Another strategy dealing with insurance companies
Jim DeWees
Description
Collection
Title:
Another strategy dealing with insurance companies
Creator:
Jim DeWees
Date:
7/16/2008
Text:
Recently I had a patient come to my office with a broken prosthetic leg. He has been a BK amputee for about 10 years, and he was still wearing his first definitive prosthesis, which is about 9 years old. The foot was literally broken in two pieces (Seattle light foot, toes broken off after all these years), and the shock pylon was also broken and had no rotation control in it, and so the patient just drilled a hole and put a screw in it to keep the pylon straight until he could get a new leg made. In the mean time, the pylon broke and so now the leg is in 3 pieces, literally, and he had no leg to get around with. He was also wearing about 18 ply of socks to make the socket fit now, and so his medical doctor wrote the prescription for a new prosthetic leg. He has had the same job for years at a local employer (a major employer in the area), and has insurance through his employer.
We submitted the information for a precertification, and it was determined by some very brilliant doctor at Anthem that a new prosthetic leg was not medically necessary at this time. We got a call from the insurance informing me that it was denied, and a letter was mailed to explain the options and what we need to do at this point.
The letter came about 12 days after the phone call, and I kept the envelope with the postmark on it (which I heard a while back from someone else to make it a practice of keeping envelopes because of this very reason...the postmark is enough to file a formal complaint with the Dept of Insurance showing that they hold the mail to a point where there might not be any options left to do an appeal or corrective action). The letter was written on June 4, the postmark was on June 13, and received here on June 17th. The letter explained that I must mail in more information about the leg and why he needs a new one, along with all the medical documentation, and I have 10 days to get that to them....that is from JUNE 4TH. That time period had already expired!!! Now, the only option was to appeal the decision, and that process can take up to 30 days. In the mean time, the patient has no leg to walk on, and can't do his job without a leg.
I spent over 38 minutes on hold before I was able to talk with the Utilization Management dept at Anthem, and then was transferred to the nurse's dept., and sat for another 54 minutes on hold with that line. Finally I spoke with a nurse that totally understands why this guy needs a new leg, and was floored when she saw that it was denied. In the meantime, while on hold, I made some other calls, and managed to get the doctor's name, and using Google I got his location and address (which Anthem is very careful to not give that information out, or send any letter from that doctor with his name on it), but I did this so that I could give it to the local newspaper reporter that would love to talk to this doctor and ask what he was thinking when he decided to deny this person the ability to walk and work, and deny him a new prosthetic leg.
When I told them the nurse that I had the doctor's name and address, and why I had his name, then she escalated my concerns, being that Anthem really doesn't want any more negative press around here, especially one that is this visual, like a man not being able to get a new leg to replace a totally broken prosthetic leg that is over 9 years old.
That got the process rolling, but still not as much as I was wanting to have happen. This took all afternoon, and actually I got a call back from a manager at about 6:00 pm (a local call, so there was no time-zone difference involved here) and I am sure she was counting on me not being here to answer the phone, then she could just leave a message and document that she tried to contact me, etc. But, I did talk to her, and told her how frustrated I was, and how frustrated this amputee was and that he has a right to be very upset with his insurance company, and to a point where he WANTS to go on TV to share his anger and frustration. She understood our frustration and appologizes for that, and is doing everything in her power to get it fixed. Yeah, blah, blah, blah....this is after I was told that Utilization Management is not the ones that make decisions, that the doctors do that, and that they are powerless. But, now this manager is saying she is doing everything possible....whatever.
So, the next morning I decided to call the Human Resource Dept of this employer and talked to the insurance person, and she is the person that works with Anthem to work the contract with them, and everything else. I explained to her what was going on, what this decision by Anthem actually is doing to their employee, and how horrible this is, and how awful it will look when the local paper writes it up on the front page of the paper here. She didn't want that to happen, since there are already enough problems here, and already many bad feelings and frustrations with the insurance company. This employer is self funded and pays Anthem to administer their benefits and process claims, and so there is a HUGE contract with them.
This person at the employers HR dept made some phone calls, and called me back in about an hour and had the claim all approved and ready to go. She made sure that she pushed it through just to keep me from having any valid reason to still have it published. She called me back a couple hours later to give me the precert number and let me know it is official. I got the letter in the mail from the insurance company a few days later with the number on it.
That was about 3 weeks ago, and the patient has gotten his new leg, and the claim was submitted.
