My Bitter Bitter Insurance Gripe - Where's help when you need it?

[Kittycat]

We're insured through my husband's employer. Until a recent merger, we had our bumps, but bills got paid. Now we're insured through (un)United Healthcare. I think their mission statement should be as follows:

Confuse the customer and redirect them at all times. Recommend they seek state medical assistance programs for their disabled child that is covered under said insurance policy. Put coverage in writing, but deny all claims until they're appealed at least 3 times. Never pay any claim that has been pre-approved. When the customer is in debt collection over our failure to pay pre-approved claims, redirect them to someone else who cannot help, then forward them to the disconnect line. Make sure you state that supervisors are not available, ever, and hang up on the customer when they show the hint of frustration. Our number one goal is to make money, not pay claims - ever.

The above has been our life since March 2007. Our son has a variety of global delays from an extremely premature birth (23.6wk surviving twin). He is now 3.5yo, and just learning to walk. He has severe oral aversion, does not eat, and due to lack of use, rarely swallows anymore.

Prior to changing insurance, we had therapy for Speech, Occupational & Physical therapy. Speech included oral motor (eating) and verbal motor (talking) therapy. Currently, he has verbal motor and Physical. Physical therapy is a major regression in structure - he's only learned to walk by our working with him - not from any advice or guidance from therapy. The speech therapist won't even attempt feeding therapy, or give us suggestions at home. She was supposed to start throat stimiluation therapy (to help him remember how to swallow), but has since withdrawn from that - despite drs orders to go forward with it. Their occupational therapist (who is new) is a complete nutjob. I wouldn't even trust him with her. Wouldn't you know it - in a one hour drive radius - this therapy group is the only group approved under our insurance (and I drive 30-35 min just to get to them). We can go to one of their satellite offices over an hour away if I want to switch. Did I mention that none of this even matters since only the first few claims have even been paid since we started going there in April? Yes, the therapy group is going to drop us soon because of it - we already received our warning letter.

Then there's is physical needs... We had a walker on loan to us that had to be returned when we lost our old therapy group (5 min away, no less). So our son went 2 months without a walker, and used a broken/duct-taped one at school while insurance decided if is was necessary.

Then there's his feeding needs. We can use a vendor that charges 3-4 times retail price, and have to pay 20% copay - or we can use an unapproved vendor (who charges retail) and nearly buy the items out of pocket for less than our copay. Did I mention that his food alone costs around $600/mo? then there's feeding bags, syringes, g-tubes, the list goes on. Thank god we own his feeding pump, and I stocked up on food before the insurance change - or during the 1.5mos it took to get approval to even reorder food - he would have starved to death. Should I bother mentioning that after jumping through hoops, getting DH's benefits admin involved, etc that they still denied the first claim - then gave us a 6mo pre-approval, after that we have to be re-approved.

Oh yes, and then 3 pre-approved surgeries, one for one son, two for the other (with special needs)... None have been paid. Surgeries occurred in March, April & May.

Then there's the problem with finding providers. It seems that none of the drs in the area want to carry United HC patients, not even entire health systems. It's one of the reasons why we have to drive past a hospital not even 10 minutes away, and go over to the next town - 35-40 min away to see a dr. That makes sense, right? what happens during an emergency? Well, they told us they'd pay the bill if it was an emergency - somehow I doubt that will ever happen.

So here we are, sorting through the mound of drs bills - trying to find out how many debt collectors are going to call this week. Wondering if some day we'll have to file bankruptcy over bills that our policy clearly states are covered expenses.

So someone please tell me - what's wrong with a single payer healthcare system again? Because I'd take it in a heartbeat. As for universal healthcare... Bring it on. My child has been on 2 waitlists for a neurlogist, and still hasn't seen one. the first wait was for a year, the second 7mo. Our health insurance changed a month before our appointment, so I had to cancel it. Guess what - we're on another wait list. My son is 3.5yo, and we're still trying to find out if he has mild CP or some other syndrome. We know he has something, but can't even see a dr to tell us what.

[SoCalDem]

1. They want you to go away and quit "bothering" them..

Sadly insurance is more about collecting money in the form of premiums, than it is about the paying of claims..

I cannot imagine how upset you must be, and you do not deserve this.. :hug:

[Mythsaje]

2. I HATE insurance companies...

This is a good example of why.

