Wednesday, October 28, 2009

When Your Insurance Company Won’t Pay: 12 Tips

I was doing some "googling" tonight and came across this article, here is the URL
Since many people are finding my blog by way of search words related to insurance companies and unfair denial of claims, I thought I would post this

By Mary Shomon, with Dr. William Cline
1. Don’t assume that the first “no” you receive is final.About 10 percent of all insurance claims are unjustly denied but less than 1 percent of people making insurance claims even question their insurer when their claim is denied. The majority of policyholders who do contest their cases either win their cases or improve their settlements.

2. Insist on a written explanation. Most state laws require insurance companies to provide written explanations of claim denials. Failure to comply may constitute an illegal practice by the insurer.

3. Read your policy carefully to determine if the claim was legitimately denied. The insurance company may have interpreted a clause in your policy differently from the way you understand it. Respect your sense of fairness and what you expect the policy to cover. If the ruling doesn’t sound fair, there’s a good chance that it isn’t.

4. Do not accept filing errors as ground for refusal. Always follow your insurer’s instruction for filing a claim. But if you fail to fill out a form correctly, or if you miss a deadline for submitting a claim – even if you are months late – an insurance company cannot refuse to pay an otherwise valid claim unless the company can show it has been harmed by your error or prevented from making an adequate investigation due to your delay.

5. Do your own research to support your claim. If your insurance pays less than you expected for care provided, check what other doctors in your area charge for the same care. If other doctors charge more than you received, challenge the payment.

6. Ask your insurance agent or group policy administrator at work for support. The agent from whom you purchased your insurance has a duty to make sure the coverage protects your interests.

7. Contact the insurance company directly. If your insurance agent or claims administrator doesn’t resolve the problem within 30 days, telephone the insurance company yourself. Be polite but persistent, and keep going up the corporate ladder. Be sure to make a record of all phone calls, including the names and positions of everyone with whom you speak. Save your phone bills that list the calls. Follow up each call with a brief letter stating your understanding of the conservations, and requesting a response within 30 days.

8. Complain in writing if your phone calls don’t work. Begin with the person who denied your claim, then write to the person’s supervisor. Include your policy number, copies of all relevant forms, bills, and supporting documents and a clear, concise description of the problem. Request that the insurer responds in writing within three weeks. Keep copies of all correspondence. Send letters by registered mail. Explain what negative effects the denial of your claim is having. Use a courteous, unemotional tone and avoid rude or blaming statements.

9. Write a follow-up letter. If you receive no response, send follow-up letters, with your original letter attached to the insurance company’s consumer complaints or customer service department and to the company president. In most states, failure to respond promptly to letters regarding claims is an unfair insurance practice.

10. Enlist outside help. If necessary, add pressure from:
Your state Department of Insurance – this is free. The amount of these departments can help varies from state to state. But some states with strong departments (California, New York, Illinois) will mediate your dispute.
A professional arbitrator.
A lawyer.

11. Gain doctors’ support. If you can enlist your doctors’ support for your claim, you have a better chance of successfully challenging a claim. 12. Look for violations. If your claim is denied because of a reduction in coverage, determine if you were ever notified about that reduction in coverage. If you were not, then you have a good chance of winning your claim since failure to notify the patient of a reduction in coverage is a violation of the law.

Resources for Additional InformationConsumer Coalition for Quality Health Care1275 K St. NW, Ste. 602Washington, DC 20005Phone: 202-789-3606Web site:
Center for Patient Advocacy1350 Beverly Rd., Ste 108McLean, VA 22101Phone: 800-846-7444 or 703-748-0400Web site:
Consumers for Quality Care1750 Ocean Park Ave., Ste. 200Santa Monica, CA 90405Phone: 310-392-0522Web site:
Excellent Book to ReadFight Back & Win – How to Get Your HMO and Health Insurance to Pay Up, by William M. Shernoff., Barnes & Noble

Tuesday, October 27, 2009

Other Trouble With UHC

A few months ago J had an endoscopy done by an in-network provider, at an out of network facility with an out of network anesthesiologist. We got a bill from the anesthesiologist because our deductible was applied to his bill.

Last night I called UHC to complain, we used an in-network doctor, we had no choice regarding the anesthesiologist. Last night I got the run around and was told the only thing to do is file a written appeal (this didn't get me very far when I wanted the CPM covered).

