Friday, March 29, 2013

Taking on Health Insurance Companies - David vs Goliath

How do you navigate your health insurance?  This is a question many haven’t really faced recently, given the changing climate of health insurance, with the implementation of the Affordable Care Act of 2010. It’s important as consumers each of us understand how to ensure we received both coverage and payment for services covered under the plans we sign up for as individuals, through our employers, or via government offered insurance. 

One of the biggest challenges for consumers is navigating the claims process. Most consumers of health insurance expect that their doctors will submit their claims for them.  Some doctors will do this, and an additional fee is included in the doctor’s overhead fees.  However, many consumers are now finding that many of their doctor’s are no longer submitting claims for them.   However, this isn’t the biggest challenge for consumers.

Advocating with your health insurance company for payment for services that should be covered under your insurance plan is. Ensuring you receive payment for medical services covered by your plan and rendered by your doctor is something that consumers have been fighting since HMO’s became the standard for health insurance and care in the mid-1980’s.

We’ve all heard stories on the news about health insurance companies denying claims for treatment of serious diseases, some denials having serious consequences.  Here’s a short article from US News & World Reports about how Health Insurance Companies try to drag out the process: How Crafty Health Insurers Are Denying Care[1]

As consumers, it’s our responsibility to understand what our Health Insurance Plans cover regarding medical services, and the associated cost.  However, very few people really pay attention to what their plan covers, and how much the plan will pay for those services that are covered.  Each type of plan has different requirements that must be met prior to payment.

So why am I writing about this?  Recently I’ve been running the gauntlet of health insurance claims denial. Havoc, my son has been taking speech therapy.  He has a problem articulating sounds and words correctly, which makes understanding him very challenging.  Typically we only understand 10% of what he says.  His articulation problem is the result of chronic ear infections as a infant and toddler.  Prior to pursuing speech therapy, I contacted my health insurance company to verify if speech therapy was covered under my plan. 

According to my health insurance plan " The benefits for speech therapy state the plan will pay benefits for speech therapy only when the speech impediment or dysfunction results from injury, sickness, stroke, cancer, autism spectrum disorders or a congenital anomaly, or is needed following the placement of a cochlear implant."  I received confirmation via email correspondence from my insurance company that this what my plan covers.

In December I submitted the first set of claims to my health insurance company. I received notification at the beginning of Jan 2013 that those claims were denied. So, I called up my health insurance and started asking questions. After a week of badgering - the insurance company actually told me verbatim what I needed to do to receive payment, based off Havoc's diagnosis codes (ICD codes). 

They told me his medical file had 4 ICD codes, related to his ears and speech therapy (387.9, 382.9, 307.9, 784.59). The even pointed out which ICD code met the criteria above to receive speech therapy benefits, for Havoc. They also told me what language they needed in the letter from the provider to support the appeal of the current claims, and justification for all subsequent claims. 

Here's what they told me to have the provider provide, on their letterhead: "Havoc 's speech impediment/dysfunction, ICD 784.59 resulted from a congenital anomaly ICD 387.9 deformity in the ear which is pathological condition of the bony labyrinth of the ear, in which there is formation of spongy bone; may cause bony ankylosis of the stapes, resulting in conductive hearing loss; cochlear otosclerosis may also develop, resulting in sensorineural hearing loss."

So, after receiving this information from the insurance company I contacted the provider of Havoc’s speech therapy, and after discussion – we realized the insurance company gave us an ICD code that was not diagnosed by the otologoist Havoc saw in July 2012 or by his pediatrician.  So we decided that was not the best course of action for ensuring coverage of his speech therapy.   We decided to continue perusing coverage using the diagnosis code for chronic ear infections, which is the IDC 382.9. 

I submitted an appeal to have the original claim re-evaluated base upon chronic ear infections being a “Sickness” and the direct cause that required Havoc’s speech therapy.  This was submitted within the 30-day appeal window.

At the beginning of March 2013, I received the response from my insurance company.