Fucking parasites.

[China_cat]

3. I'll bet they'd pay up in a skinny minute

if the claim was for euthanasia. :sarcasm: (well, almost sarcasm)

[cutlassmama]

4. I think so. I think they are waiting for me to die instead of paying for my

necessary surgery. :mad: I've been waiting for over two months now.

[left is right]

6. Isn't that just about the same amount of time

that you would have to wait for health care in Canada? And that seems to be the reason we as a nation should not go to a single payer health plan. I hate insurance!

[China_cat]

19. Yep, it's cheaper for them to pay a wrongful death suit

than it is to actually pay for treatment.

[Skittles]

5. recommended

Kittycat eloquently describes the disaster that is insurance-for-profit

[1932]

7. Have you thought about contacting your congressional reps and your state legislators and your county

reps too?

[dsc]

8. I would follow post 7's advice plus I would go to the local tv station

and complain there and would complain to the HR department of your company. At least you might be able to get your employer to drop this insurance and go back to the other company.

[B Calm]

9. Then when you do finally get in to see a doctor, they will probably

deny payments by saying your claim is under review.

[RebelOne]

10. The company I work for was just bought out by another corporation.

They switched our insurance to guess who? -- United Health Care. This doesn't sound good at all.

[Kittycat]

22. I'll keep you in my thoughts. It's a complete nightmare!

What state are you in? We're in the Chicago area. When we first got the information on the plan, it sounded almost too good to be true. Nearly everything was either covered 100% or 80/20. The plan even covered a couple things our BC/BS plan didn't. Then we started looking at the dr list, and it was a little slim. It meant changing numerous specialists for my son. In some cases, we were okay with that, in others - it was frustrating.

Then we started talking to our current providers that did accept them, outside of one dr, all the others said they were horrible. When we contacted Apria to register our son for their feeding program (he used to be on their oxygen service when he was younger) - the woman told us that they'll never approve his food. I was so confused - my son doesn't eat by mouth, and we had been in extensive therapy for some time to get him to eat (used to forcibly gag at the sight of a spoon due to his oral averssions). I'm thinking, he has a g-tube and allergies - what am I supposed to feed him? He needs this special diet. We went round and round, and finally got the approval - only to have it instantly denied. Apparently, or so we were told, there's an immediate denial script in UHCs system that kicks out any such claim. Once denied, the patient can appeal, then get it approved (which we did). It made me wonder how many people didn't want to wait on hold for hours - being transferred all over, as we were, just to get it approved. And yes, we had drs scripts from the pediatrician, gastroenterologist & therapist prior to going in to this. The same thing happened with his speech therapy, unfortunately with that, they paid the first few claims, and now have stopped.

I could go on and on, and it's only been 5.5mo.

Two months in to this we contacted our State Department of Insurance Regulation. They informed us that we had to file directly with the State's Atty against my husband's employer, due to the structure of the plan (PPO). If it was an HMO, they had regulatory oversight.

[colinmom71]

11. Wow... I have a former 24 weeker too...

And my experience has been almost entirely opposite from yours. Colin was signed up for Early Intervention services before he even left the NICU. We were on Medicaid when he was born (Georgia's "Right From The Start" pre-natal program, which has pretty generous income limitations above usual Medicaid maximums), and he later continued to be on Medicaid when we applied for SSI Disability for him. He still has Medicaid, albeit as secondary coverage to our private health insurance through my husband's employer, and yes our coverage is also through United HealthCare. UHC has so far been pretty darn good about covering all our claims, but then our plan may be different from yours and its particular covered services...

One thing that might help you with UHC is to see if your plan provides for a Coordinated Care Manager. This is essentially a nurse administrator who will be your personal liaison to coordinate you son's specialized care, managing the varied referrals and specialists claims. This may be a more efficient way to get your claims in order and addressed more quickly instead of being bounced from operator to operator. Colin no longer needs as many specialists as he did when he was your son's age, so I have not yet felt the need to exercise this option and therefore cannot tell you how helpful it may be...

