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Disputing Insurance Claims & Payouts

Berkeley Parents Network > Reviews > Insurance > Disputing Insurance Claims & Payouts



Health insurance won't cover son's vision therapy

May 2007

Does anyone know if it's possible to get a health insurance provider to change their mind about covering something if you can make a good case? My 5-year-old son has had severe social problems (aggression, hyperactivity, explosiveness, extreme sensitivity) which has turned his life and ours upside down. After 18 months of research and endless attempts to evaluate and treat, we discovered he has significant vision impairments and is improving at a dramatic rate as a result of vision therapy. As was the case with a majority of the treatment avenues we've tried, our insurance doesn't cover vision therapy. We attend weekly appointments which cost about $500 a month and will likely continue for the better part of a year I imagine (we started 2 months ago). We're tapped out financially from all our other treatments and if I thought there was a way to appeal to my insurance company (United Healthcare), it would be well worth the time and energy of going through the appeal process. Is that even possible or is it an open and shut case with what they cover?

Someone told me if I could get letters from professionals that have been involved with his care (teachers, occupational therapists, his pediatrician, etc) that could express his need for help, his vision impairments, and his progress thus far, that they might appeal. Do they ever change their minds? If I were to build a case, who would be the best people to get letters from? What would the letters need to say to get their attention? Who would I send the letters to? If anyone has any experience with this I would love to hear about it, even if it's to say that I shouldn't bother. Thanks alot! anon


You didn't mention in your post if your child is seeing an OT right now, but an OT may be able to administer some of the vision therapy. My son was tested by the binocular vision clinic at Cal and in their report they recommended a series of exercises which were carried out by his OT at school. anon
Hi, the therapy we offer at the sensory learning center has vision therapy as one element. The question of insurance coverage comes up quite frequently. United has paid in the past, but it does seem that arguing your case well makes a difference. What works for our patients is: a) A referral from a licensed health care practitioner. b) A procedure code for the therapy c) Tax id for the therapy center d) date of birth for the patient e) health coverage # for the patient f) diagnosis code for the patient (usually a part of the referral) Even with all these in place, there is sometimes resistance. Persistance does pay off. Sincerely, Bryan
I'm not exactly sure what his Vision Therapy consists of, but my daughter required multiple Opthalmologist visits because one eye was much weaker than the other. She had to be checked at least every several months, and for awhile once a month. She wore a patch on her strong eye to try to force the weak one to improve (it did, significantly.) These visits were billed as medical rather than vision services and were fully covered by our health insurance at the time (Aetna). Our vision coverage provided for only one visit per year. If your son's issues are behavioral rather than medical you may be out of luck. However, if there is a medical component to the behavior problems you may be able to come at it from that angle. Sandi

HMO won't pay for alternative health therapies

March 2007

I would love some advice from anyone who knows how to go about appealing services denied by an HMO (Health Net) for (alternative) health therapies. Has anyone had any experience with this? Health Net has approved services for the western/ allopathic care (pediatrician, neurologist, prescriptions (which has very little to offer for my teenage daughter's ''transformed migraine'' and chronic fatigue syndrome) and deny the things that have actually brought releif (acupuncture, osteopathic manipulation, etc.) I would be grateful for any recommendations, names of professionals who could help, similar experiences, etc. Kris


Hi Kris, I understand your frustration. But unfortunately, if it's not written in your policy, then the insurance company doesn't have to pay and the likelihood of getting them to pay is close to none. Double-check your policy. If they cover procedures that are like these, then you may want to ask your doctors / actupunctursit, etc. to amend the writing of the treatment in your claim. I don't mean lie. But sometimes insurance companies will only cover something that's stated with specific language and procedure. You can have had that treatment, but the insurance company won't pay because of how the claim is written. But essentially if the insurance company doesn't cover these procedures, you may want to look for another provider who does. Anon

Insurance won't pay for anesthesia for child's ear tube surgery

Jan 2005

I have Blue Cross/Blue Shield PPO medical insurance. Under the terms of my plan, I have minimal costs associated with medical procedures so long as I use a ''preferred provider.'' In addition, I am not responsible for the difference between the billed amount and the allowed amount negotiated by my insurance company so long as I use a ''preferred'' provider. Last May, my daughter had ear tubes placed in her ears. We selected to ''preferred'' surgeon and a ''preferred'' hospital (Children's Hospital Oakland) Unbeknownst to me, the hospital outsourced the anesthesia for my daughter's procedure to a ''non-preferred'' anesthesiologist - who then promptly sent me a bill for $540. My insurance company sent me a check for $150 which was 90% of their allowed amount for a ''non-preferred'' provider and says that I am responsible for the difference. Needless to say, I'm outraged. I did everything I could to maximize my insurance benefit but now I am required to pay almost $400 for anesthesia - which by the way is more than double what I had to pay for the entire surgery. I have already appealed and lost the benefits determination with my insurance company. Does anyone have any advice on what I can do about this or am I just stuck? Thanks. anonymous