I was advised by a fellow hip friend (thanks Maria) to ask for 'rapid resolution'. So I called again today and explained to the rep that I was unhappy with the outcome of my call yesterday, she voluntarily (without me asking) transferred me to rapid resolution. The rep at rapid resolution (again) explained that because the facility was out of network, they will not pay for the anesthesiologist at the in network rate. I didn't back down when she told me (again) to file a written appeal. Since I again, kindly asked that UHC pay for the anesthesiologist, she decided to look into my plan. She then told me that I have the "fully insured plan" (not sure what that means) and that she can forward this to the appeals department. I should have an answer in 15 days.

What is the point of my story? Had I just accepted what was told to me on the phone yesterday, I would probably be screwed. I still may end getting screwed, but I feel like something was accomplished today because I was persistent with them.

The Way Things Used to Be

Without going on and on, and sounding like a super complainer, I will leave it at this. I am in so much %$&*@%$##$%% pain (use as many descriptive words as you feel is necessary). It has been 1 1/2 weeks since the super fun synvisc injection and no, it is not helping, no, I don't feel even a teensy bit better. In fact, the pain is so horrible that once again I am trying to figure out what the easiest way to cut off my leg would be.

I am sick of people saying "try PT", "try drugs", "get another opinion", "give it more time". I think I have given it plenty of time, for gods sake, this happened at the beginning of June. How much more time do I need before I lose it altogether, as opposed to just a little, like now. Case in point, I almost had a nervous breakdown last night when I asked for cucumbers and tomatoes to be cut into little pieces for salad. I came home, first, to find they were cut in chunks, and the cucumbers were not peeled, just sliced. As I was re-cutting the tomatoes, J kindly pointed out that the so called cucumbers were in fact mini zucchinis. Poor J didn't think I would lose it over zuchinni.....well.....super bitch is back! If you are reading this and have never dealt with pain and the frustration involved, you probably think I am nuts, for those of you who have, I'm sure you can easily relate.

What brought me to write this (and no, it was not just to complain) was that I was walking Jk to school last week and can distinctly remember the day 2 springs ago that I was walking L to school on the same path and finally was able to say to myself, "OMG, nothing hurts". I was thinking about that as I was walking last week, and the left hip still feels perfect, yet the right one feels like ice picks are running through it. I hope that I can have that same feeling once again really soon. What keeps me from the brink of insanity is that I have the left to remind me that things can be good again, and were, for a very long time, and it is possible to fully recover from these issues.

Had I not had such a good outcome on the left, or the 1 1/2 good years on the right, I think I may have given up and resigned myself to live like this, but I know that there is bigger and better out there, so in the meantime, I will keep trying to remember that day in the spring, and try to keep super bitch at bay as much as possible!!

Friday, October 23, 2009

Having a Shitty Day

I am in so much pain today I am contemplating biting off my leg. I don't know how it got this bad, its not like I am out running marathons, or climbing mountains, or anything even remotely physical. The only thing I did yesterday that I haven't done in a while is go to the park with the kids. We had a gorgeous day yesterday, I couldn't let it go to waste. It is about a 10 minute walk, if that, I pushed Z in a single stroller, and I sat for most of the time that we were there. This morning I went to the supermarket. That's it, nothing else. I have been cooking today and have had to take breaks from standing in the kitchen. This has never happened. I am so shocked, and depressed as well, how could things get so bad all of a sudden? If I can't even make dinner, how am I going to work? I guess we'll cross this barrier on Monday, by then things should have calmed down I hope.

Thursday, October 22, 2009

Let The Waiting Game Begin

It has been 6 days since the Synvisc injection. I hurt. It has not helped. I am not happy. In fact, the pain has been worse since before the injection. Why do I always get so lucky!

BK wants me to wait it out a little longer....which is fine, given the alternative, but my feeling is is this going to get better? I don't want to waste any more time, this has been going on since June already. It is starting to really drag on and it is really getting to me. I haven't had a good night's sleep in a while, I am up every few hours from anxiety. When I first went into practice, I was surprised at the number of patients who came to see me whose medication list included some sort of anti-depressant or anti-anxiety drug. It all makes sense now.

