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Topic: Use your State Insurance Commissioner's office!

Forum: Employment, Insurance, and Other Financial Issues —

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Posted on: Apr 29, 2014 06:56AM

vlnrph wrote:

I was having problems getting payment for services initially denied then approved upon appeal as well as pre-authorized durable medical equipment until I filed two on line complaints with the government. Amazingly, checks were issued to both providers within weeks.

If months of delay are frustrating you and the company refuses to investigate your grievances through normal channels, don't give up. They can be penalized for lack of good faith operation. You have a right to receive contracted benefits.

IDC too! Rt MX/DIEP 4-2011; ALND 5-2011 d/t micromets; TC X 4; tamoxifen; lymphedema as of 9-18-11; switch to letrozole 3-15-14; Discovery made during chemo=I'm a human BEING, not a human DOING Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Aug 16, 2014 10:15AM vlnrph wrote:

An update now that a few more months have gone by: I thought the story would be over once my providers got paid (although one check was for only half the amount originally billed). 

Turns out the investigator at our state capital in Madison was not satisfied with the insurance company response and informed them that they needed to answer several questions about their claims processing procedures and calculation of interest payments. Just a couple weeks ago, further funds were issued including the remainder of that incomplete reimbursement. The file is still open so I'm wondering if this major national insurer will also be fined for their delay and initial refusals. Again, don't give up when your benefits are denied. You can win this fight but may need government help!

IDC too! Rt MX/DIEP 4-2011; ALND 5-2011 d/t micromets; TC X 4; tamoxifen; lymphedema as of 9-18-11; switch to letrozole 3-15-14; Discovery made during chemo=I'm a human BEING, not a human DOING Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Jan 10, 2015 03:07PM vlnrph wrote:

Another installment (and perhaps the conclusion of this particular saga): Wisconsin required additional interest payments because of the long time it took for these claims to be properly addressed! Not all states are so consumer oriented but if you have a good one, the insurance commissioner's office can do a lot of work on your behalf. Take notes & keep records...

IDC too! Rt MX/DIEP 4-2011; ALND 5-2011 d/t micromets; TC X 4; tamoxifen; lymphedema as of 9-18-11; switch to letrozole 3-15-14; Discovery made during chemo=I'm a human BEING, not a human DOING Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Jan 10, 2015 03:15PM proudtospin wrote:

thanks for the info and so glad for you that they are helping you

iris Dx 6/2008, DCIS, Stage 0, ER+ Dx 2/2017, Left, Stage IV, metastasized to bone/liver, Grade 3, 1/1 nodes, ER+, HER2+
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Jan 13, 2015 06:49AM DoggieBytes wrote:

Good info. Glad it worked out in your favor!

Suffering is a part of life, that does not justify adding to the suffering of others. Namaste. Dx 6/2/2014, IDC, 1cm, Stage IIB, Grade 2, 3/10 nodes, ER+/PR+, HER2- Surgery 7/9/2014 Lymph node removal; Mastectomy: Right Chemotherapy 8/11/2014 AC Chemotherapy 10/21/2014 Taxol (paclitaxel) Radiation Therapy 2/22/2015 Whole-breast: Lymph nodes, Chest wall Hormonal Therapy 4/6/2015 Femara (letrozole)
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Feb 6, 2015 04:47PM oceangirl654 wrote:

Thanks so much. I'm going to try this!!

Dx 12/5/2014, IDC, <1cm, Stage IA, Grade 1, 0/1 nodes, ER+/PR+, HER2- Surgery 1/6/2015 Lumpectomy: Right; Lymph node removal: Right, Sentinel Radiation Therapy 2/16/2015 Whole-breast: Breast Hormonal Therapy 3/29/2015 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Feb 28, 2015 10:13AM Jazzygirl wrote:

Vinrph- thanks for this post. I have had some issues in the past with getting things paid through my insurance (most genetics testing, two finally got paid through multiple appeals and one denied because the BS office did NOT get the prior approvals for an out of network lab).

I may have a new battle on my hands with some audits that were being done on my initial bc treatment claims in 2012-2013. I got two letters from the insurance company last fall about them auditing two of my claims from my surgery and now they have come back and said they are not paying the imaging center claim and seeking a refund. My guess is the surgery bill audit will go down the same path. And who knows if this is the tip of the iceberg?

I have always kept very good documentation around my medical care (huge file around my care, copies of approvals and EOBs, records of conversations). I will be ready if this becomes a fight. I will be seeing my BS this Friday for a six month check up, and plan to go in with all these denials and to talk to them about what is happening. I am not sure where the root problem is, but find it amazing the insurance company can come back two years plus after treatment and say "we changed our minds, we are not paying for it after all." I don't know if that puts me on the hook to pay for this care but am worried. You know, you are the final guarantor on the account and all. I will start with the place this all began but will leverage the state insurance commission if this becomes an problem.