Today we got a check from Anthem, but was only for a few of the codes. The main codes (L5301) and the code for the foot we both denied with the explanation that Utilization Management Denied the benefit and also another reason that there was NO precertification for this claim.
So, today I was back on the phone with the employer, and she was very upset again over this, because she KNOWS there was a precert given, she has the number, and she is the one that relayed that to me right when it was approved a few weeks ago. I have the precert here in writing (but we all know that means nothing really, until you take it to the appeals process and go through all those hoops and all).
She made some phone calls again today, and was not happy about this. She thanked me for bringing this to her attention. Within a short time, I got a call from Anthem asking me some questions about the claim and she claimed that there was no precert, and it was my fault for not getting that in the beginning, and then I informed her that I have the precert, and so does that HR person at the employer's office because this has been such a mess that I decided to get them involved so they can see how awful it is to deal with Anthem, and hopefully this employer will get tired of seeing stuff like this and choose another company to administer their claims, and tell Anthem to go bye-bye.
With that being explained to her, she changed her tune, and said that she DID see the precert (it was buried in another file in the system, but she just happened to find it at this moment...hmmm, funny how that works), and so she said that she just got it paid and the check will be printed in a couple days and mailed. I asked her if it was that simple, and she said she just had to push a button basically and release that payment and approve it, and it is paid now.
So, my point here is that for any of you that are constantly dealing with issues like this (and I imagine that is a lot of us), start calling the employer's Human Resources dept and talk to the actual person that is the liason with their administration company. The HR dept doesn't like hearing that their employees are getting a bad deal, and they don't want other employees hearing or reading about these incidents in the newspapers either. They can call the insurance company and get things worked out rather quickly, because the insurance companies do not want to loose their clients or their accounts like this. The insurance companies have to get the situation resolved quickly at that point to do the damage control and to save a contract like this. So, call the HR departments whenever possible and explain it to them, and let them feel the frustrations and problems, and maybe they will consider these issues in the future when it is time to negotiate new contracts with their administration companies.
I just wanted to share this, and this new method I have found to get claims processed quickly and avoid the long appeals process and the frustrations that go along with them. Try to inform and educate the HR people how this takes up our time and energy, and let them share that frustration with us. That is one of the only ways I can see that will hopefully make a difference down the road, either the insurance companies will have to start playing nicer with the providers, or they could lose their clients and these big self-funded groups that pay them millions a year for these services.
Good luck out there,
Jim DeWees, CP
_________________________________________________________________
Time for vacation? WIN what you need- enter now!
<URL Redacted>
We submitted the information for a precertification, and it was determined by some very brilliant doctor at Anthem that a new prosthetic leg was not medically necessary at this time. We got a call from the insurance informing me that it was denied, and a letter was mailed to explain the options and what we need to do at this point.
The letter came about 12 days after the phone call, and I kept the envelope with the postmark on it (which I heard a while back from someone else to make it a practice of keeping envelopes because of this very reason...the postmark is enough to file a formal complaint with the Dept of Insurance showing that they hold the mail to a point where there might not be any options left to do an appeal or corrective action). The letter was written on June 4, the postmark was on June 13, and received here on June 17th. The letter explained that I must mail in more information about the leg and why he needs a new one, along with all the medical documentation, and I have 10 days to get that to them....that is from JUNE 4TH. That time period had already expired!!! Now, the only option was to appeal the decision, and that process can take up to 30 days. In the mean time, the patient has no leg to walk on, and can't do his job without a leg.
I spent over 38 minutes on hold before I was able to talk with the Utilization Management dept at Anthem, and then was transferred to the nurse's dept., and sat for another 54 minutes on hold with that line. Finally I spoke with a nurse that totally understands why this guy needs a new leg, and was floored when she saw that it was denied. In the meantime, while on hold, I made some other calls, and managed to get the doctor's name, and using Google I got his location and address (which Anthem is very careful to not give that information out, or send any letter from that doctor with his name on it), but I did this so that I could give it to the local newspaper reporter that would love to talk to this doctor and ask what he was thinking when he decided to deny this person the ability to walk and work, and deny him a new prosthetic leg.
When I told them the nurse that I had the doctor's name and address, and why I had his name, then she escalated my concerns, being that Anthem really doesn't want any more negative press around here, especially one that is this visual, like a man not being able to get a new leg to replace a totally broken prosthetic leg that is over 9 years old.
