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Getting insurance to cover treatment for a child. Anyone been successful?

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Have any of you successfully convinced an insurance company to continue coverage for a treatment for one of your dc?


Some background: Ds11 was has pretty major eye issues including pediatric glaucoma that make his vision somewhat precarious. He was born with cataracts and has had four pretty major eye surgeries including two at Duke Hospital one of which was planned, but turned into emergency, vision saving surgery.


His glaucoma specialist is at Duke University Hospital and is one of the top glaucoma researchers in the world. She is on a first name basis with my child and came in twice, in the middle of the night, to meet us at the eye center when my son had complications after one of his surgeries.


It is treatment by this doctor that our insurance has decided our son doesn't really need. There want his to stop seeing her and see someone at UVA... and I am sure they are good, but no one there has been his doctor since he was six. :(


The insurance company has let us know that they will stop covering his trips to Duke in January. How do I get them to change their minds? If we have to, we will pay out of pocket for his continued treatment, but financially, that could break us. Why does this have to be so $$#$# hard?

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Contact the doctor at Duke and tell them what is going on. They will most likely work with you in some fashion. Also, I would check and see if your insurance *can* do what they are doing. I am assuming Duke is out of network? Do they cover out of network? And they have covered this doc at Duke for 5-6 years, so why are they stopping now?


I would not take just being told you can't.

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I know with my PPO if it's a continuing dr/patient relationship, there are grounds for getting them to cover it as in-network.


I agree about talking to the dr's office and seeing if they know any way to work with/around it. Do you have a PPO or an HMO?

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Are they trying to switch you to an optometrist, or just a more local physician?


First, get the doctor at Duke to send them a letter explaining the medical need, and make sure you get a copy.


Then get on the phone and demand that they explain to you why they believe this treatment isn't medically necessary. Quote from the doctor's letter. Use those big words with confidence, because the person you're speaking with has a lot less knowledge of your child's medical condition than you do. If your insurance company uses a research/review process, demand that they submit this for review. And keep moving up the chain. When you've reached an impasse with one person, insist on escalating to the next level, whether that's their supervisor or a different department.


If this is employer-based coverage, you may also be able to get some help from them. Usually there's a liaison of some sort in HR who can put pressure on the insurance company. If your company is self-insured, as many large companies are, your employer may actually be able to make the final call. Companies that self-insure often use an insurance company to administer the program, but technically the insurance premium money pot belongs to the company.


We recently successfully fought to get my daughter's ophthalmologist covered. Her diagnosis is bilateral refractive amblyopia secondary to astigmatism. They wanted her to switch to an optometrist, which we'd have to pay for out of pocket. In the past, after informing them that untreated amblyopia is the leading cause of organic low vision (a type of blindness), they'd capitulate, but this time they were more stubborn.


After much hassle, it was determined that the world "refractive" was the problem. Because surgery to correct refractive error is not covered by insurance, even though we aren't considering surgery, any diagnosis with the word "refractive" is automatically rejected. They would prefer that it be submitted under an alternative name: anisometropic. What genius.


All this to say that you really need to find out exactly why the claim is being denied. It could be something silly like word choice.

Edited by jplain
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We dropped our insurance because of issues like this. Every time we needed to use the insurance for our children the insurance company would not cover it. They always had an excuse. Like it was a non coverable item or it was preexisting and such. Like my oldest had a few ear infections that just would not go away, well since it was something he had a continued problem with they considered it a preexisting condition and would not cover anything with them, not even when he needed tubes in his ears. So, I figured we were spending $500 a month on insurance premiums on insurance that would not cover what we needed then having to pay for the doctors anyways, it was time to drop it.

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More info: Insurance is a PPO (I think) Would you believe that my insurance card doesn't say?


We were forced to change insurance providers when Dh's work switched to a cheaper carrier last year. LONG story. His boss was basically taken by an insurance rep who was fired weeks afterward. He was getting kickbacks from the company that we are now stuck with.


Dh works for a very small company, less than 15 employees. We told them at the time of the switch that they would cover the treatment , which was post-operative at that time, as in-network for a year and then we would revisit it.


It infuriates me. DH's boss was convinced to switch from Anthem BCBS (who were not wonderful, but who at least covered Duke as "in network") to a tiny "local" company. Turns out that "local" company has its offices in Ohio. :glare:

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Unfortunately, I have some experience in this area. My insurance denied to continue covering my daughter's tube feedings a few years ago. First thing...they deny stuff to find out who is willing to roll right over and take it. They save a lot of $$ that way, simply because people won't fight them. Don't be that person.


I wrote a lengthy letter, making it obvious that I wasn't some dingy idiot...I explained my child's history and diagnosis and the connection to the treatment. I obtained and attached related medical records. I got letters from specialists that backed up our side.


It didn't take long for them to back down after that. I think making it obvious that you mean business will change their approach many times. Good luck!

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Are there medical reasons to stay at Duke or is it just your relationship with the doctor? If you can get the same services from UVA, then its highly unlikely that the insurance company will cover Duke as in-patient. If Duke offers treatment that you can't get at UVA then you might have a chance to get in-network treatment of those procedures.


Ten years agoMy dad was in clinical trials for erbitux in LA (he lived in MO); insurance paid for the administration of the drug but not for basic cancer care b/c UCLA wasn't in network--never mind that only three places in the whole US offered the drug at the time (UCLA, Sloan Kettering and somewhere in NY none of whom were in network).


Unless its for emergency room services I have never had luck getting coverage for out of network medical expenses. I've had a fight for er expenses as well--always had to contest denial of benefits.


I'm sorry. Any chance your DH's company might go back to BCBS?

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