Pajama Mama Posted November 18, 2009 Share Posted November 18, 2009 I am so upset, scared, p@ssed, etc. Our insurance is denying my son's food. He is 100% tube fed and has been for 7 yrs. I understand that his formula is expensive. I agreed to a trial of a cheaper formula that he used about 5-6 yrs ago even though it would probably NOT work for him. But the cheaper formula is considered over the counter so the insurance then denied THAT formula. The cheaper formula is one that *I* can't find OTC because we need unflavored. Follow this Catch-22. They denied his tube formula because they wanted us to try an OTC formula to prove that he needs the expensive formula. They then denied the OTC formula because it's OTC. We cannot find that formula OTC and all pharmacies we've called say that it cannot be bought or ordered from a regular pharmacy. Sigh. I have calls into the appeals dept of our insurance, our parent advocate and ds's doctor. Luckily, I order ds's supplies early so I always have a surplus. But we are now using the surplus and have about a week or so left of his food. Any prayers or good thoughts would be appreciated. Quote Link to comment Share on other sites More sharing options...
Jean in Newcastle Posted November 18, 2009 Share Posted November 18, 2009 Praying here. Be that squeaky wheel. Will your Dr. be able to advocate in your behalf with the insurance company? Quote Link to comment Share on other sites More sharing options...
Mrs Mungo Posted November 18, 2009 Share Posted November 18, 2009 Appeal, have your doctor try and intercede. I'm sorry, insurance problem really suck, especially when it's your child's health at stake.:grouphug: Quote Link to comment Share on other sites More sharing options...
Pajama Mama Posted November 18, 2009 Author Share Posted November 18, 2009 I will not go away. I told the lady with my insurance that I will not stop calling. She was very nice because I made a point of apologizing to her in advance for any rudeness on my part. The folks who answer my calls have nothing to do with a decision to deny something. But being polite makes those people try harder for me. I do think this will be resolved. I've made it clear that I have no problem calling a lawyer or the local TV station if I need to. The insurance company would look really bad on the 6 o'clock news denying a severely disabled child's only source of nourishment. This was the same insurance earlier this year that denied ds's TMJ surgery as "elective". When faced with the numerous letters from my son's doctors they approved it. The problem I have is that this is food that we will run out of soon. I can't wait out the 30 day appeal process this time. I will haunt them until I get what my son needs. Quote Link to comment Share on other sites More sharing options...
SandBeach Posted November 18, 2009 Share Posted November 18, 2009 My son had EE and he had a special formula prescribed. He no longer needs it, and we have extra. If you PM me with the name of the formula, maybe I can get you some. I have Neocate and Elecare. Sandy Quote Link to comment Share on other sites More sharing options...
elegantlion Posted November 18, 2009 Share Posted November 18, 2009 Hugs and prayers coming your way. :grouphug: Quote Link to comment Share on other sites More sharing options...
nova147 Posted November 18, 2009 Share Posted November 18, 2009 The problem I have is that this is food that we will run out of soon. I can't wait out the 30 day appeal process this time. I will haunt them until I get what my son needs. Can your doctor direct you to a resource that could give you an emergency supply? Or perhaps the company that makes it has a program? I'll keep you in my prayers! Quote Link to comment Share on other sites More sharing options...
Rosie_0801 Posted November 18, 2009 Share Posted November 18, 2009 How do they forget that their clients are people? That's something you'd think everyone would take for granted, huh? :grouphug: and best wishes... Rosie Quote Link to comment Share on other sites More sharing options...
Sputterduck Posted November 18, 2009 Share Posted November 18, 2009 I am so sorry! Insurance almost denied me something today that would cost me nearly 800 dollars a month. Eek. Also, my son has a skull fracture and needed a ct scan when he was an infant and it took insurance a month to approve it. Meanwhile, my son was crawling around with a broken head. It was very scary. When it's your child and something is very wrong, it is so much harder. Can you call the manufacturers of the rx formula? I know that some companies will help out someone in need for good p.r. Quote Link to comment Share on other sites More sharing options...
littlebug42 Posted November 19, 2009 Share Posted November 19, 2009 Make sure you put your appeals, etc in writing. I have had problems with insurance jerking me around over stuff regarding my daughter and the phone was just endless people with different stories and reasons for denial. After I made my written appeal, including names and dates of all people spoken to, I won. I pray you get it all worked out soon. Quote Link to comment Share on other sites More sharing options...
melmichigan Posted November 19, 2009 Share Posted November 19, 2009 I agree, an appeal written and faxed to a supervisor with report of reciept. There should be an address if a fax isn't accepted. You can always keep calling, but often appeals must be done formally in a written manner. Read the fine print on your EOB's to see your plan policy. Keeping our fingers crossed they come to their senses quickly! :grouphug: Quote Link to comment Share on other sites More sharing options...
