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Fighting Cancer, Insurance Company and Doctor's Office Politics
The Schedulings Begin
I got a call from the surgeon’s office for the tests to be taken that had been scheduled: blood work, EKG, PET scan and MRI along with chest x-ray. Since the blood work was a walk in I got it out of the way immediately. I prepped for the PET scan by eating a low carbohydrate diet the day before the test and relaxing all day as I was directed. But just as I was going out the door with my husband from our home to get the PET scan we get a call that the scan had to be rescheduled because the authorization is still pending. They rescheduled me two days forward. Right away I called my surgeon’s office to let them know what had happened. I talked to the office manager and she asserted that my insurance company usually does not pay for PET scans. Really? I called my insurance company’s customer service line once, twice, three times, four times, five times… I kept getting different answers: your doctor’s office needs to submit additional information, the authorization is still pending, we do not have a request for an authorization. Needless to say, my second PET scan appointment was canceled also. I was very frustrated.
Always follow your instinct - Doctor knows Best
Earlier this summer I was mountain biking and my front wheel caught a rock a wrong way so I fell down. The handlebars hit my chest and that is how it all started. It hurt. Actually it really hurt.
About two to three weeks later I felt a hard lump on my right breast and my first reaction was it was from the fall. But it was soon due to my annual physical and something in me wanted my doctor take a look at it just to be on the safe side. My primary care physician referred me to MRI/ultrasound, which came back suspicious. From there I was referred to a surgeon for a biopsy, which confirmed the suspicious diagnosis: Invasive Ductal Carcinoma. Wooh! Am I glad I got it checked. So, the surgeon’s office started working on scheduling appointments for tests for me. I don’t know about you, but when you are diagnosed with cancer it wakens you. You take it quite seriously and you hope that the team that works for you also sees it in the same way.
About PET Scan
Why is PET scan done? A PET scan is useful when your doctor thinks the cancer might have spread but doesn't know where. The picture may not be finely detailed like a CT or MRI scan, but it provides helpful information about your whole body.
Birth of a poppy - by Karoliina Urso
I must get in action when nobody else seems to move
After I received the doctor’s dictation of my visit along with the pathology report, I sent faxes to the insurance company appeal division for fast decision request. I submitted the copies of the pathology records along my office visit with the surgeon. I also copied and pasted a Medicare announcement for a national Medicare payment policy that expanded coverage of PET scans in the initial treatment strategy of most solid cancers, including breast cancer (I found it in the internet). Then I faxed my fast decision appeal to my insurance company, hoping that they would take notice. The information was in black and white and the insurance company needed to see the facts in case they did not get them all from my doctor’s office. The next day nothing happened. I called back the customer service line and talked to a nice understanding representative. She related to me that the insurance company was waiting a response to a fax that had been sent to my doctor. Apparently, he needed to fill to verify whether I meet the criteria of PET scan. When I heard this I was already discouraged trying to talk to the surgeon’s office manager, therefore I asked if the customer service representative would kindly call the doctor’s office and tell the manager. She agreed. The representative put me on hold and placed a call and came back and let me know the doctor’s office told her they never got a fax. So OK faxes sometimes do not get through.
Do you understand you insurance Evidence of Coverage?
How PET scan works
Always Educate Yourself about your Insurance Policy
So I thought everything was moving along then. We were waiting for the doctor to fill out for the last fax and then I could get that PET scan. All of a sudden, I get a phone call from the insurance company: you have been making quite a few calls lately? Yes, I have. I have been diagnosed with cancer and my PET scan has been canceled now twice. The voice in the other end says: ”Your PET scan has been approved.” I said are you sure?
My problem though is that the office manager at my doctor’s office was adamant about my insurance company not covering the PET scan. Whenever I tried to talk to her and ask her to send her information back to the insurance company, she asserted that it already had been sent. I was talking to a wall. I had to take this issue in my own hands otherwise the PET scan would never been approved. The office manager would have let it just let it slide. Come on people. It is my life and I deserve better. I will fight for better service.
Lesson learned: don’t take no from your doctor’s office for insurance authorization coverage especially if you have a Medicare HMO. A Medicare HMO must work within Medicare guidelines otherwise it will lose funding. Make noise if you feel that you are getting a runaround from your insurance company when you need coverage. Call your customer service representatives. Check your Evidence of coverage. Find out what you can do to expedite the process. Some diseases need to be treated fast – find out what your options are to expedite to get your services authorized in expedient manner. If your doctor’s office says it cannot be done, do not always believe them. You need to know your policy. Be informed or find someone who knows about insurance.
Patience and prayer in time of crisis
- Precertification, Denials and Appeals: Reducing the Hassles - Family Practice Management
The author, who writes from experience inside a managed care organization, offers suggestions for making the precertification process easier.
- Selling Seniors on HMO's | Alicia Patterson Foundation
- U.S. GAO - Medicare: HCFA Needs to Take Stronger Actions Against HMOs Violating Federal Standards
Your Health is Important!
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© 2014 Karoliina Urso