“This appeal was reviewed by XXXXXXX, MD, DDS MBA specializing in DDS Otolaryngology Head and Neck.  This decision was based on the XXXXXXXX policy for Speech-Language Pathology Services.

            Per Dr XXXX,
The appeal request and submitted documentation was received and reviewed, including the speech records from XXXXXX, the Speech Language Pathologist and the normal hearing tests. 

Based on this review, the appeal denial is upheld.  The plan only covers speech therapy for a dysfunction, or impediment that results from injury, stroke, cancer a congenital anomaly or autism. Speech therapy is specifically excluded per your plan documents to treat stuttering, stammering or other articulation disorders.

Therefore, CPT code 92507 is not eligible for reimbursement.  If you choose to appeal this decision, it is recommended that you submit for consideration why you believe the speech dysfunction is a result of injury, stroke, cancer, a congenital anomaly or autism.

Base on our review, according to your Benefit Plan, under the Additional Coverage Details section, Rehabilitation Services – Outpatient Therapy and Manipulative Treatment subsection, this request for payment was processed correctly.

The Plan provides short-term outpatient rehabilitation services for the following types of therapy:
-       Physical Therapy;
-       Occupational therapy;
-       Manipulative treatment/Chiropractic care;
-       Speech therapy;
-       Post-cochlear implant aural therapy;
-       Pulmonary rehabilitation; and
-       Cardiac rehabilitation.
For all rehabilitation services, a licensed therapy provider, under the direction of a Physician, must perform the services.

The Plan will pay Benefits for speech therapy only when the speech impediment or dysfunction results from Injury, Sickness, stroke, cancer, Autism Spectrum Disorders, or a Congenital Anomaly or is needed following the placement of a cochlear implant.

Benefits are limited to
-       36 visits per calendar year for physical therapy;
-       36 visits per calendar year for occupational therapy;
-       36 visits per calendar year for speech therapy;
-       36 visits per calendar year for manipulative treatment/chiropractic care;
-       36 visits per calendar year for post-cochlear implant aural therapy;
-       36 visits per calendar year for pulmonary rehabilitation therapy; and
-       36 visits per calendar year for cardiac rehabilitation therapy.

These visit limits apply to Network Benefits and Non-Network Benefits combined.

Because the claim(s) for this was processed according to the above plan provisions, the original determination remains unchanged, and is upheld.  This decision does not reflect any view about the medical appropriateness of this service(s).  Only you and/or your (or the patient’s) physician can make decisions regarding proper medical care.”

Receiving this letter was a kick in the gut. I read it and got mad. Then I read it again.  After reading it a 2nd time, I realized the insurance company denied the claim for everything but “Sickness”, which should have been covered for the plan.  Chronic Ear infections are a “Sickness”.  After reading this and discovering that the insurance company wasn’t adhering to the Plan, I decided to have it reviewed by a lawyer for breach of contract.  I’ve had enough legal experience to realize I might have a shot at Breach of Contract.

The legal review confirmed that my insurance company was in Breech of Contract. Booyah!  Knowing that I had a solid case against my insurance company I contacted my Human Relations Department, and brought them up to speed on the claim.  I also informed HR I was considering my legal options.  HR asked me to wait before I did anything, because they needed to have my company’s legal team review this to verify Breech of Contract.

Why did my company need to review my denial of claim for Breech of Contract?  Well, when you receive health insurance from your company, they are entering a contract on your behalf with the insurance company.  So, if I pursued a suit against my insurance company for Breech of Contract, my employer would also be a party to the suit.  Health Insurance Companies don’t want to have their clients taking them to court, especially if they’re a major player like a Fortune 500 Company.  That’s not good for business.

Within two days of contacting HR, I received notification that my insurance company would cover Havoc’s speech therapy.  It took me four long months to garner coverage for a service that should have been approved when it was first submitted as a claim.  This timeframe is relatively short, given others struggles with claims.