Guest myfourblessings Posted November 19, 2009 Share Posted November 19, 2009 Hi, I am a former account mgr for an insurance company. My advice to you is to go to your benefits manager, or, better yet, your company president or "insurance decision maker" and let them know what is going on. He or she needs to place a call to the sales representative or the director of the local office and very nicely ask that someone take care of it ASAP. They need to be polite but direct. Insurance companies do not like to lose accounts. You could also ask your physician to fax an emergency appeal. Also, check your policy for an appeals process. Document names, dates, times, and nature of the conversation each time you speak to someone, and try to talk to a manager. It is better to do everything in writing, or at least follow up the phone calls with a letter. It is important to be calm and polite. There are people in the insurance company who will take up your case and personally go to bat for you. I was one of them! :grouphug: Quote Link to comment Share on other sites More sharing options...
sunshine Posted November 19, 2009 Share Posted November 19, 2009 I don't know if you thought of medicaid for this? I know you have private insurance but in this case you may be eligible for the medicaid benefits. I would call someone just to check. You may have to deal with this over and over if the company is trying to tighten it's belt and cut costs. Usually the sickest or most costly patients seem to be the ones they try to cut first. So, for my child's sake I would start looking into other options in case something happens permanently. This is one area where Federal regulatioins should be clear. It should be criminal to deny a child or a helpless person nourishment. Quote Link to comment Share on other sites More sharing options...
Blessedfamily Posted November 19, 2009 Share Posted November 19, 2009 Hi, I am a former account mgr for an insurance company. My advice to you is to go to your benefits manager, or, better yet, your company president or "insurance decision maker" and let them know what is going on. He or she needs to place a call to the sales representative or the director of the local office and very nicely ask that someone take care of it ASAP. They need to be polite but direct. Insurance companies do not like to lose accounts. You could also ask your physician to fax an emergency appeal. Also, check your policy for an appeals process. Document names, dates, times, and nature of the conversation each time you speak to someone, and try to talk to a manager. It is better to do everything in writing, or at least follow up the phone calls with a letter. It is important to be calm and polite. There are people in the insurance company who will take up your case and personally go to bat for you. I was one of them! :grouphug: This is good advice. Maybe they will listen to the person who chooses insurance for the company. It might hold more weight. We had this issue with Neocate, but dd ended up not needing it. :grouphug: Quote Link to comment Share on other sites More sharing options...
LNC Posted November 19, 2009 Share Posted November 19, 2009 I have had two children w/ tube feedings for the last 15 years. We have had a variety of insurance plans and none have denied Pediasure,though you can buy it over the counter.It is coded as a "medical food"bc of the tube feeding. I hope this is resolved quickly! Quote Link to comment Share on other sites More sharing options...
Ottakee Posted November 19, 2009 Share Posted November 19, 2009 If you don't already have it, call your local health department about Children's Special Health Care Services or try disability. Either of these will get you medicaid which then should pay for the formula. I don't know if it was the expensive kind or not but I know that when we had a foster child that was tube fed medicaid picked it up with no problems and even sent it to our house. Quote Link to comment Share on other sites More sharing options...
Dayle in Guatemala Posted November 19, 2009 Share Posted November 19, 2009 I often wonder why they have the right to play with a child's life like that. I hate that they sit in their offices, get paid what they do, and make life and death decisions for people they have never met. I often wonder if they knew these people personally would the outcomes be different? :grouphug:I'm sorry you are going through this stress. I wish you didn't have to. Quote Link to comment Share on other sites More sharing options...
Haiku Posted November 19, 2009 Share Posted November 19, 2009 Unfortunately, I am not surprised. Our insurance company forces us to get our daughter's medicines at a mail-order pharmacy because, they claim, the discount they receive there saves them a lot of money. (I've checked: the discount is 2.2%.) Four times now we have had problems with the mail-order pharmacy sending the wrong meds or sending them late (even when I call early to re-order). I finally asked for an "override" so that we could get the meds at the pharmacy around the corner, where we get my son's meds. They denied us. This month I bought my dd's meds without insurance assistance, to the tune of $1700, so she would have them on time. Tara Quote Link to comment Share on other sites More sharing options...
Pajama Mama Posted November 19, 2009 Author Share Posted November 19, 2009 The GI doc called this morning to say that his original food was approved. I asked the reason for the change of heart. The insurance claims that they did not realize the food was for a tube feeding. My son has been on tube feedings for 7 yrs--4 with this insurance. So besides the monthly food supplies: feeding bags, other items and a feeding pump should have clued them in. They knew he was tube fed. They just weren't expecting me to be so aggressive. I told them how horrible they would look on a news report denying a special needs child his food. Ds does have Medicaid as his secondary insurance. But they denied the claim as well. The medicaid is the same company as our private insurance. I'm glad they came to their senses though. I wasn't sure where to turn next. My son's food is about $1500 per month. I would never been able to afford it. Thank you all for your advice, prayers and good thoughts. I appreciate it greatly. Quote Link to comment Share on other sites More sharing options...
