On May 13 an MRI found 20 tumors in my husbands brain. On May 15 he could barely breathe and was in a lot of pain. A CT scan that day revealed he had a softball-sized tumor in his lung, tumors in his other lung, his liver and possibly his bones. On our way home from the imaging center our primary care doc called and told us to turn around and get to the hospital right away. My husband was admitted and they promptly removed more than a pint of fluid from his lungs, which helped him breathe better. We were there for 6 days while they performed a bronchoscopy, did more scans, gave him drugs to stop his brain from swelling and administered emergency chemo.
Today I got a letter from Anthem Blue Cross regarding his hospital stay:
"Coverage for the requested service is denied because the service does not meet the criteria for “medical necessity” under your description of benefits. To assist our Medical Director in making this decision, we have put a process in place to send all information about the service to a clinical reviewer with appropriate credentials. Based on their opinion, we have determined that coverage for the requested service is denied. Our Medical Reviewer Layma Jarjour MD has determined we cannot approve your hospital stay for cancer. We do not have enough facts to show that it was medically necessary. "
Anthem is owned by WellPoint. Did you know Wellpoint CEO Joseph Swedish earned almost $17 million during his first year on the job? Now you know how they can afford to pay him.
Update, Thursday May 29:
Yesterday the local CBS station KPIX came out to report on our story.
I also got a call from a women named Patricia at Anthem, who told me not to worry, my husbands hospital stay would be covered. I spoke to Patricia at length today. It’s a little hard for me to explain the reason they denied my husband’s hospital stay, because frankly, I still don’t understand it. But luckily I have an excellent memory and can type fast, so you can just read my transcription below.
Hopefully our situation is resolved and I can go back to focusing on my husband and son. I post this in the hope that it will help other people (people who do not have 1 million twitter followers or who’s stories don’t get covered in the the press) get their denied health insurance claims reversed. What should you do? Keep meticulous notes. Be persistent. Make noise. Do not take no for an answer. Tell everyone. Why this all has to be so convoluted, I do not understand. It makes me livid to think of how many families suffer needlessly because of corporate bureaucracy and greed.
Thank you so much for your help and words of encouragement.
much love, Zoe
Patricia: let me tell you what my research has found out so far. one of the things that happens is that when someone goes to the hospital, the hospital sends an electronic notification to the insurance company and then the insurance company calls the hospital and says ok, give us the information like we understand you’ve got a patient going in, what’s the information, give us the medical records. and apparently in this case there were 3 calls made and we didn’t get any answers back. and so what we were trying to say is that we need this information from the hospital and when we get it we can further handle this case but in the meantime they have a timeframe requirement to make a determination that is under the regulatory requirements that you have to have made a determination by a certain time and if they don’t have the information at the time they have it them um, that’s, that’s, ah, all they can go on and then when more information comes in then we can um of course overturn that. so what we’re gonna do is pull the information to us and get that handled quickly because it’s clearly a covered service and we’re going to work on how we can better word the letter when it goes out to say and let you know we’ve contacted the facility, we’ve asked for these records, once they come in we can consider this, but at this time and at this particular moment we don’t have a claim and we don’t have the information.
Patricia: so it’s one of those things where they notify us and they’re supposed to send that corresponding data and for some reason that didn’t come in and we have made three attempts to get it. so um this is something that we’re going to work on, making us do better
Patricia: and uh, in the meantime i wanted to let you know that we got you a good care manager, i don’t know if she’s reached out to you
Me: yes, yes, she has, thank you. ok, i hear what you’re saying . i think probably from the patient’s perspective of somebody who’s not a health care expert, i just see a letter that says “denied”. so yes, i think you’re correct that if you can do a little bit better to explain the process to your customers, to let them know how this is supposed to work and what they’re supposed to do and this is not a bankruptcy sentence, in addition to a death sentence that would be, um, kind of important. (start laughing). sorry i’m laughing, i’m going through a lot and i don’t know what else to do except laugh because every time i read this letter it seems more and more alarming. so i think that of course, if you don’t have the information that you need in order to approve a claim then yes, that makes sense, but i would think that the letter would say….
Patricia: the letter does say that you can file an appeal
Me: yes, that is at the end. there is a separate page here that talks about how I start a grievance procedure. but the letter says very clearly from the beginning, “we cannot approve your hospital stay for cancer”. so it’s not obvious from this that you just don’t have enough information to make the claim, it just says “we can’t approve it”. so that’s very misleading because the letter, it says, it’s not being approved and that i have to file a grievance when actually the situation is that you just don’t have enough information. so that’s a clear difference in understanding between what you guys think you’re telling me and what i think the letter says and I think you could do a lot better with that because that’s a really alarming letter to get when your husband has a serious illness that you just learned about in the previous week.
Me: i appreciate your calling me with this and talking about it and I’m going to sleep a lot better tonight knowing that we’re not about to go bankrupt.
Patricia: what is is, uh. it’s a very important. um. i mean, we’re very highly regulated in order to do the right things for everyone. i mean especially in california you know, they want to make sure we acknowledge the receipt of your issue when you file an appeal so you get something within five days and it says we’re working on this. and there are things that we can do expeditedly for you when it needs to happen quickly, you can say I need this to be rushed through in an expedited case, we can do that in 72 hours and there’s a lot of good people here that want to make sure the right things happen for your family.
Me: ok, thank you. so going forward. say something happens to my son and I have to go to the hospital with my son. how can i stop this from happening the next time? because you can imagine when you have a catastrophic illness happen to your family, it’s not like you have a heck of a lot of time to be on the phone with the insurance company all day and to be filing more paperwork and all this stuff and, i actually don’t feel like i should have to be doing that. so is this going to happen again the next time we go to the hospital?
Patricia: well, we would hope not. uh. but I’m hoping that i can provide a little more insight for you to understand how everything works and give you resources to contact so that we can work with you if anything doesn’t go the way it should. what usually happens is that the hospital notifies us that someone’s gone inpatient and we reach out to them and then there’s a response right away and they can go and say, oh, we see what’s going on and everything goes through. for some reason, in this case, the response didn’t come even after three attempts and we’re looking into why, into what was the obstacle in getting the information to us in the time period of those calls we made to them. so we’re dealing with the facility to see how can we do that better because we don’t want you to go through that.
Patricia: and so in normal circumstances we ask for the information and they send it and for some reason it didn’t get sent and we’re going to try and find out why and do better on that. and then we can also say in the letter a little more clearly, um, there wasn’t enough information at the time and then maybe give some explanation as to what, uh, would, you know, something along the sense that says when this information comes in, we can reconsider this. and that would put you at ease.
Me: uh, oh, ok. thanks. so, um, what do I need to do today?
Patricia: you don’t need to do anything today because what I will do is, um, we’re gonna pull that information from the hospital and say, let us have those medical records and we’ll get the claim, because we don’t even have the claim yet, they’re preparing that for us. and when it comes in, it will go through processing and then if you have any questions once you see how that was all paid, um, you can always call me. you also have an appeal process and we can put this through the appeal process and we can do what we need to do to make sure everything gets handled the way be within the plan structure.
Me: ok. that makes sense
Patricia: and I think you can get a lot of questions answered through your nurse care manager. I’ve told her to keep you copied so i can make sure you’re getting your questions answered quickly and you’re getting to the care that you need on time and all of that.
Me: ok, I think I understand it now. Thank you for calling to help.
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