Yesterday was a beautiful day in NYC. I had a great afternoon with fellow hipster Carrie, who was in town seeing BK following her 3rd surgery (2 scopes and 1 open). She is still having pain and inflammation post-op, and limping quite a bit. We walked around the city a bit at a leisurely pace. Towards the end of the walk, I had to ask her to slow down because I couldn't keep up. Sorry Carrie but that was so pathetic on my part!

About the Synvisc, I spoke with BKs nurse while Carrie was seeing him. She said another one of their patients had relief about 3 or 4 days after having it injected. BK thinks the cortisone can still kick in within the next few days.

Keep your fingers crossed!!!

Sunday, October 18, 2009

Who Wants To Bring It To The Media

There was recently a newscast locally which spoke about FAI and labral tears

I have thought about contacting that station to see if they would run a story about UHC calling the surgery experimental, my only issue is that I am not currently being denied anything, rather, it seems, just a trouble maker!!!! Does anybody out there have a pending denial who would like to initiate this, I would do everything I can to help, as I am sure others would too. This would make a great headline!!

I Forgot To Mention About the Synvisc One

I received the statement from the pharmacy that filled the prescription...
Amount Charged: $844.80
Amount Paid by Insurance: $844.80

What more could a girl ask for!!!!!

Saturday, October 17, 2009

Synvisc One Injection....Done!

It has been a very long week and I am finally getting tot he computer now! Yes, the injection is done, and I am REALLY sore!

I had it done yesterday around 3pm, same radiologist as always, so I wasn't too nervous bc he is so gentle, although no intra-articular injection is ever going to be 100% pain free, this was no exception.

Apparently, the makers of Synvisc One suggest using a fatter needle to inject the material, fatter needle translates into more pain! Also, the radiologist explained that he couldn't inject Lidocaine into the joint for me, like he normally does, because it will dilute the Synvisc. He did offer to flush the needle at the end with a tiny amount of Lidocaine, hey, a little Lidocaine is better than no Lidocaine, right!! He did numb my skin with Lidocaine first though, that helped a bit.

Unfortunately, I did feel every move of the needle as it pierced muscle and the joint capsule, and came to rest inside my hip joint. He first injected the Synvisc One, followed by Kenalog (like cortisone) and then my vitamin dose of Lidocaine!

I am supposed to be keeping a pain log but have been too busy to even think about it. Last night I was in a lot of pain, and even immediately following the injection I was in a lot of pain. The radiologist explained that the Lidocaine that he normally uses probably masked that pain for me all the other times. I am still not too happy but I guess only time will tell. I am hoping the Cortisone kicks in soon, or maybe it did but I am sore from the fat needle....who knows!!!

I know that I have not written the UHC letter as I promised, or been very proactive with that lately. I have been thinking about making some changes in my life, which I will get into when I can, and have been really busy with that, as well as my vacation last week. I will keep you posted on how the Synvisc One works!

Monday, October 12, 2009

The SynviscOne is Here

Now if only I could inject it myself......

Tuesday, October 6, 2009


I think the solution to my problem is not Synvisc, or cortisone or exploratory surgery, it is a lifestyle change. I am in Miami now, we have been here for a week, with nothing really to do. I have had a great week! My hip pain has been so manageable here, I think I will start doing nothing all day and solve this issue!

Sunday, October 4, 2009

...The hip bone's connected to the...foot???

I guess the pain in my hip is starting to take its toll on the rest of my body. I started to develop pain in my right foot (right hip is the problem) over the past few weeks. It is right around the 2nd metatarsal. I am currently on vacation in Miami where luckily, a friend is a podiatrist, who just happened to be over for dinner Friday night.

I asked him to look at my foot since it was really bothering me. He started feeling around and said that the area I was having the pain in had developed a nasty callous. Since I am favoring my right hip, I must be twisting the foot in some way and putting unnecessary pressure there. He also thinks there must be inflammation inside, in that area. Additionally, I have developed a callous on the outside of the left foot too. So I must be shifting all of my weight to the left, sub consciously, to unload the right side. He recommended I get new orthotics which is probably a good idea anyway since mine are about 7 years old.

He came over tonight and shaved off the callous (I know, eww) and casted me for new orthotics! They should come in about a week and a half!