Insurance refusing to pay!!!

[mrjmom]

Hello everyone. I haven't been on in awhile. I have been taking the meds the GI put me on but my insurance refuses to pay for the Remicade stating my GI is doing a "top down approach" It is so frustrating. We have appealed to no avail. So My GI decide since they refused to pay for the Remicade treatments (after I had already had 2) that she would put me on 6MP. But now the insurance co. is dragging their feet on a pre-dertermination to see if they will pay for the liver test that is required before starting 6MP. The insurance siad no pre-D is required but that is what they said about the Remicade and then refused to pay and I am now stuck paying $3700.00. I called them today and they said it could be 30-45 days before the pre-D is done. Meanwhile I haven't had anything but Pentasa since Dec.29. I felt like up until today I was ok without any other meds even though my fistula has been bothering me it's not out of control. Then I went to the bathroom today and it was bleeding like mad. Has anyone else dealt with problems with insurance not wanting to pay for meds? I don't know what to do any advice would be helpful. P.S my seven year old son was tested for Crohn's. He does NOT have it
Thanks, mrjmom

 

[My Butt Hurts]

Yikes! Well - great news about your son at least!
My insurance wouldn't pay for Cimzia or a double shot of Humira until I tried Remicade first. But I have never started a med without prior approval. I'm surprised in fact that they let you start the Remi without a referral number.
Duh - you NEED a blood test before starting 6mp, no? (Idiots) I have never had a predetermination for blood tests though. The doc just sends me with lab sheets like he's giving out candy. Hmm...
Good luck with everything.

 

[mrjmom]

With our insurance no pre-cert. or pre-det. is required. and the blood test for the 6mp is a genetic liver test and a liver enzyme test. I am not worried if they will cover the enzyme test I am concerned about the genetic test cuz we have been round and round with them over this with my son. They will pay for diagnostic testing not genetic testing. But if they want me to try something else first you would think they wouldn't be such hardasses about the testing to determine if I can take it. I PRAY the Gov. does something about insurance coverage for people with cronic illness.

 

[D Bergy]

If your policy does not specifically exclude this test and is is usual and customary before using your medication, they should pay.

Insurance companies count on wearing you down even if they are obligated contractually to pay. If there is no exclusion, your doctor makes the determination as to what medication you should be on.

If they refuse to pay, and no exclusion exists, call or write your state insurance commissioner. That will usually get things moving fast. They do not like to be under the state spot light. We do medical billing for a living. Don't let them buffalo you.

Good Luck

Dan

 

[mrjmom]

Dan, thanks so much.
Considering the info you just gave me should I then go the the state insurance commissioner regarding the Remicade treatment they are refusing to pay for? I had met my 2008 deductible and it should have been covered 100%. They are deeming Remicade "not medically necessary" because my GI has not tried anything else first. Now the funny thing is I had 2 treatments in Dec., they paid for the first one but not the second. I spoke with someone in the claims department and she said it was a mistake it should not have been paid. I feel helpless.

 

[D Bergy]

I would ask the insurance commissioner if the insurance company has the right to decide your medical treatment. Explain the situation as you have here. If not, then what grounds do they have to refuse to pay?

I do not know what the answer to that question is state by state, but I suspect it is going to be in the doctors favor, and therefor they would be obligated to pay.

From a common sense point of view, if they are going to decide your treatment based on coverage, then you should be going to the insurers office, not the doctors. If you put it in that context, they will get the point.

If that treatment is not excluded in your policy they have a contractual obligation to pay, whether they tell you that or not. You may want to call the insurer first, try to resolve it again and if they refuse to cover the medication simply say: " Can I have your name?" They will either give it to you or ask why you want it. Then you tell them:
"I guess I really have no other recourse than to file a complaint with the state insurance commissioner and I want to know who he/she should contact." If you know the name of the commissioner it will be more convincing.

That may end the problem right there and then, but if it does not, follow through. They will put a note in your file that you called the commissioner once before. They will be more reluctant to try deny further claims in the future.

Dan

 

[mrjmom]

Dan,
You have been a blessing. I have been running over and over this in my head about how I could try to get it resolved. For the record I live in Cincinnati Ohio. I feel like after as much as I pay for medical coverage I should have coverage you know? Anyway I am going to get right on this tomorrow. Thanks again soooo much

 

[Stleger88]

I hope you get everything sorted out, insurance companies are really a pain, they seemed more inclined to pay for my meds when i started alternative medicine though? not sure guess cause its cheaper lol

I have tried 6mp, I hope it works for you, the side effects for me so serious I couldn't go past the first dosage

 

[D Bergy]

My insurance should not pay for my LDN on three different counts.

1) It is not approved for use with Crohn's.

2) It is experimental.

3) Compounded drugs are supposed to be compounded at their contracted
pharmacy. But they do not do LDN.

They pay it anyway. I think it is such a small cost they do not care. They may also realize that standard Crohn's medications are much more expensive.

Dan

 

[Sojourn]

When I was first diagnosed, my GI told me that we would have to try all other drugs before I could be approved for Remicade unless my condition worsened or it began to fistulize. But that was a few years ago and now many GI's are using Remicade right at the start, or the "top-down" approach.

I think you have a good case because you mentioned that you have a fistula. I can't think of any good reason that Remicade would not be approved for fistulizing Crohn's. And I don't know the industry, but of the manuals I've read for a few different policies I've been on, Fistulizing Crohn's was an automatic qualifier for Remicade or any other of the biologics.