Pink Fairy Posted November 19, 2009 Share Posted November 19, 2009 I'm sorry you had to go through the stress of making them do the right thing. Life would be so much easier if people just did the right thing in the first place. :grouphug: Quote Link to comment Share on other sites More sharing options...
sassenach Posted November 19, 2009 Share Posted November 19, 2009 Wow, as the mom of a 100% gtube fed child, I was freaking out for you! I'm so relieved that you got the approval, but p*ssed that they even tried to deny something as vital as your child's food. Good job Mama! The GI doc called this morning to say that his original food was approved. I asked the reason for the change of heart. The insurance claims that they did not realize the food was for a tube feeding. My son has been on tube feedings for 7 yrs--4 with this insurance. So besides the monthly food supplies: feeding bags, other items and a feeding pump should have clued them in. They knew he was tube fed. They just weren't expecting me to be so aggressive. I told them how horrible they would look on a news report denying a special needs child his food. Ds does have Medicaid as his secondary insurance. But they denied the claim as well. The medicaid is the same company as our private insurance. I'm glad they came to their senses though. I wasn't sure where to turn next. My son's food is about $1500 per month. I would never been able to afford it. Thank you all for your advice, prayers and good thoughts. I appreciate it greatly. Quote Link to comment Share on other sites More sharing options...
Dayle in Guatemala Posted November 19, 2009 Share Posted November 19, 2009 The GI doc called this morning to say that his original food was approved. I asked the reason for the change of heart. The insurance claims that they did not realize the food was for a tube feeding. My son has been on tube feedings for 7 yrs--4 with this insurance. So besides the monthly food supplies: feeding bags, other items and a feeding pump should have clued them in. They knew he was tube fed. They just weren't expecting me to be so aggressive. I told them how horrible they would look on a news report denying a special needs child his food. Ds does have Medicaid as his secondary insurance. But they denied the claim as well. The medicaid is the same company as our private insurance. I'm glad they came to their senses though. I wasn't sure where to turn next. My son's food is about $1500 per month. I would never been able to afford it. Thank you all for your advice, prayers and good thoughts. I appreciate it greatly. Yay! I'm so glad it worked out. :grouphug: Quote Link to comment Share on other sites More sharing options...
Sputterduck Posted November 19, 2009 Share Posted November 19, 2009 Woot! I'm glad they changed their minds! I think mentioning the news report was a good idea! Good job fighting for your kid. :) Quote Link to comment Share on other sites More sharing options...
Blessedfamily Posted November 20, 2009 Share Posted November 20, 2009 I just checked in to the thread to see how this worked out. :001_smile: Quote Link to comment Share on other sites More sharing options...
sheryl Posted November 20, 2009 Share Posted November 20, 2009 I am so upset, scared, p@ssed, etc. Our insurance is denying my son's food. He is 100% tube fed and has been for 7 yrs. I understand that his formula is expensive. I agreed to a trial of a cheaper formula that he used about 5-6 yrs ago even though it would probably NOT work for him. But the cheaper formula is considered over the counter so the insurance then denied THAT formula. The cheaper formula is one that *I* can't find OTC because we need unflavored. Follow this Catch-22. They denied his tube formula because they wanted us to try an OTC formula to prove that he needs the expensive formula. They then denied the OTC formula because it's OTC. We cannot find that formula OTC and all pharmacies we've called say that it cannot be bought or ordered from a regular pharmacy. Sigh. I have calls into the appeals dept of our insurance, our parent advocate and ds's doctor. Luckily, I order ds's supplies early so I always have a surplus. But we are now using the surplus and have about a week or so left of his food. Any prayers or good thoughts would be appreciated. I hate that for you. Your plan of action is good. I'd add to that social workers with the hospital. Also, try your state ombudsman (I know this is spelled wrong). And, have your dh's company write a letter (assuming they would agree to do this) and go into battle on your behalf. I had some kind of athlete's foot that was systemic and I needed lamisil tablets. Now, I was scared to take this because it is a very potent drug, but nothing else would clear it up. Insurance denied it. I was perplexed because I clipped off toenail shavings, took to the dr per their request to do so, and it came back positive. My doctor wrote a letter to insurance. What got the ball rolling was this. My dh's employer took over this battle and basically told insurance that they (dh employer) would foot the bill. Ins coverage is only as good as the specific policy the company purchases. It really is company=specific coverage. I hope this helps. I'd persevere. Quote Link to comment Share on other sites More sharing options...
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