Have you applied for SSI for your son with special needs? Because I think you should regardless of your battles with insurance. While you may worry about the income thresholds, SSI is determined upon the *child's* resources, and family size and back medical bills do play a factor in approval. But the big benefit with SSI is that approval for SSI also grants the child automatic access to Medicaid eligibility. And that Medicaid coverage is invaluable when you have a multiply disabled child, regardless of how (in)adequately covered you are by private insurance. The application process for SSI is somewhat daunting but if you give thorough explanations and fill out the forms as completely as possible, you should receive final approval notice within a month of filing, if not less.

Even if you do not qualify for SSI, your next step is to apply for the Katie Beckett Waiver program (may be called the Deeming Waiver in some states). This waiver basically grants a child Medicaid coverage regardless of the parents' income if the child's disability and/or medical needs are so severe that they would require in-patient hospitalization or institutional care without their current home care situation. That your son has developmentally regressed and seems to be on full time parenteral nutrition should meet the qualifications for the Waiver. My son is now on the Deeming Waiver program after our family income put us beyond SSI eligibility levels.

I have to admit I'm baffled that your pediatrician has allowed your son to go for so long without having been evaluated and tested by a Pediatric Neurologist. Frankly, that should have been taken care of as soon as he was showing gross global developmental problems given his history of prematurity. I think the longest I've had to wait for a specialist appointment for Colin has been about two months, and that was without asking for consideration to fill in for a patient cancellation.

As for what's wrong with a single payer system- absolutely nothing! It's is a complete sin that a family with a disabled and medically needy child should have to battle for their child's needs being met. I'll admit I've been lucky in that I've had few issues arise with Colin's care, but I do know that a good part of that is because of his dual coverage. His medical providers know they will get their money above and beyond what their contracted service prices are with the insurance company with the secondary Medicaid in place... But still, a universal system would be better...

[Kittycat]

26. following up...

SSI application was a NICU requirement, because the NICU receives funds. We've maintained our paperwork annually, as requestioned, and receive $30/mo. I think it's the minimum.

Care coordination with UHC is a joke. The woman we were assigned is new, and I've requested someone else - but we were denied. She even sent us a letter following up on Kyle's supposed heart condition (that he doesn't have). I don't know how in the world she got our son's medical records mixed up with another child, but she did.

Loyola's health system had 1 pediatric neurologist at the time (for post NICU). We were initially on a waitlist for 8 or 9mo (it's been a while). I received a phone call not long before the appointment cancelling it, pending rescheduling. We were at Loyola's pedi ortho one day, and I mentioned it to her - because she suggested a neurological issue might be associated with his inability to walk and low tone. She then informed me that the Pedi Neuro left Loyola, and they didn't have any candidates for replacement yet. I called and confirmed that - yelled at someone for not being honest about it - then called the Pedi (also a Loyola Dr). Just to note - the Pedis were always very hands off and disconnected with Kyle (one of the reasons we switched). We pretty much saw them to get his weight and shots back then. Every colds where funneled back through the pulmonologist. So then they referred us to Children's. We were told immediately that there was a 6mo waitlist, after paperwork and history was received, reviewed and processed (which took about a month). Now we're waiting to see another Neuro, who isn't even remotely as qualified as those we were waiting to see. But we have no choice because so few accept UHC.

As for EI, it was a total joke here. They messed up or accidentally canceled the request coming out of the NICU (none of which I believe), and even after my numerous calls, it was September before they were ready to schedule his assessment (he was released July 8, 2004). By then, I already had him in private therapy through our Insurance. Due to ILs limited funds, they informed me that they would have to cut back his therapy from weekly to 1-2x/month. In addition, we had to pay $200 out of pocket, and they would bill our insurance. The $200 did go against our deductible - however, the way everything was structured, it would have ended up costing us more, because other services received before the therapy would also have out of pockets associated. So ti would have been $2400/yr + out of pockets from other services + insurance premiums. It was cheaper and better for Kyle that we stay in private care. EI did do his 3yo assessment so that he could get in EC preschool - and that program is excellent - no complaints on that. We're also in a different county now that has more funds - so I'm sure that's a contributing factor.

I copied the information on the Katie Beckett program for my DH, and we'll be looking in to that ASAP. We're stuck in a hard place with income levels. On paper, we appear to be doing great financially, but we live in an area with a high cost of living (chicago burbs). It's that middle class black zone where we make too much to qualify for anything, but make to little to actually afford to pay for all of this. We budget so that I can stay at home - because we can't afford special healthcare for our son if I went back to work. Plus, he has so many appts, it would be impossible to hold down a job (i'm sure you understand).

