Navigating Insurance

Back in March, I did a post on navigating referrals. It’s only right that we circle back and talk about insurance. I want to make a disclaimer. I am no longer a licensed insurance professional, this is all based on my experience navigating Maddie’s needs. Alright, I just needed to get that out of the way.

There are really a few main areas that are the most important for dealing with insurance companies. The first one is the preauthorization process. With Maddie’s insurance, this is initiated by the referring doctor. For Maddie, she needs preauthorization for her MRIs, EEGs, physical therapy, occupational therapy, speech therapy, feeding therapy, and therapeutic devices. Every time we get an approval or denial, we get an explanation of benefits in the mail, or an EOB.

These EOBs are very important to read. In the case of Maddie’s speech therapy, her prior authorization was partially denied. It was partially denied because she “might one day speak.” What a load of garbage. If Maddie was speaking or on the verge of speaking, we wouldn’t need speech therapy. However this partial denial is due to the fact that they do not have any notes on Maddie’s speech capabilities. What they really meant was that they needed the speech therapy to start and those notes then sent over to their authorization team.

Every time you get an EOB, read the explanation. There could be information that the insurance company is missing or that they overlooked. Also the diagnosis code that is used plays a big part in the prior authorization process. It’s important to know your rights as well. You have the right to appeal the decision that was made. Typically there is a set amount of days that you can initiate this. You should speak with your PCP’s office to coordinate the appeal.

Another vitally important part of navigating insurance is knowing your numbers. You should know what your deductible is, what your coinsurance is, and what your max out of pocket is. With Maddie’s second EEG, we received a bill for $12,000. Now this number was way more than our plan allowed. So when I called Spectrum’s billing department, they never sent the prior authorization information alongside the claim. This was an easy fix, or so I thought.

The woman who I spoke to did not give me the correct information. She then started talking about an outstanding $8,000 bill from Maddie’s first EEG. She told me that I needed to call my insurance company to get this authorized. I knew this was not the case. Now granted I was a little annoyed at this point, so I was probably a little more curt than I should have been. The woman then proceeded to transfer me out of the billing department to the rehab floor because I “clearly did not understand how billing worked.”

Now why she transferred me out of the billing department to rehab is a mystery to me. It was probably a way to get just me off of her phone line. What she didn’t expect was the rehab floor to transfer me back to billing. The same woman answered the phone again. We proceeded to dance around the issue yet again. I asked for a manager and she said that she would transfer me. She told me, “I don’t understand why, he’s going to tell you the same thing.”

This woman and I were not friends. In another diabolical move, she actually just muted the phone. There was no hold music, just dead silence. After ten minutes of this, I began to click my pen into the phone receiver. After a few minutes that must have done the trick because the hold music started to play. Once the manager got on the phone he explained that the $8,000 bill was already paid by the insurance company and that I had nothing to worry about. As always I asked for a call reference number, just in case.

That phone call took an hour to complete. The biggest thing I can say is to stick to your guns. Your insurance company can guide you through what you need from the provider’s billing department. You should always ask for a call reference number when on the phone. That way you can have something to reference back to, if different information is provided the next time.

There are certain things that we know will be denied by Maddie’s insurance company at this point. Most of Maddie’s therapeutic devices are being denied. This is partially due to Maddie’s age. Just like with her speech therapy, they take the wait and see approach. Since Maddie’s diagnosis is so rare, the road map is murky at best. Thankfully we have our own know-how to lean back on. Also we have an amazing team of providers. Then lastly there’s always the Angelman Syndrome Foundation. They have a lot of information on how to navigate insurance with Maddie’s needs in mind.

I’m sure there will be more hours spent on the phone, dealing with billing departments. There will be countless appeals filed with her insurance company. There will be times where it feels overwhelming. As always, her well being is certainly worth it.

-Written by Adam Birchmeier