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Topic: When insurance won’t give a prior authorization

Forum: Employment, Insurance, and Other Financial Issues —

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Posted on: Jan 10, 2019 07:56PM

elise24601 wrote:

Is it just a gamble as to whether they will end up paying for something?

I’ve never encountered this before but BCBS is telling me that they can’t provide prior auth for a surgery, even though according to the codes from my doctor it’s covered.

Wondering if anyone has dealt with this or has any advice

Dx 5/4/2016, IDC, Left, 4cm, Stage IIIC, Grade 3, 15/28 nodes, ER+/PR+, HER2- Surgery Mastectomy; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Radiation Therapy Whole-breast: Breast, Lymph nodes, Chest wall Chemotherapy Cytoxan (cyclophosphamide), Taxotere (docetaxel) Chemotherapy Xeloda (capecitabine)
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Jan 10, 2019 09:18PM edwards750 wrote:

We have BC/BS too. What reason are they giving for not giving a prior authorization? It’s a gamble depending on their reason. Some facilities won’t accept your insurance without it. They always verified my insurance before any procedure could be scheduled.

Diane

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Jan 11, 2019 05:02AM gb2115 wrote:

What surgery are you trying to get prior authorization for?

Dx IDC in October 2016, stage 2A, 1.2 cm ER/PR+ Her2-, Grade 2, 1/3 nodes. Mammaprint low risk luminal A, Lumpectomy + radiation + tamoxifen. Age 38 at diagnosis.
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Jan 12, 2019 03:37AM elise24601 wrote:

A procedure to improve my lymphedema

Dx 5/4/2016, IDC, Left, 4cm, Stage IIIC, Grade 3, 15/28 nodes, ER+/PR+, HER2- Surgery Mastectomy; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Radiation Therapy Whole-breast: Breast, Lymph nodes, Chest wall Chemotherapy Cytoxan (cyclophosphamide), Taxotere (docetaxel) Chemotherapy Xeloda (capecitabine)
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Jan 12, 2019 08:26AM gb2115 wrote:

They may consider that not medically necessary since it's probably considered elective. See if your doctor will do a doc to doc call (called a "peer to peer") with the insurance company. That could push it through maybe.

Dx IDC in October 2016, stage 2A, 1.2 cm ER/PR+ Her2-, Grade 2, 1/3 nodes. Mammaprint low risk luminal A, Lumpectomy + radiation + tamoxifen. Age 38 at diagnosis.
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Jan 12, 2019 02:54PM BellasMomToo wrote:

Even if you get autho from BCBS, make sure to keep a copy of it. I have BCBS. In 2017 I was hospitalized for a abdominal infection and spent 5 days in the hospital. The Drs would only release me if I continued on IV antibiotics at home for another 9 days. So they got autho from BCBS for an in-home nurse visits and IV antibiotics. A few days after being home I received written autho from BCBS. The wording was weird and I wasn't exactly sure what was covered, but I didn't think much about it. A month later I started receiving EOBs from BCBS -- I was being penalized $500 for each bill (5 separate bills!) because they claimed I didn't have pre-authorization for the in-home care.

I called BCBS, they researched my file, and claimed I didn't have pre-autho. I gave them the (case?) number that was on the autho that I received and they couldn't recognize that number. Finally after more digging, they found the authorization and acknowledge that all the penalties will be reversed. It took a few more phone calls to get ALL the penalities reversed.

So even if you receive autho from BCBS, be sure to keep a copy of it because they may not be able to find it in their records!

Dx'd at age 56. Tumor found by my annual mammogram -- cancer can grow fast! Dx 10/6/2016, IDC, Left, 2cm, Grade 2, 0/1 nodes, ER-/PR-, HER2+ (IHC) Dx 10/6/2016, DCIS, Left, Stage 0, ER+/PR- Targeted Therapy 11/2/2016 Herceptin (trastuzumab) Chemotherapy 11/2/2016 Carboplatin (Paraplatin), Taxotere (docetaxel) Targeted Therapy 11/2/2016 Perjeta (pertuzumab) Surgery 3/27/2017 Lymph node removal: Sentinel; Mastectomy: Left
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Jan 12, 2019 10:32PM vlnrph wrote:

Everything written above rings true. However, even when you have a prior authorization in place, sometimes the company will refuse to pay. In my case, I filed a complaint with our state insurance commissioner's office who required them to act promptly and add a percentage to their payment as a penalty.

The data on LE surgery is still somewhat sketchy. Unless you are getting frequent infections, they might count it as experimental. If they won't talk to your doctor, try to gather whatever scientific reports you can and submit them with a formal letter requesting approval.

IDC too! 🎻💊👪🐩 🇫🇮 Rt MX+DIEP 4-2011; ALND 5-2011 d/t micromets; TC X 4; tamoxifen; lymphedema 9-2011; switch to letrozole 3-2014 for 1 yr; bone mets 8-2018: Zometa, rads to spine, Faslodex/Versenio Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Jan 13, 2019 08:07AM edwards750 wrote:

Elise - idk if it’s the same procedure or not but a lady in our church group flew to Houston to have surgery done to improve her lymphedema. She is in constant pain too. She read an article in a magazine about this new procedure and called the doctors who perform the surgery.

She has Medicare which approved the procedure. All she is responsible for is her hotel stay while she is there.

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Jan 13, 2019 08:10AM edwards750 wrote:

Also, I had prior authorization for my Oncotype test but BC/BS subsequently denied it. Genomic Labs who conducts the tests said they do that all the time and they weren’t worried. They had to appeal multiple times. The test was $5k at the time. My low score from the test allowed me to dodge chemo.

Diane

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Jan 13, 2019 02:38PM vlnrph wrote:

How ironic that Medicare would pay for a procedure but not the basic compression garments every LE patient needs! The technique I am most aware of is microsurgical anastomosis which requires highly specialized instruments and training - certainly not as cheap as simply wearing a sleeve and glove...

IDC too! 🎻💊👪🐩 🇫🇮 Rt MX+DIEP 4-2011; ALND 5-2011 d/t micromets; TC X 4; tamoxifen; lymphedema 9-2011; switch to letrozole 3-2014 for 1 yr; bone mets 8-2018: Zometa, rads to spine, Faslodex/Versenio Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Jan 13, 2019 04:43PM edwards750 wrote:

That makes zero sense for Medicare to do that. I have to admit I was surprised they were footing the bill.

Diane


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