I know you need insurance, but why oh why do they have to be so difficult to deal with. Austin's EEG's are routine...we do them every six months. This is not new to the company. They have always approved them at an in network level, but this time they are being difficult. I have gotten calls from both the PCP's office and the billing office at Children's. They asked if I could call and figure out what the problem is.
So I call
Me: I am following up on a request for a 24 hr EEG. It is out of network but we are waiting for approval at the in network benefit level.
Utilization Mgmt rep: yes, we originally denied it and asked for more information. We just got it yesterday. A determination has not been made.
(now I KNOW the info was faxed on Friday!)
Me: So, this is scheduled for tomorrow, can I expect a determination today.
UM rep: mostly likely not today.
Me: How about tomorrow?
UM rep: possibly, but I can't promise it
Me: so what will it cost me if it's not approved
UM rep: let me transer you to a benefit specialist
Me: (Grrrr!) Fine
Benefits rep: How can I help?
Now does she want my real answer or my polite answer?? I go with polite...
Me: My son is having a procedure done out of network. So far a determination has not been made if it should be covered at an in network level. I am trying to figure out what it will cost me.
Benefits rep: well, you have 70/30 coverage, with a $1000 deductible and a $5000 out of pocket max.
Me: Can we talk actual dollars? The procedure is about $4000.
Benefits rep: It doesn't matter what it costs. We make a determination on what we think it costs regardless of what the hospital bills. So we may think it only costs $2000, and then the hospital can bill you the remaining $2000. But then we have to adjust for the 70/30 and deductible....
At this point I am about to lose my lunch, no wait, haven't had lunch yet...well, I am going to lose something.
Me: So you can't tell me how much?
Benefits rep: well if you had the procedural code and how much they are charging, I might be able to figure it out.
Me: fine I will call back
I truly think part of getting hired by these insurance companies is a training course of how to completely annoy the beneficiaries. Because I feel like anytime I call, I end up mad and with no answers.
So I tried calling Children's for a procedural code and cost and shockingly no one has called me back. So right now I don't even know if we are still going.
Stay tuned, it's got to get better...right?
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I dunno Jen, I think you'll win this one even AFTER the fact, just based on former precedent alone.
They've done it once or even twice before, then I beleive you can base an argument on that alone. Even if you have to fight it for 6 months after the EEG and go to arbitration....I still can't see why you'd lose. Even Children's is doing their part (like they have in the past), so they can't pin it on the wrong paperwork. It's not like you don't know how to get the in-network benefit level. This is old hat.
If it were me, I would go instead of risking the EEG being pushed off too far down the road. It's really all a matter of who you're talking to at the ins company anyway. If you had gotten one person over another, you would've probably had everything in place. It's probably all fine, you just haven't talked to "the" person yet. Stupid, I know, but it's reality.
Does this ins company have case managers? If so, then you need one. A child with Austin's needs should have his own advocate within the company to do all this dirty work for you. It was a big help to us when Michaela needed her wheelchair....
Good luck. Let us know the outcome!
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