There is a department of insurance in California. I don't know if it will oversees your medical insurance, but it might. They are there to help you get treated fairly by the insurance companies, and complaints to them go on the insurance company official records. You should get useful help if your problem falls under their auspices, they just helped us out after a 4 month nightmare of arguing with our insurers and feeling powerless to get them to do their job. www.insurance.ca.gov anonymous
Boy do I know what you are going through. I had a similar situation with the birth of my second child. It turned out that the pediatrician who happened to be on to check my baby when she first came out was ''out of network'' despite the fact that the hospital is in network. My friend had a similar situation when she went to the emergency room at a network hospital and the doctor who happened to treat her wasn't ''in network.'' I don't know what insurance companies expect you to do in these situations. Was I supposed to stop the doctor from checking my newborn and before I had even delivered the placenta get on the phone and talk to some insurance company bureaucrat to check her credentials? In my case, eventually the insurance company paid, but it took a long fight, with the help of my HR person at work, and in the end they acted like they were making a special exception for me in allowing me to do something not allowed by the policy. My only advice is to not accept it and keep fighting it until they give in, but I would love to hear if anyone else has any advice about changing this ridiculous situation overall. Fed up with health insurance companies
If Blue Cross/Blue Shield has already determined you a responsible it is probably just an expensive lesson in just how uch homework you have to do when dealing with a PPO. At a fraction of the cost I also learned the hard way with my 'PREFFERED'' provider who did lab work for me and sent it out to a non-preffered lab. At length I discussed the situation with my preferred provider facililty who in the end didn't cover an of the cost for me but did ask more questions about insurance before making assumptions. Unless you are willing to ''go all the way'' and get a lawyer etc. involoved I am not sure that you have much choice, I would certainly talk to Children's Hospital and make sure they are aware. kriz
The Medical Board of Calfornia offers services to consumers that deal with quality of care to dishonesty issues. This group has made things happen for both me and my wife. I believe that the insurance company's front line people are often told to deny claims, coverage, or complaints as many consumers just drop their issues then. Check them out, and then follow through. It can be a lengthy process but worth going through the exercise. http://www.medbd.ca.gov/complaint_info.htm Jeff
We have this exact same problem right now. In August, we landed in the Children's Hospital ER with our one-month baby who, as it turned out, had pyloric stenosis. He was very dehydrated because of all the vomiting (it will take me years to get over the guilt of not taking him in sooner, but I thought he was just spitting up alot, ugh). He is totally fine now. Everything was covered as ''in network'' in our Blue Shield PPO plan. Just this weekend, however, I got a bill for over $1300 from the anesthesiologist. Apparently, although the hospital, the surgeon, the ER doctors, the primary care doctors, etc., were all part of the PPO plan, the anesthesia group is not ''contracted'' with Blue Shield. Of course, we had absolutely no way of knowing this, and no one ever said anything to us about choosing our own anesthesiologist. In fact, we had absolutely no benefits counseling whatsoever. So, I called Children's Hospital today, and eventually spoke to an ''in patient'' representative who was somewhat helpful. She told me that because our baby was admitted through the ER, the insurance should pay the claim at an ''In network'' rate. This is apparently because we had no way of knowing anything about or choosing our own doctor (duh). She told me to dispute the claims processing with the insurance company, and that they might pay more. I am not sure how this will turn out. I suspect an unfair business practice by someone (the anesthesiologists? the hospital? the insurance company? not sure, but consumers are the ones getting screwed). If you want to email me directly about this issue, feel free. xialiu
If you filed a grievance with your health plan and got nowhere, try filing a complaint with the Department of Managed Health Care at www.dmhc.ca.gov. --Sounds shifty to me
I actually had almost exactly the same thing happen to me a few years ago. I had to have surgery for a broken ankle. I have Blue Cross and I researched a Blue Cross hospital (Alta Bates), a Blue Cross surgeon, then the hospital used a non-Blue Cross anesthesiologist who insisted that I pay the difference b/w what Blue Cross paid him and what his actual fee was, which was several hundred dollars.