That got the process rolling, but still not as much as I was wanting to have happen. This took all afternoon, and actually I got a call back from a manager at about 6:00 pm (a local call, so there was no time-zone difference involved here) and I am sure she was counting on me not being here to answer the phone, then she could just leave a message and document that she tried to contact me, etc. But, I did talk to her, and told her how frustrated I was, and how frustrated this amputee was and that he has a right to be very upset with his insurance company, and to a point where he WANTS to go on TV to share his anger and frustration. She understood our frustration and appologizes for that, and is doing everything in her power to get it fixed. Yeah, blah, blah, blah....this is after I was told that Utilization Management is not the ones that make decisions, that the doctors do that, and that they are powerless. But, now this manager is saying she is doing everything possible....whatever.
So, the next morning I decided to call the Human Resource Dept of this employer and talked to the insurance person, and she is the person that works with Anthem to work the contract with them, and everything else. I explained to her what was going on, what this decision by Anthem actually is doing to their employee, and how horrible this is, and how awful it will look when the local paper writes it up on the front page of the paper here. She didn't want that to happen, since there are already enough problems here, and already many bad feelings and frustrations with the insurance company. This employer is self funded and pays Anthem to administer their benefits and process claims, and so there is a HUGE contract with them.
This person at the employers HR dept made some phone calls, and called me back in about an hour and had the claim all approved and ready to go. She made sure that she pushed it through just to keep me from having any valid reason to still have it published. She called me back a couple hours later to give me the precert number and let me know it is official. I got the letter in the mail from the insurance company a few days later with the number on it.
That was about 3 weeks ago, and the patient has gotten his new leg, and the claim was submitted.
Today we got a check from Anthem, but was only for a few of the codes. The main codes (L5301) and the code for the foot we both denied with the explanation that Utilization Management Denied the benefit and also another reason that there was NO precertification for this claim.
So, today I was back on the phone with the employer, and she was very upset again over this, because she KNOWS there was a precert given, she has the number, and she is the one that relayed that to me right when it was approved a few weeks ago. I have the precert here in writing (but we all know that means nothing really, until you take it to the appeals process and go through all those hoops and all).
She made some phone calls again today, and was not happy about this. She thanked me for bringing this to her attention. Within a short time, I got a call from Anthem asking me some questions about the claim and she claimed that there was no precert, and it was my fault for not getting that in the beginning, and then I informed her that I have the precert, and so does that HR person at the employer's office because this has been such a mess that I decided to get them involved so they can see how awful it is to deal with Anthem, and hopefully this employer will get tired of seeing stuff like this and choose another company to administer their claims, and tell Anthem to go bye-bye.
With that being explained to her, she changed her tune, and said that she DID see the precert (it was buried in another file in the system, but she just happened to find it at this moment...hmmm, funny how that works), and so she said that she just got it paid and the check will be printed in a couple days and mailed. I asked her if it was that simple, and she said she just had to push a button basically and release that payment and approve it, and it is paid now.
So, my point here is that for any of you that are constantly dealing with issues like this (and I imagine that is a lot of us), start calling the employer's Human Resources dept and talk to the actual person that is the liason with their administration company. The HR dept doesn't like hearing that their employees are getting a bad deal, and they don't want other employees hearing or reading about these incidents in the newspapers either. They can call the insurance company and get things worked out rather quickly, because the insurance companies do not want to loose their clients or their accounts like this. The insurance companies have to get the situation resolved quickly at that point to do the damage control and to save a contract like this. So, call the HR departments whenever possible and explain it to them, and let them feel the frustrations and problems, and maybe they will consider these issues in the future when it is time to negotiate new contracts with their administration companies.
I just wanted to share this, and this new method I have found to get claims processed quickly and avoid the long appeals process and the frustrations that go along with them. Try to inform and educate the HR people how this takes up our time and energy, and let them share that frustration with us. That is one of the only ways I can see that will hopefully make a difference down the road, either the insurance companies will have to start playing nicer with the providers, or they could lose their clients and these big self-funded groups that pay them millions a year for these services.
Good luck out there,
Jim DeWees, CP
_________________________________________________________________
Time for vacation? WIN what you need- enter now!
<URL Redacted>
Citation
Jim DeWees, “Another strategy dealing with insurance companies,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 24, 2024, https://library.drfop.org/items/show/229557.
