New member D3HOckey (moved from accidental post in Anxiety/Panic Forum)

The following in the scoop

Husband dx June 2012

We read, spoke with others, emailed, and visited doctors who recommended surgery. I know a man (54 years of age) personally who had the surgery done by a "very good" surgeon. He is both incontinent and has ED. At that point my husband was leaning toward Proton Therapy, had a friend who was going through it and after hearing about the one that went through surgery, was convinced PT was the way to go. I know "everyone is different" which makes this even more confusing.

PSA 2.32

Gleason 3+3

He has had 9 treatments thus far and last week is when I get the EOBs from BCBS of Alabama who is denying ALL claims for the actual beam therapy. The claims for the prep work went through but not the therapy itself. Has anyone had any luck in appealing this insurance company?

What am I suppose to do now, tell my husband to stop treatments? At $5,300 a session this is just a financial nightmare.

D3HOckey

I moved this post...I assume it belongs here...it was in Anxiety/Panic forum...hope this is okay.:)

Scaredy Cat

I'm sorry to hear of your predicament, but am trying to understand how it came about. Both for testing and when arranging for my davinci surgery the hospital checked my insurance coverage and confirmed the various procedures were approved and would be covered. In fact, they wouldn't have treated me without prior approval. Also, my wife and I spent a great deal of time talking with BCBS about what level of coverage would be provided.

Good luck to you. I hope you're able to work this out with your insurer.

Post Edited (clocknut) : 10/16/2012 9:02:26 AM (GMT-6)

Well that is the problem because now I have to see who is not telling me the truth and trying to get the documentation for it.  The person at the facility told me that she advised my husband of this (but he was already on his third treatment) and that she is  currently going through the "reconsideration" phase with the insurance company. 

I am just wondering if anyone ever had any luck with appeals.  The benefit booklet states that radiation therapy is covered at 80%, Proton Therapy is radiation therapy no? The common man would just assume it was one in the same. There is no where in the plan that it shows exclusion of Proton Therapy.  Not until I was on the phone with a rep from BCBS of Alabama who had me go to the "Provider" tab on their website and showed me in their directory that they do not cover Proton Therapy as show it to be no better than other covered methods.  Why would I ever go to the "Provider" tab as I am a patient not a Provider.

   Yes, I know they will rely on their precertification rule which was always taken care of from my other doctors for c-sections and his other doctors for previous operations so I assumed the provider again would be taking care of that but not AFTER he started his treatments.   So am I to assume that this Provider dropped the ball? 

Perhaps I should be both here and Anxiety/Panic? 

Thank you for moving me! 

 

Thank you for your response. I don't even think my house is worth that much anymore!

Appeal, appeal, appeal ....... don't give up.. Frustrating. If can, try to talk personally with medical director. Document. Did they send an original letter of denial? Can always send a letter with copies to state insurance board, medical director of BCBS, Drs., etc. Did work in HMO PPO and listened to the discussions.. Extremely frustrating.

I know I know but when denied on the pre-cert the health provider individual advised me that she had already appealed the denial and they work "very closely with the insurance carriers, we will work it out". We had already waited four months after diagnosis and were advised by Proton facility and the surgeons that they normally tell patients to make a decision by three months so we decided and began all start up procedures needed and those claims were paid until we got to the actual beam. Do we feel like absolute fools right now? You betcha!

I am now pouring over the internet for appeal documents and trying to work at my job at the same time. I am not an idiot by any means but this medical terminology and these insurance procedures and codes are definately swelling the brain.

We always paid more for the PPO insurance thinking "we're covered". Joke is on us.

Listen, the same thing happened to me but for a very different condition. My wife was hospitalized for major depression and a social worker told me that my wife needed after discharge from hospital  "partial hospitalization" or basically a psych adult day care program for a month or two. I said to her does insurance pay for that? She said medicare does, I said I don't have medicare, I have BC/BS, she said it might. So when she was dcd from hospital I took her to the adult day care and showed them my insurance, they said they would take it. And then I checked my policy and it said she had 30 days of outpatient psych care. After being there for a month the center said her coverage ran out so I said I would keep her at home. THEN bc/bs started sending those EOBS saying that the psych center was charging for 3 services a day so my coverage ran out after one week. She was there a month.  So the psych center started sending me bills for $50,000, as did bc/bs. I freaked out and called the psych center and said, "look if you try to collect this I am going to declare bankruptcy. I showed you my health insurance when she came to you, you should have checked as to what they were going to pay." I did appeal the insurance's decision but was denied. Basically bc/bc paid $2530 on a $50,000 bill, and I waited 3 days and the psych center said just pay us what insurance paid and we'll write it off. That's what I did, that proton center had no right treating your husband  without authorization, they didn't check just like the psych center my wife went to didn't check. Don't feel bad, when our loved ones are at risk we are not thinking clearly. They take advantage of us. I would tell the proton center no more treatments until you clear with insurance. Your husband has a gleason 6, you have time for them to get their act together...............