Hard enough to go through this stuff, never mind not have things paid or payment decisions reversed! Be aware folks!

Dx 9/14/2012, DCIS, 1cm, Stage 0, Grade 1, 0/1 nodes, ER+/PR+, HER2- Dx 9/14/2012, IDC, <1cm, Stage IA, Grade 1, 0/1 nodes, ER+/PR+, HER2-
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Jun 11, 2015 08:19AM vlnrph wrote:

Bumping this thread because I am hearing about more situations like jazzy girl described in which insurance companies are attempting to reverse past claims and then demand reimbursement. This trend seems to be linked to a tendency to either deny coverage or offer approval initially but then refuse to pay.

As if maintaining our health isn't difficult enough to begin with...

IDC too! Rt MX/DIEP 4-2011; ALND 5-2011 d/t micromets; TC X 4; tamoxifen; lymphedema as of 9-18-11; switch to letrozole 3-15-14; Discovery made during chemo=I'm a human BEING, not a human DOING Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Oct 13, 2015 07:59PM vlnrph wrote:

bumping for hopeful82014

IDC too! Rt MX/DIEP 4-2011; ALND 5-2011 d/t micromets; TC X 4; tamoxifen; lymphedema as of 9-18-11; switch to letrozole 3-15-14; Discovery made during chemo=I'm a human BEING, not a human DOING Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Mar 7, 2016 02:51PM vlnrph wrote:

bump

IDC too! Rt MX/DIEP 4-2011; ALND 5-2011 d/t micromets; TC X 4; tamoxifen; lymphedema as of 9-18-11; switch to letrozole 3-15-14; Discovery made during chemo=I'm a human BEING, not a human DOING Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Mar 9, 2016 08:36AM april485 wrote:

Very valuable information. I called my State Commissioner's office about a denial for payment due to not getting pre-approval for an out of network lab and the decision was reversed. I had to pay a co-pay that I would not pay for an in network lab, but instead of 947.00, I had to pay 20% of that...huge difference. I had to take it to the State to get this settled though. It works!

"Fear has been a huge dictator in my life - so I am trying to stage a coup!" ~ a friend Dx 1/30/2013, DCIS, <1cm, Stage 0, Grade 2, ER+/PR+ Surgery 2/20/2013 Lumpectomy: Left Surgery 3/10/2013 Lumpectomy: Left Radiation Therapy 4/21/2013 3DCRT: Breast Hormonal Therapy 6/19/2013 Aromasin (exemestane) Hormonal Therapy 1/1/2016 Femara (letrozole)
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Mar 9, 2016 09:20AM Paxton29 wrote:

My insurer just sent a letter they are denying my second round of TC (I've already had my third and they paid for the first). It better be something as simple as a stupid coding error or you better believe I'm going to the Texas Department of Insurance. My husband did something online last night and said he would call them today. Very disturbing that you can have care approved and THEN denied--especially when their denial comes too late for you to address it in a timely manner. I guess they finally caught on to my scam to get them to pay to remove my breasts and install a port and go through chemo! I am just love love loving these hard tissue expanders, the hole in my skin over my catheter because I'm too thin for this size port apparently, and of course who can forget the hair loss, nausea, loss of taste, constipation and all the other joys of chemo

Stage IIA left, Stage I right, Dx 11/20/15; BMX, TC chemo, rads--DONE. ER/PR+, HER-. Tamoxifen to resume after exchange surgery soon!
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Mar 9, 2016 10:35AM AmyQ wrote:

AND I love that they (the insurance companies) treat everyone as if they are a drug addict. Just this month mine unilaterally decided that the quantity of pills dispensed shall not exceed X number. They didn't say dosage, they said quantity which forced my physician and pharmacist to adjust the dosage so as to satisfy the arbitrary number of pills. Unfortunately by adjusting the dosage, I am suffering more pain because I don't need the higher amount in one shot - I'd rather it were spread out over the course of the day. I may call my Department of Commerce which governs Insurance in my state.

Amy

Dx 2/7/2013, IDC, 1cm, Stage IV, Grade 2, 2/3 nodes, mets, ER+/PR+, HER2- Chemotherapy 4/8/2013 Cytoxan (cyclophosphamide), Taxotere (docetaxel) Hormonal Therapy 7/18/2013 Femara (letrozole) Radiation Therapy 11/24/2015 External: Bone Hormonal Therapy 1/9/2016 Faslodex (fulvestrant)
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Mar 6, 2017 08:38AM vlnrph wrote:

It's been a year since this topic was at the top of the list so here's a bump for those experiencing problems receiving benefits!

