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Battle for the Benefit By Kathy Russell
Dealing with insurance claims is one of the less-than-joyful tasks that those of us with CF must face. Although we may not enjoy the task, there is no getting out of it. We need the coverage that the insurance policies provide, and that means we have to “jump through” the insurance company's “hoops.” The frustrating part is that they don't tell us where or how high the hoops are.
Let me illustrate. Last year, my doctor prescribed a portable oxygen concentrator for me. My husband, who is an accomplished patient advocate, checked our insurance policy, and then he checked with the insurance company to see if I was covered for such things. Since I am covered, the company gave us a green light.
So we researched where we could get the concentrator that I wanted and found a “preferred provider” about 20 miles from us. Perfect! When we arrived, the salesman at the store told us that there was “no way” our insurance company would pay for the concentrator. We assured the salesman that they would. He, in turn, assured us that they wouldn't. And so it went…
After a lot of back and forth discussion, we learned that the provider wanted a letter from our insurance company confirming the company's intention to pay for the device. Our insurer would not provide such a letter. They insisted that “the provider has to bill us and then we send a letter telling them how much we'll pay. That is the only way it happens.”
The provider said that they couldn't let us have the concentrator unless we paid for it in full and we would have to bill our insurance company. If we did it that way, we would have to pay a higher portion of the total cost. We pay only 20% with preferred providers and we pay 40% with non-preferred providers. Neither side would budge. In the mean time, I was without portable oxygen!
During our battle for the benefit, we had to jump through one hoop after another. First there was a special letter that was needed from our physician. Then, that letter had to go to a special review committee. Then, there were other letters and other committees that had to be consulted. Finally, our claim went to a medical necessity committee. Sometimes I think it's easier to stop the sun from setting than it is to get what you need in the health care industry today.
Eventually, we gave up on the local provider and went with a well-known and trusted provider in another state. That company was very willing to work with us, and I got my concentrator. The insurance company paid for it, minus our share, and the local provider missed out on a big sale.
The entire process took about five months and a lot of our patience. My husband and I developed very strong legs from jumping through all the hoops – some of them two or three times -- and most of them moving.
Kathy, 64, has CF. She lives in Gresham, OR. She is a Director of USACFA, the publishers of CF Roundtable.