As a consumer always ask what's covered under your plan, and get it in writing. It used to be at the beginning of each New Year the health insurance companies would send you a book of legalese that described in boring detail what was and was not covered by your plan. Now to "save paper" you can access it on line, if you know where to go. Be proactive - find out what's covered, and what isn't - so when you submit claims, and they get rejected - you know how to appeal each claim, and get the money you should be getting for services that are covered. Additionally, as a patient you have the right to know all of your diagnosis codes, and your health insurance company must provide them to you when you ask for them. So start asking and use this as leverage to make your health insurance work for you.

Additionally, you might want to consider submitting your medical claims yourself- instead of having your doctor do it for you. Why? You then have ownership of your health care. Take control of your health from all aspects of its management. Figure out how to make it work for you, not against you, this is just one component of Jack Kruse’s health IPO

Here are my tips for ensuring your health insurance covers the services your Plan stipulates.

1)    Know what your Plan Covers
2)    If your not sure a medical service is covered by your plan – ask in writing for verification.
3)    Keep track of your claims
4)    If your claims are denied contact your HR department to see if they can help.
5)    Be wiling to consider all options, including legal actions, sometime you have to go BIG to get the results you want.

Remember YOU are your best advocate.  If you discover you need assistance reach out and ask for it.  You can even ask me, and I can try to point you in the right direction.  My hope is that others can use my experience and leverage what I’ve learned and apply it to their own situations.  If you do the research, have the back up material, you too can take down Goliath.


Thursday, January 24, 2013

180 Degrees of Health Degradation in 2 months

               When the world you know is incorrect, you need to adjust your perspective so you can see it as it actually is, instead of believing that which isn’t true. – Gretchen Bronson

I’ve been documenting my struggle with PCOS, Migraines, and high Fasting Blood Glucose levels for several months here on my blog.  It’s time for an update.  Many people have contacted me privately asking when I was going to be reporting on my N=1 Cold Thermogenesis experiment that I started back in November 2012.  I’ve been waiting, because I wanted to discuss the set of lab work I had run back on the 21st of December 2012.

I got my labs back on Monday 21 January 2013.  The data I received at my PCP’s was interesting to say the least, and it wasn’t at all what either of us expected.   In two months I went from making forward progress, to a backward slide of EPIC proportions.  My PCP couldn’t explain it.   My initial response in my head was WHAT THE FUCK HAPPEND?  I ate clean.  I was CTing my ass off in the stock tank. I was adhering to circadian cycles strictly.  Intuitively, I knew what caused this back slide, but was struck by the magnitude of what my environment was doing to me, even though I was perfect in diet, exercise, CT, Circadian Cycles, and Sleep.  

That morning, I was privileged to have the opportunity to preview Dr. Jack Kruse’s EMF2 blog.  Reading EMF2 was both empowering, and daunting in all that it lays forth.  But when I read it I didn’t realize the implications it actually had on me until I was sitting in my PCP’s office, getting my lab results. 

HOLY SHIT!  OMFG! SHIT!  The pit of my stomach dropped out from beneath me.   For every individual out there that clamors that we need more clinical trials on drugs, and how we should manage disease: LOOK NO FURTHER.   I. AM. YOUR. CLINICAL TRIAL.   Oh, and by the way SO. ARE. YOU.  That’s right every person reading this blog is a clinical trial.  MY N=1 holds more power than I could have ever imagined.

So, for those of you reading for the first time, I’m a soon to be 40yo woman struggling with migraines, PCOS, high fasting blood glucose, hypothyroidism, and I can’t lose weight regardless of diet or exercise.  I work in a windowless office building 8-10hrs a day, illuminated with florescence light. I get up between 530-6am every day, get everyone ready and out the door to daycare and work. Commute in traffic in one of the worst cities for traffic in the world. I’m using Bio-Identical Hormone Therapy to treat my migraines and PCOS, I’m taking armour to treat the hypothyroidism, I’m taking metformin to address the PCOS and the fasting Blood Glucose issues, and cycloset to help reset my circadian cycles and address the fasting blood glucose.  I eat epi-paleo, and I CT almost daily.