IDC too! Rt MX/DIEP 4-2011; ALND 5-2011 d/t micromets; TC X 4; tamoxifen; lymphedema as of 9-18-11; switch to letrozole 3-15-14; Discovery made during chemo=I'm a human BEING, not a human DOING Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Mar 6, 2017 11:11AM - edited Mar 6, 2017 11:15AM by mustlovepoodles

Absolutely! Your State Insurance Commissioner is there to help you! I had a terrible time with my doctor's business office. She is associated with one of the biggest hospital systems in the Southeast. Interestingly, they were willing to take my insurance's negotiated rate for all my office visits, so the doctor was paid at 100%. However, they had different rules for the chemo portion, for some reason. They waited about 9 months and then started dunning me for money--over $93,000 worth of chemo. This was on top of the payment they had already accepted from my insurance. I absolutely refused to pay this! I do not understand how a hospital system which has negotiated a contract with an insurance company can then change their rules and balance bill. I live in a very competitive healthcare market. NO OTHER HOSPITAL SYSTEM has ever tried to do this to me. After going around and around with both the insurance AND the hospital billing office for 5 months, I submitted two complaints to the State Insurance Commissioner, along with all the copious notes I had taken with every phone call. Two weeks later, those bills had miraculously vanished.

Now, I'm getting additional bills from an office visit in November. Erg! That's it! I'll pay the damn bill but I have decided to leave my beloved MO because I can't keep going through this~

Oncotype 23. Positive for PALB2 & Chek2 gene mutations. My breasts are trying to kill me! Dx 7/20/2015, DCIS/IDC, Right, 1cm, Stage IA, Grade 3, 0/2 nodes, ER+/PR-, HER2- Surgery 8/19/2015 Lumpectomy Surgery 9/2/2015 Lumpectomy: Right Chemotherapy 10/19/2015 Cytoxan (cyclophosphamide), Taxotere (docetaxel) Surgery 2/3/2016 Prophylactic mastectomy: Left, Right Surgery 10/18/2016 Hormonal Therapy Femara (letrozole) Surgery
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Mar 30, 2017 07:11PM gardengypsy wrote:

Wow. So glad I found this thread!

Dx 10/29/2015, ILC/IDC, Left, 5cm, Stage IIIA, Grade 3, 1/1 nodes, ER+/PR+, HER2- Surgery 12/3/2015 Lymph node removal: Sentinel; Mastectomy; Reconstruction (left): Tissue expander placement Chemotherapy 1/9/2016 AC + T (Taxol) Surgery 5/23/2016 Hormonal Therapy 5/28/2016 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Radiation Therapy 6/6/2016 Whole-breast: Breast, Lymph nodes, Chest wall
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Oct 19, 2017 12:53PM amaasing wrote:

Thanks for the thread. My insurance company is refusing to pay any of the cost for my yearly preventative Mammogram. Due to the BC last year my provider is required to code it as "diagnostic" and the Insurance company says if it's not coded as 'screening' they don't have to pay any of it. I did find a State Mandate on Insurance on line for my state and it includes the verbiage that the preventative part of the insurance coverage has to include both diagnostic and screening if there has not been any other mammograms within the prior year. I wasn't sure who to contact in the state to get the help I am going to need to appeal this - so finding this is very helpful.

Wish me luck and thanks for the info.

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Oct 22, 2017 07:27PM gardengypsy wrote:

amassing,

They are nuts not to cover your yearly mammogram. I hope you engage in the appeals process and take this to the highest level!!

Dx 10/29/2015, ILC/IDC, Left, 5cm, Stage IIIA, Grade 3, 1/1 nodes, ER+/PR+, HER2- Surgery 12/3/2015 Lymph node removal: Sentinel; Mastectomy; Reconstruction (left): Tissue expander placement Chemotherapy 1/9/2016 AC + T (Taxol) Surgery 5/23/2016 Hormonal Therapy 5/28/2016 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Radiation Therapy 6/6/2016 Whole-breast: Breast, Lymph nodes, Chest wall
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Nov 14, 2017 08:53AM scaligirl wrote:

Does anyone know if calling the State Insurance Commissioner is valid for single-payer insurance only or employer-sponsored insurance as well? I know employer plans are governed by ERISA so a lot of state protections don't apply. But I'm having insurance issues as well so think anything that doesn't cost me can't hurt.

Dx 8/10/2017, IDC, Right, <1cm, Stage IA, Grade 1, 1/2 nodes, ER+/PR+, HER2- Dx 8/10/2017, DCIS, Right, 1cm, Stage 0, Grade 1, 1/2 nodes, ER+/PR+, HER2- Surgery 9/8/2017 Lumpectomy: Right; Lymph node removal: Sentinel Chemotherapy 10/2/2017 Cytoxan (cyclophosphamide), Taxotere (docetaxel)

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