Anyway, I was outraged as well, especially since the insurance company agreed with me that I had no choice over the anesthesiologist chosen. After numerous outraged phone calls I finally ended up talking to a woman at Alta Bates who was familiar with this situation and who told me to call Blue Cross and ask for some kind of special exception based on the circumstances....she gave me a catch phrase to use which unfortunately I can't remember exactly....which allowed them to treat the doctor as if he was a blue cross doctor. Anyway, I promptly called back and used the phrase with Blue Cross only to be told that they didn't use that kind of exception in CA (can't remember why). To which I of course said that my Blue Cross hospital just told me that you could. Then they finally caved and said OK and paid the anesthesiologist.

Anyway, what to recommend? Perhaps call Alta Bates and try to get the exact wording of what you sould tell the insurance company? Sorry I'm a little vague on the details, but the upshot is, I didn't have to pay the anesthesiologist bill. Been there with Blue Cross


Although I'm sure there are some pieces of info missing in your story this is what I can tell you. First, Childrens hospital does not outsource any of it's anesthesia services. The anesthesia is 100% pediatric anesthesiologists who are part of the Childrens Anesthesia Medical Group. All members of the group are part and parcel to the contracts with the insurer, in this case blue cross/shield. You need the insurer to tell you first of all whether or not they have a contract with the CAMG medical group (the anesthesiology group). The answer should be yes. Then ask them why the particular member of the group who did your childs anesthesia is not considered a preferred provider. I suspect they will review this and see they made an error. Sometimes the lower level agents at an insurer will pass on some erroneous piece of information such as the ''outsourcing statement in order to explain a billing mistake. dave
At the very least you should contact the appropriate government agency or agencies regulating your PPO. I don't know who that is, but the CA Dept. of Insurance and the CA Dept. of Consumer Affairs would be two good places to start. If that fails, call your assembly member or state senator. Sometimes merely the threat of regulatory action is enough to convince a business to treat you fairly. David
We had the EXACT same thing happen with Children's Hospital. And, my son had an emergency appendectomy - like we had a choice on the anesthesiologist! I battled with Blue Shield and they did pay at the higher rate, minus my deductible. It wasn't great, but better than what you got. Get your insurance broker involved. Their intervention I've found works wonders. Keep being persistent. Last resort, negotiate a reduced fee (what the insurance would have paid) with the anesthesiologist. I'm so sorry this happened to you. got the insurances blues...
I also have been caught in this billing catch 22 between my health care plan and the Anesthesiology group at Children's Hospital. It sadden's me to read about all the others who were caught when they were at thier most vulnerable with a sick child. You can(with preserverance)get your health plan to acknowledge that you did not have a choice of anesthesiologist and they will pay out at the preferred rate. That does not obligate the Anesthesiology group (other than ethical obligations perhaps) to accept that as payment. And they won't. Why should they? They have a monopoly on the service and you are just one person. You can check your provider. You can check your hospital. That just leaves everyone else. How many folks get caught in this predatory business practice? The CEO of Children's Hospital is Tony Papp. The e-mail address of the head of the Hospital charitable foundation is Mpetrini@mail.cho.org. The email address of the head of the anesthesiology group is maustin@mail.cho.org. Hope this helps. Robert
I was surprised to learn that so many people have been going through the same thing! My son has been treated at childrens hospital Oakland now and he needs to have surgical procedures quite often. We have a health insurance (United Healthcare), and I am dealing with exactly the same thing. While Childrens Hospital, my son's oncologist, and lab work are in network, my anastegia fee and fee from sergical center (clinic?) are out of network. What I have learnt by talking with insurance company is that they have an exception called SAP (Surgery, Anastegia, and I forgot what P stands for). If SAP was performed with in-network doctors at the hospital (or ER) which is also in-network, SAP is also considered in-network and should be covered as in-network. It is because my son had no choice but to go with those anastegists who are out of network, because they work in the same in network facility (in this case, Childrens Hospital Oakland) with in-network doctors. Maybe you can ask your insurance company to see if they have this SAP exception policy. My son's case has not yet been resolved, and I may have to move on to request an audit (they processed our claims as out of network first, and I am requesting them to handle those claims as in-network) but that is supposed to be a policy (and my right to receive coverage). Mika
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