So, what happened? My Labs Tanked.
In October 2012 – my Progesterone:Estradial (Pg:E2) ratio was 104, Ideally it should be above 400.  In December 2012 my Pg:E2 ratio dropped to 59!  At the end of October we increased the percentage of my Bio-Identical Hormones from 5% to 10% and we increased the Dosages.  My Pg:E2 should have gone up, but it didn’t.

The following labs also decreased: 
Estradiol: October – 90pg/ml; December 174pg/ml
Testosterone: October – 47ng/dl; December – 35ng/dl
My IGF-1 increased in October to 240ng/ml from 185ng/dl but in December it dropped to 231ng/dl.  The same thing happened with the following Labs as well:
DHEA: October -344 ug/dl; December- 267ug/dl
Prolactin: October-  3.8ng/ml; December -3.2ng/ml
LDL: May -243mg/dl; December – 285mg/dl
Trigs: May – 66; December - 90mg/dl
hsCRP: May - .4mg/L; December - .2 mg/dl.  This is actually a very good thing because it means CT is helping me live in a reduced metabolic state
HbA1C: May – 5.6%; December – 5.3%.  Also a good thing – it means my over all blood glucose is down, but I still haven’t fixed the high fasting blood glucose first thing in the am.

On the bright side the following labs increased:
HDL: May - 66mg/dl in May; December - 71 mg/dl – I need all the Zeta Potential I can get right about now.
Bun/Creatine ratio: September – 20;  December - 27– so my mitochondria at least have the water they need to create energy.
Progesterone: October - 10.9ng/dl; December - 12.7ng/dl.  While this increase is a good thing it couldn’t compete with the increase of Estradiol, which caused my Pg:E2 ratio to plummet.
Thyroid – well, that had some serious swings as we continued to work on my armor dosage. Unfortunately I’m not at the right level yet, and I’m going to need to re-test again in four to six weeks after I’ve been on 120mg of Armour to see if we’ve found the sweet spot.

Over the past eleven months we’ve thrown everything including the kitchen sink to get my issues under control.  We should have seen forward progress… not the backward progress, where I went from being a soon to be 40 year old woman trying to treat a few challenging medical issues that could have an impact on my health, to a woman whose labs resembled a 60 year old woman in menopause struggling with her health across the board.  In two months I aged 20 years according to my labs.

How?  It all goes back to EMF2, which Jack Kruse gave me a peak of on Monday morning.  What caused this rapid aging? Jack Kruse lays out how this happens in the EMF2 blog, and its pretty powerful, and based of the work of the greatest mind to grace human kind: Einstein. But in a nutshell: Electromagnetic Frequency. Yes I said EMF. Break out your tinfoil hats ladies and gentlemen you’re going to need them. 

I work in a building that is a giant EMF Avalanche.  I can walk into this building every day with a fully charged iPhone, turned to airplane mode, and come out after an 8 hr day with less than 20% charge.   All the phone is doing is sitting on my desk or in my backpack.  I’m not using it.   If this building is doing that to the phone – what is it doing to my body?  In two months it aged me 20 years at the biochemical level.

What does this tell me? Where you live, & the environment you spend the most time in has the greatest impact upon your health.  You can eat clean, work out at the proper time, CT, pay attention to circadian light cycles and seasonal eating – but if you’re living or working in an area of EMF pollution it’s not going to matter, unless you can re-charge your SCN with the earths magnetic field via the Schumann_Resonances.[1] 

So. What am I going to do with this newfound insight?  I’m still struggling with the implications of what this means for me, & for my family, especially Chaos and Havoc and how I’m going to mitigate what’s happening to me. Monday I was given a great and wonderful gift.  It opened my eyes, and I can no longer ignore that which is directly in front of me. Open your eyes you’ve been blinded by incongruent thoughts and actions.  When you see the truth in its pure form as nature intended – it will astound you at its simplicity and beauty.  It may also scare the shit out of you as well, but now that you know the truth you can fix yourself, through change.