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Health insurance delaying medical services #281666
10/07/18 02:00 AM
10/07/18 02:00 AM
Joined: Apr 2014
Posts: 14
Silver Spring, MD, USA
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mutagen Offline OP
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mutagen  Offline OP
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Joined: Apr 2014
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Silver Spring, MD, USA
I’m in a lot of pain and have multiple health problems, and I’m on short term disability. I have health problems that affect a lower percentage of Ankylosing Spondylitis patients. I’m on Remicade and multiple painkillers and muscle relaxants, and I still have unbearable pain. My rheumatologist is seriously against prescribing pain killers aside from NSAIDs, but has prescribed them. I’m constantly waiting for the health insurance company to approve medical services to receive treatment.

My health insurance company continues to lengthen the treatment process by intentionally prolonging the prior authorization process. Many of the medical services, i.e. MRIs, medical treatments require a prior authorization for my current health insurance plan. The health insurance carrier is the only carrier provided by my employer and I selected the plan with the highest level of coverage. My prior authorizations on average take 3 to 4 weeks for approval.

The doctor submits the prior authorization and it rarely comes back with an approval within a reasonable amount of time. The insurance company consistently asks for more information on why the medical service is necessary. Once the insurance company receives the medical necessity response from the doctor, the insurance company responds stating the medical service is medically unnecessary and provides recommendations for specific medical treatments prior to approving the medical service. This still occurs even though the doctor already tried those recommendations. After multiple peer reviews, where my doctor presents their case why I need the medical service to a doctor working for the insurance company, the insurance company finally decides to approve the medical service. This arduous prior authorization process is not just with one single doctor, but multiple doctors/specialists.

The MRI results that were deemed medically unnecessary all showed abnormalities. I’ve repeatedly rescheduled medical services due to consistent denials of medical care. I’ve had Aetna, and Blue Cross Blue Shield in the past and did not encounter these problems. When a doctor at Johns Hopkins ordered an imaging test, immediately after the appointment I was able to go next door to get my MRI or CT scan.

I’ve contacted the State Insurance Administration to address the issue with the health insurance company. They were not able to do much, because self-funded Health insurance plans are not within their jurisdiction. I was told to contact my employers Health insurance Administrator and The Department of Labor (DOL) Employee Benefits Security Administration. I contacted my employer’s health insurance administrator and they were not able to provide much assistance. I contacted the DOL and they said that they couldn’t directly contact the health insurance company, but would send a letter to my employer.

I believe the health insurance company is abusing the prior authorization process by intentionally prolonging the process to discourage treatment. Has anybody else dealt with these problems and how did you get faster treatment? What recourse do I have?

Re: Health insurance delaying medical services [Re: mutagen] #281667
10/07/18 02:58 AM
10/07/18 02:58 AM
Joined: Jun 2012
Posts: 618
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seymour Online
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Joined: Jun 2012
Posts: 618
I'm sorry that you have to deal with this on top of your AS. I wish I could help, really.

I sympathize with you a lot cause I am too on short term disability for depression and the insurance company constantly ask for more paperwork from my doctor and each time they suspend my payments for about two weeks while they're "evaluating" a sheet of paper that takes 2 minutes to read....

Then they call me and ask me questions about how I feel even though I have a doctor's note and report that says I can't work for now. Clearly they're trying to pressure me or find a contradiction that they can use to stop paying me.

Insurance companies are the scum of the Earth.

Re: Health insurance delaying medical services [Re: mutagen] #281668
10/07/18 09:04 AM
10/07/18 09:04 AM
Joined: Jul 2006
Posts: 6,587
New York
Banana Offline
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New York
Very sorry, I too use to have that same problem. I actually bought a fax machine to deal with .......... One time they denied something because I needed to be on MTX. I was ON MTX but it wasn't covered so they said I wasn't on it. Catch 22. I started faxing them daily, as soon as I got a denial I would refax how I answered last time.

The only other thing that worked was crying. They were denying something and said two more weeks for approval. A new biological. My ribs were so painful and I started crying and said how it was affecting my breathing. I got instant approval.

Anna


Actema IV once a month (with pre loading for allergic reaction), Cymbalta x1 daily, Arava 20mg daily. Diagnosed with AS in 2004, suffered undiagnosed since 1982.
Re: Health insurance delaying medical services [Re: mutagen] #281706
10/09/18 08:26 PM
10/09/18 08:26 PM
Joined: Mar 2016
Posts: 532
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sdot Offline
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Insurance companies being insurance companies. Always looking for a way to avoid paying.

Re: Health insurance delaying medical services [Re: mutagen] #281710
10/09/18 09:53 PM
10/09/18 09:53 PM
Joined: Mar 2013
Posts: 2,002
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SouthernMoss Offline
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SouthernMoss  Offline
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You could consider filing a complaint against the insurance company with your state's department of insurance.


Ginny - 57 year old female
Dx with USpA in March 2013; changed to AS in July 2015
Iritis and Scleritis
unicompartmental knee replacements: right-June 2014, left-Aug 2018
MTX, Humira, Cyclobenzaprine, plus Celebrex as needed
Supplements: Folic Acid, Vitamin A, Vitamin D, Calcium, Fish Oil, Culturelle probiotic, Melatonin (as needed)
Re: Health insurance delaying medical services [Re: mutagen] #281726
10/10/18 11:18 AM
10/10/18 11:18 AM
Joined: May 2010
Posts: 1,430
Whidbey Island WA
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WhiteCell Online
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WhiteCell  Online
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Whidbey Island WA
Locate the Congressional and/or Senator in your area and bring your paperwork, explain your issue, and request a Congressional/Senatorial Inquiry. Make sure the Senator you see is the one who will be in office in 30 days. Go to the local newspaper and speak with their health reporter.

Insurance companies hate the light of day. Be assertive, persistent and take no prisoners. Embarrassing them is your weapon.


Starting at 18 yrs old > Reiter's Syndrome. Diagnosed 2001 Ank Spon.
Started Remicade 2002 - 5mg/kg every 7 weeks.

Right Eye Glaucoma- Trabeculectomy/lens replacement 2006.
Right eye DSEK Cornea Transplant 2009.
Right eye Ahmed Shunt 2016.
Right eye DSEK Cornea Transplant 2016.
Supra Ventricular Tachycardia. 2004. Cured by RF ablation 2008.

ICU RN - Seattle, WA

~Grasp The Challenge and Succeed~
Re: Health insurance delaying medical services [Re: mutagen] #281777
10/13/18 06:38 AM
10/13/18 06:38 AM
Joined: Jan 2016
Posts: 10
Joshua Tree, CA
jtmak Online
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Joshua Tree, CA
So sorry for pain in all directions. Might ask local MRI clinics if they have a cash pay option for MRI. I had similar experience and clinic gave me their cash pay option which was 300$. It was a free standing mri lab. Good luck!


California, USA
Reoccurring Bilateral Uveitis Dx 1985
Reiters Syndrome Dx 1985
AS Dx 2015
SI joint fused

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