Well, we are about to undergo a major battle! We had to change insurance because of a job change, and they just denied our request for our daughter to be seen at the CF clinic. (Actually, it is pretty complicated how this works. Our medical group denied it, we need to appeal through the Insurance CO.) We should get the official denial and info on appeal next week. So has anyone been through this before? Any suggestions on what to present. I have always heard it is best to be seen at an accredited clinic, but can someone point me to a document that I can print out. Any help would be appreciated.
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Help with getting approval to go to CF clinic
- Thread starter 2005CFmom
- Start date
I have never been through something like this, but I'm thinking a well worded letter from your last doctor at the CF clinic should help. It seems like it shouldn't be very legal for them to keep you from going to an accredited facility. Oh, I know you could check with that attorney.... Beth Sufian. Does anyone have her phone number or email. I've met her, she has CF and represents people with CF related problems, she would most likely be able to give you a few pointers for free or let you know if there is something she can do for you if they deny your request.
Here is some really good information I found on the Boomer Esiason site
<a target=_blank class=ftalternatingbarlinklarge href="http://esiason.org/newsResourcesRights.html
">http://esiason.org/newsResourcesRights.html
</a>
CF Legal Information Hotline
1-800-622-0385
The Hotline is sponsored by a grant from Chiron Corporation. Individuals with CF and their families members and healthcare providers can contact the Hotline for information on the laws that protect people with CF and their families. The phone number for the Hotline is 1-800-622-0385. The Hotline is run by Beth Sufian, Esquire. Beth is an attorney who also has CF. Beth has practiced law for 14 years and focuses her practice on representing individuals with CF and other medical conditions in matters concerning Social Security benefits, insurance coverage, and long term disability benefits, education and employment. All calls to the Hotline are free and confidential.
About Beth Sufian
Beth Sufian, ESQ., a Houston, Texas lawyer with CF who specializes in laws to protect people with disabilities, will be answering legal questions pertaining to the rights of people with CF once a month.
You may send questions of a legal nature, regarding cystic fibrosis, to:
Beth S. Sufian
Sufian & Passamano, L.L.P.
811 Rusk Avenue, Suite 712
Houston, Texas 77002
Telephone: 713-224-1166
Facsimile: 713-224-1161
<a target=_blank class=ftalternatingbarlinklarge href="http://esiason.org/newsResourcesRights.html
">http://esiason.org/newsResourcesRights.html
</a>
CF Legal Information Hotline
1-800-622-0385
The Hotline is sponsored by a grant from Chiron Corporation. Individuals with CF and their families members and healthcare providers can contact the Hotline for information on the laws that protect people with CF and their families. The phone number for the Hotline is 1-800-622-0385. The Hotline is run by Beth Sufian, Esquire. Beth is an attorney who also has CF. Beth has practiced law for 14 years and focuses her practice on representing individuals with CF and other medical conditions in matters concerning Social Security benefits, insurance coverage, and long term disability benefits, education and employment. All calls to the Hotline are free and confidential.
About Beth Sufian
Beth Sufian, ESQ., a Houston, Texas lawyer with CF who specializes in laws to protect people with disabilities, will be answering legal questions pertaining to the rights of people with CF once a month.
You may send questions of a legal nature, regarding cystic fibrosis, to:
Beth S. Sufian
Sufian & Passamano, L.L.P.
811 Rusk Avenue, Suite 712
Houston, Texas 77002
Telephone: 713-224-1166
Facsimile: 713-224-1161
Alyssa beat me to it. I was going to recommend you contact Beth Sufian.
Have you been given an explanation of why they denied it, or is that what you are waiting to recieve next week? It might help us help you to post the specifics of what they said (when you recieve it).
In addition to contacting Beth (Who is a WONDERFUL person!!!!!!!), I would recommend you contact your local CF chapter as well-they might have some literature or be able to help.
Keep us posted
Have you been given an explanation of why they denied it, or is that what you are waiting to recieve next week? It might help us help you to post the specifics of what they said (when you recieve it).
In addition to contacting Beth (Who is a WONDERFUL person!!!!!!!), I would recommend you contact your local CF chapter as well-they might have some literature or be able to help.
Keep us posted
Thanks for the responses. Don't know for sure, but basically the CF clinic is not in our group (although the hospital it is at is affiliated with our group) so they want us to go a Pulmonary Doctor in our group. (I think it is just to save $$) Everyone we talk to seems to understand and agree with us, but they don't make the decisions. We got the name of the dr they want her to be treated by. My husband is going to talk to him (or atleast try) on monday...ask how many CF patients he has/had...what other experience in CF...and ask him if it was your daughter, wouldn't you demand that she be seen at an accredited CF center? Basically try to get him to decline her care, that way they are more or less forced to send her to the CF clinic. If he doesn't decline with use of mere logic we will resort to use of threat. Basically if he agrees to take her case, and her health declines, we will pursue a malpractice law suit (hopefully we won't have to resort to this). But my husband says that if he gets a chance to talk to the doctor, the doctor won't want to have anything to do with us! I hope this all makes sense, it's hard to think straight when I'm so mad. If we don't seem to get anywhere, we will contact Beth Sufian.
Thanks again, and I will keep you informed on what is happening!
Thanks again, and I will keep you informed on what is happening!
