Insurance

Get help finding a doctor or discuss questions about/difficulties with your insurance or employer.

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Insurance

Postby NBogue » May 22, 2007 7:25 pm

Not sure where to post this, but I have an insurance question. Can your insurance company decide to stop paying for Matria even if your OB says you need it and so does Matria? Cigna is threatening to not approve treatment, but I am wondering what my recourse is. I started trying to wean yesterday morning (I am already getting queasy, but we can't afford $500/day) just in case they do deny it on 6/1. Has anyone gone through this? Any resources? Thanks for the help!
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Postby kyatksn » May 22, 2007 7:50 pm

Do you have an insurance case manager that is working on your case? I have nurse case manager that reviews my case for the insurance company- she is the go between me, my doctor, Matria, and the insurance. There has to be something someone can do for you! The other thought would be speaking directly to accounting at Matria and seeing if there is something they can do- maybe writing off/discounting your care. I don't know if they would do something like that, but I know that drug companies have programs in place that help out when patients have insurance issues.

Good luck!! As if the stress of this is going to help your weaning- talk about instigating an HG flare up!!
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Postby NBogue » May 22, 2007 8:23 pm

The insurance case manager is the problem. Everyone at Matria knows her. Apparently she used to work for them and they parted, but not on good terms. According to Matria she makes it hard on all her patients that have HG.
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Postby kyatksn » May 22, 2007 8:46 pm

Oh that isn't good!!

Could you request a different one? Does your/your husband's employer (whoever carries your insurance) have a Benefits Coordinator? My husband's employer contracts a third party, a company called Corporate Benefit Consultants. That company has a Consultant that is specifically assigned to employees of his company- she is the one that goes to bat for the employee if there is an insurance issue. She has gone head to head w/ our insurance several times to fight things, and has always been successful. If you don't have someone like that available for you, what about going right to Human Resources and letting them know of the situation. Maybe someone in benefits for HR can get in touch w/ the insurance and request a new case manager review your case.

I just can't believe that you have to deal with this. I mean, come on, they have had you on it, and paid for it this long.... and now that you are rounding the last bend of this pg they are going to take it away from you?!?! RIDICULOUS!!! I wish I could share pump/meds w/ you :lol: .

Are you at least introducing oral Zofran as you attempt the wean from the pump? I wonder if that would at least get you through. Although I am kind of doubting it if you are still at such a high dose via the pump at this stagge of the game, orals aren't going to even touch it.
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Postby mammaclare » May 22, 2007 10:12 pm

Shorrt answer is yes, they can deny it despite the OB and Matria--just like when a patients' doctor says they need a heart transplant but their insurance won't cover it, or some other extreme example.

Long answer would be starting an appeal, but those can run for a long time and you'd need to know if you were to WIN an appeal, will Cigna then be required to cover it all retroactive to when they stopped paying (benefits at the employer is a great place for this info too). Otherwise even if you DID win an appeal, but it was after 6 weeks of fighting, you may still have 6 weeks worth of Matria bills to have to pay.

Drug assistance isn't for something like home health, and is only for those w/ both a low enough income AND no prescription insurance...and they also only cover actual prescription meds. Home health/pump/IV meds aren't billed under the pharmacy benefit but under the healthcare benefit. Also, since Zofran isn't officially approved for pregnancy/HG then Glaxo will not and really can't (liability) provide free. Sorry.

I like the idea of both asking Cigna (demanding?) for a new case manager, AND calling your employer. Often if an employer makes enough noise, the insurance carrier will bend on something...Cigna won't want to lose the business of that employer in the end and so are more likely to bend a bit. Another suggestion would be to call Cigna (not a direct line to the case manager, but the "general" line) and ask for whomever supervises all the case managers.

:hugs: :hugs:
Clare
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And Kieran Alexander 12-15-06
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Postby JasmineHG » May 23, 2007 5:18 am

i had to push off the pump issue (until it was either that or the feeding tube) due to cost---even with insurance. Matrai does give big discounts- i think i got it like at a 60% discount. Now here is the kicker- they charge insurance the full rate but breakdown what you have to pay. (stick it to 'em!) but i guess that won't help you since you can't even get them to OK your treatment. Can you demand a new case manager? Go up the chain- don't stop!!! i will be reserving your room for you at the HG hilton!
Severe HG survivor and major Colts fan!
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Postby Princesshood » May 23, 2007 9:50 am

:hugs: :hugs: :hugs: :hugs: :hugs: :hugs:
:hugs: Sara
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Postby JennyK » May 23, 2007 11:28 am

Go for a new case manager!

I had very poor home health coverage. My doctor told my ins co that without better home health coverage I'd be in the hospital four out of every seven days. They immediately agreed to pay 100% of my home health costs since it is obviously cheaper than in-patient care.

Ins co's care about money, so help them see why the pump is actually saving them money.
Jenny
Annie, January '04
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Postby krdoty » May 23, 2007 11:30 pm

I agree with the others that you need to go up the chain of command. Definitely contact your HR department to let them know of the issue. Has the Matria office filed a complaint with Cigna? Ask for supervisors. Get the name of this woman's supervisor and send a certified letter so they have to sign for it.
Kendra, M.W.F.E.
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Postby MichellevsHG » May 24, 2007 6:35 pm

:evil: Insurance companies ONLY care about money - "how much will it cost THEM" is their main attitude. I find it appauling that THEY dictate our healthcare, NOT our doctors. I can only blame our government for this debacle. :twisted:

I agree with the others. Contact your HR person to tell them the issue and see who their insurance contact is. Someone (you or HR) needs to communicate the issue to this contact person. Let this person know that Matria has a negative history with her and she continues to make things difficult for Matria patients.

Ok, I'm off my soapbox now. :wink:
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Loss, 9/17/13 (11w6d), Aggressively treated severe HG from 5w - 5% weightloss in 6 days, IV protonix/fluids/zofran @ 8w; zofran pump, benedryl, phenergan, zantac, baby aspirin

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