[Vinca]

12. My heart breaks for you. This damn country and its lack of healthcare for all.

I found United Healthcare's mission in an April 20, 2006 article from the MSNBC site: "One man, United Health Care’s William McGuire, could be America’s first billion dollar CEO. Some of his stock options, granted at low points in the company’s share price, came with the potential for maximum profit when the stock rose." United Healthcare's mission is to make money. The only way they can do that is to take your son's therapy and walker away, forget about teaching him to eat and put all your claims in the circular file. And they don't particularly care if you end up in a box on the street. Contact your state insurance commissioner, all of your elected representatives and Michael Moore. I don't understand how anyone can be opposed to universal, single-payer healthcare for every American.

[GardeningGal]

13. Are you keeping a log of your attempts to solve this with UHC?

If you are, I suggest contacting your state's insurance commissioner and see if they can help you.

[Kittycat]

27. We're on a PPO, not HMO - have to file against the employer with State's Atty

I already looked in to it. We backed off, given the circumstances of my husband's office being acquired. We didn't want to give them a reason to look his way when making employee cuts.

[RedEarth]

14. Download a "'SiCKO' Health Care Card" so when your insurance company says 'no,' you can say "yes'

You now have the opportunity to print and carry your very own "'SiCKO' Health Care Card." Playing the 'SiCKO' card has worked for a family in DeBary, Florida, whose daughter suffered profound hearing loss and was denied a cochlear implant. Her father sent a letter to Cigna asking, "has your CEO ever been in a film before?" Before he knew it, his daughter's denial was overturned. It also worked for a family in Flint, Michigan who was stuck with a $66,000 medical bill until they posted their healthcare horror story on YouTube. Click here to see what happened next.

Download the PDF of the card below and follow these simple guidelines:

Carry the card in your wallet with your insurance card.
If denied treatment, show your SiCKO card to your doctor/insurer.
Ask your insurer if they'd like to be in Michael Moore's next movie, DVD, or appear on MichaelMoore.com.
Tell them that, if denied, you will seek coverage from your local media.
E-mail your story to [e-mail].



http://www.michaelmoore.com/sicko/what-can-i-do/health-card/

[Wednesdays]

15. Wow, at least it's not socialized medicine

where there'd be all kinds of BUREAUCRACY and RED TAPE!

:sarcasm:

:puke:

[FooFootheSnoo]

16. Call your state insurance comissioner

They can't do this to you. Get your state senator or rep involved if possible. Don't bother calling the "customer service" number any more. It won't do you any good. I've worked in a few call centers one of which was for a large health insurance company. Customer service reps are not trained to actually help anyone. They are trained to follow a script and get you off the phone as quickly as possible so they can "help" the next customer. They are also trained to never ask their supervisor to take a call. If you do get a "supervisor" it's probably one of the rep's coworkers. Sad, but true. The only time I ever saw a supervisor get on the phone was when a state rep's office called on behalf of on of their constituents. Call centers are miserble, soulless places. Getting everything in writing or at least e-mail gives you a written record.

I'm so sorry for your troubles. I'm also a preemie mom and I know how stressful and heart wrenching it is. I agree with the above poster. Check into Medicaid and SSI. In my state the income limits are raised for preemies so that they can get the help they need, they are also considered disabled for the first year if they are under 1000 grams at birth. My daughter qualified for both until she was a year old. My daughter also had early intervention through Easter Seals which was free. We had an RN come to the house once a week and work with her. There are lots of services available to preemies.

[FooFootheSnoo]

17. here's easter seals website

I know this thread is primarily about your insurance problems, but I wanted you to have this website just in case it's something you are interested in. Our first nurse with Easter Seals was a little flaky, but the second one was awesome. You'll have to check and see if they have services available in your area.

http://www.easterseals.com/site/PageServer?pagename=ntl_early_intervention

[PA Democrat]

18. Kittycat, have you filed a complaint with your state's regulatory body?

If you live in Illinois the contact information is as follows:


Illinois Department of Financial and Professional Regulation
Division of Insurance
320 W. Washington
Springfield, Illinois 62767-0001

Phone [phone] (toll free for IL)
[phone]

Website www.idfpr.com

When my daughter was diagnosed with autism, we found that our top-of-the-line Blue Cross/ Blue Shield policy had an exclusion clause that said they would cover nothing for the treatment of autism. This is typical in the industry. We were forced to apply for Medical Assistance (Medicaid) for her under PA's waiver program that allows kids with severe disabilities to qualify for Medicaid regardless of parental income. It's outrageous that parents are forced to go this route because the for-profit insurance industry is allowed to exclude kids with disabilities in order to increase their profits.