Teri,
While I understand your frustration I would caution you about nasty conversations with the doctor your husband wants to talk to -- don't burn any bridges just in case this is the person who does end up treating your daughter. Don't get me wrong.... I think you have <b>some very valid concerns and you should by all means discuss them with that doctor </b>in the hopes he will become your advocate, but I really hope you would not have to threaten malpractic (which isn't as easy to prove as it sounds and causes a whole lot of greif & stress) or have him "not want anything to do with you" as a result of his encounters with you and your husband.
Keep up the good work, I have found that when dealing with insurance companies you need a whole lot of patience and be very persistant. Just keep pounding on them.
Best of luck!
While I understand your frustration I would caution you about nasty conversations with the doctor your husband wants to talk to -- don't burn any bridges just in case this is the person who does end up treating your daughter. Don't get me wrong.... I think you have <b>some very valid concerns and you should by all means discuss them with that doctor </b>in the hopes he will become your advocate, but I really hope you would not have to threaten malpractic (which isn't as easy to prove as it sounds and causes a whole lot of greif & stress) or have him "not want anything to do with you" as a result of his encounters with you and your husband.
Keep up the good work, I have found that when dealing with insurance companies you need a whole lot of patience and be very persistant. Just keep pounding on them.
Best of luck!
We have a nonaccredited CF clinic in our town, so it's impossible to get a referral to a regular accredited CF clinic in the City 250 miles away unless things get really really bad and you need a lung transplant. We got a referral when DS was born because the peds surgeon was on vacation and he needed surger to repair his bowel obstruction; however, the timeframes for the referral out of network limited to only a few months. So we go out of network a few times a year and go to the accreditted CF clinic, but have xrays, labs -- bloodwork and cultures done locally. We don't really pay anymore for office calls going out of network, just a larger percentage if DS needs something extra -- at that time we would ask for a referral.
Insurance companies are rule-driven and bureaucratic by design so I'd advise avoiding turning it into a battle until you've exhausted the procedural steps of an appeal. I've worked 23 years for a bureaucracy and see first hand how hard it is to find someone to ignore or override a rule even when it is a dumb rule - but even more so when they get put on the defensive right out of the gate. The best way past red tape is to find an ally in the company who wants to help you solve the problem, which usually means getting past the line-level claims reviewers and up at least a couple levels into management.
If the stated reason for rejecting the request is that the CF center is not in the group, I'd say the place to start is to find out what if any exceptions are permitted for going outside the group and work with the Dr (or more importantly their insurance claims folks) to develop a description of how your situation qualifies for an exception. Save the threat of litigation in case you hit a brick wall.
If the stated reason for rejecting the request is that the CF center is not in the group, I'd say the place to start is to find out what if any exceptions are permitted for going outside the group and work with the Dr (or more importantly their insurance claims folks) to develop a description of how your situation qualifies for an exception. Save the threat of litigation in case you hit a brick wall.
Okay, here is the update. I read your suggestings and agree that threatening is not the best. But that was my first instinct to try to get care for my daughter and I had posted shortly after hearing about the denial so I was still very steamed! Anyway...we have not been able to speak with the Pulmonary doctor they want to send her to, but we have been informed that even if he refers her to the CF clinic there is no guarantee that would happen... the group may just decide to send her to another Pulmonary doctor within the group..GRRR! So even getting the doctor to agree with us will be of no help. And if we thought we were only going to have to go through this struggle one time, I might feel the struggle is worth it...but I have a feeling that this medical group will be a pain the whole way through!
Now for the good news. My husband's boss could tell how frustrating it was for us to be dealing with this...and there is a second insurance carrier for some of the people at the company (It just so happens to be the same insurance we had before the job change. It was not an option for us to take, otherwise we would have.) Anyway, his boss let us know that he has received approval for us to change insurance carriers! So as I type, the HR department is trying to find out when we can make the switch, but at the latest it would be June of this year. So in the mean time, we will go with the flow where we are at, and make then change to the new company. Just wanted to let you know what was happening. And it is nice to know my husband is working for a company that actually cares about their employees.
Now for the good news. My husband's boss could tell how frustrating it was for us to be dealing with this...and there is a second insurance carrier for some of the people at the company (It just so happens to be the same insurance we had before the job change. It was not an option for us to take, otherwise we would have.) Anyway, his boss let us know that he has received approval for us to change insurance carriers! So as I type, the HR department is trying to find out when we can make the switch, but at the latest it would be June of this year. So in the mean time, we will go with the flow where we are at, and make then change to the new company. Just wanted to let you know what was happening. And it is nice to know my husband is working for a company that actually cares about their employees.
Thanks for the update -- that is good news !
Yes, I can understand still being steamed after just receiving the denial !! Been there just today after getting a notice from a medical supplier saying they were going to turn out account over to collections in 10 days -- I have been telling them for 3 months now that the insurance company was working on re-processing the claim and each time they told me "oh don't worry about, the statments get sent out automatically... we will make a note" Well.... come to find out my insurance company wasn't working on reprocessing the claim all along !!! Grrrrr! another 15 business days ......
Anyway, I'm glad to hear about the new/old insurance company being a possibility for you now.
Yes, I can understand still being steamed after just receiving the denial !! Been there just today after getting a notice from a medical supplier saying they were going to turn out account over to collections in 10 days -- I have been telling them for 3 months now that the insurance company was working on re-processing the claim and each time they told me "oh don't worry about, the statments get sent out automatically... we will make a note" Well.... come to find out my insurance company wasn't working on reprocessing the claim all along !!! Grrrrr! another 15 business days ......
Anyway, I'm glad to hear about the new/old insurance company being a possibility for you now.