuff ‘legalized’ in writing they by law have to follow up with it in a very timely matter then they will know you mean business. Don’t fool too much with them on the phone, get names & numbers, they will try to make you crazy going in circles. Type up a quick letter about their poor customer service etc. and put in there that your son has a SERIOUS disease. Ever since I appealed two issues, they’ve been good to me. They just want to know you mean business otherwise they will slough you off. They’re trained that way I think.

Ashley- I could scream, I am so sick of how terrible insurance companies are. Every time I have to call about something, I get the complete and total run around. We've been fighting Cigna for about 8 months now to cover the Tolerex formula because it's not something they normally cover. This happens every time I call no exaggeration. I ask a question and they ask me a question back as if I'm crazy. Then they act like they have no idea what I'm talking about and they say "can I put you on hold for a second?" then anywhere from 10-30 minutes (never sooner) they come back and say the answer is no or they don't know. I ask to talk to a manager. They put me on hold for 10-30 minutes and come back and say "i have a medical representative on the line that can help you......." Then I talk to them and say "Can I please talk to a manager?" "There is none on duty." I say "Don't tell me that there is no manager on duty, put one on the phone." "I'll see what I can do." Then I wait about 30-45 minutes before a "manager" gets on the phone and says that whatever the girl/boy I talked to before them was absolutely correct and there is nothing I can do about it. I went through the Department of Insurance for the Tolerex this last time (I think around Aug-Sept.). They sent me a letter saying that it was approved for 80/20% with a $2500.00 cap per year. I don't care; I'll take what I can get. So Christian needed Tolerex and it will be ready for pick up on Monday. Insurance says, "We have no record of that letter. You will have to pay for it in full and then mail us a copy of the letter and receipt and appeal for us to pay it back to you." WHAT CRAP!! I said "It's already been approved. When Christian goes to the doctor I don't have to pay in full and send you guys a receipt for POSSIBLE reimbursement. Why should I have to do it now, because you guys don't have your records straight?" She said "Ma'am do you want me to help you?" I said "Put a manager on the phone" We went through the whole thing again and I just hung up when she put me on hold. I tried to call the lady that handled this for Cigna and she had a message saying she'll be out sick for an unestimated amount of time and to press 0 to talk to someone else. I did and let it ring for a couple of minutes and hung up when no one answered.

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