I am not surprised that United is suggesting that you apply for Medical Assistance. It's all about profits and NOT health care for those people. I agree, it's time for single payer.

[Kittycat]

28. See post #27

http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=389&topic_id=1636813&mesg_id=1641145

[RubyDuby in GA]

20. Time to lawyer up.

Perhaps a lawyer would take your case pro-bono.

I really have no solutions for you, just a :hug:

[truedelphi]

21. My family had some horror story happenings from Kaiser here in

California- they delay delay delay and then they pretend that you could have asked for the treatments you didn't even know about when you first signed up.

Yep Universal Single Payer - bring it on.

[truedelphi]

23. What state are you in??

I'd be willing to help you call your state Attorney General's Office over this.

Sorry you are in this predicament - it's called the American Way.

[Richard Steele]

24. K&R

[OhioChick]

25. I'm Sorry to Hear About This.....

It's tough enough having a chronically ill child, let alone dealing with insurance such as UH. I speak from experience. I too, have a chronically sick kid and just recently (Thank God) switched insurance companies.......we had United Healthcare. It was a nightmare.....just as you described. I constantly had to fight with them to get bills paid for.

Maybe this has something to do with all the denial of claims....
http://www.democraticunderground.com/discuss/duboard.php?az=show_topic&forum=132&topic_id=3062484


Also, UH uses what they call "The ACN Group." I received letters from them all of time denying treatments. They're supposed to help you make the most of your healthcare. Yeah, right. :eyes:

http://www.acngroup.com/about.html

I wish you and your child the best of luck.

[Kittycat]

29. This must be what our Therapy Group was referring to.

They sent us a letter stating that they weren't going to accept UHC any more, we had to pay out of pocket because UHCs subcontractor refused to label them as a therapy provider - so all claims didn't process. After I pleaded with them, they agreed to bill, and UHC agreed to pay. Only a few sessions were covered, and now we have a bill showing that they haven't paid in since.

[OhioChick]

30. That sounds about right......

Have you ever gotten letters from The ACN Group? The ACN group will assign a specialist (within their group) to access your child's particular situation and recommend how many visits (for instance, for Physical Therapy, etc.) should be needed for your child's condition. For each therapy, they assign a different doctor....one that is in that field.

My child would need Physical Therapy several times a week, whereas the ACN Group would only allow 2 visits per month, for instance. I told them that his pain would increase should he not have the recommmended Physical Therapy as suggested by his treating physician. The ACN Group said they would only approve more visits should he get worse. They couldn't give a rat's ass........it's all about profits.

If you continue to have problems with UH and the ACN Group paying for your child's claims, tell them that you'll have to speak with your lawyer about the situation. They record calls at UH........and as soon as I made mention of this.......they began paying.

I had to eventually switch jobs to get away from UH........I was paying well over $10K a year for my child's treatments, in which other insurance companies typically cover.

Hearing your situation really pisses me off. Keep fighting them and don't give up. They WANT you to give up.

On Edit: Typo

[Raejeanowl]

31. Coverage Is Not Us

You don't really expect them to provide (payments for) health care services, do you?

United Health Care has become an abomination in all of its guises. I know from saddening, maddening, and frustrating experience. They are in the business of taking your money, and nothing more. This wasn't alway true, but apparently the current board of directors has made promi$e$ to the stockholders that they intend to keep, regardless of whether they are fulfilling their nominal mission or paying with the blood of their customers!

Other suggestions for help, besides your state insurance commissioner's office: Does your state have a developmental disability office? They may have advocacy services to help you.

If you really don't have the time and energy to search all of these down, do not hesitate to call your state legislative representative's office. Choose one, don't scatter-shot your efforts at multiple assemblymen and senators. They have staff who can advise and/or advocate for you, whose job it is to be knowledgeable about what can be done. If you don't get one moving, then go to the next.

Best wishes!