My Ongoing Showdown With Insurance

Well, would you believe it:  Things have been pretty much stable and uneventful for the last three months.  It’s not that I have forgotten my blog, it’s just that for once, our lives have been pretty normal!

Last update centered on Drew’s 11th leg surgery to remove some hardware in each leg. Since, he’s back to his normal self, running and dancing like before.  It took him a bit to get back on his feet as it was a little bit more of a serious surgery than we initially expected, but now he’s as good as he was before.

We have visited Louisville once to for a new set of braces due to one or more growth spurts.  He’d outgrown his hip piece so much so that we could no longer put it on each night.  So, now we’re just in a holding pattern since mid-December waiting for all of the red tape to be completed by the office in order to make and deliver the braces.  Drew hasn’t missed his restrictive hip piece for one moment and the longer he goes without it each night (so far over six weeks) the harder it will be to readjust to wearing the hip piece once more.  Every time there’s a change with his braces, it’s a dramatic outburst and a period of adjustment leaving us all disgruntled as a family.  So, not really looking forward to that.

The other battle that I’ve found myself in is much more tedious and frustrating though: disputing medical charges and trying to convince a very large insurance company that they are improperly denying filed claims leaving the over $2,000 of physical therapy charges to me.

The charges originated during 2016 when Drew underwent physical therapy post surgery.  After his three leg surgeries, he required six weeks of physical therapy provided by Paley’s internal physical therapy department.  Our insurance covers 30 sessions (of so many credits or some company term that I can’t quite recall) so we ceased all physical therapy back home at the end of 2015 so we could reserve our 30  2-hour sessions for the upcoming physical therapy in Florida.  We would have JUST enough coverage to get us six weeks of physical therapy as required (five times a week for six weeks = 30).

Insurance benefits verified and understood, we did precisely that (in fact, we paid out-of-pocket something like $200 for a 31st session).  Drew graduated therapy and we went on our merry way.  And we lived happily ever after…

Only, it didn’t EXACTLY end happily…

I started receiving bills for physical therapy charges summer 2017.  Didn’t think a lot about it at first as it’s common while insurance and providers settle the statements and such.  But after several bills and watching the balance get older and older past due, I first contacted the provider to inquire about the physical therapy charges.  It appeared that insurance was paying for the 1st hour, but wasn’t paying for the 2nd hour which would be a mistake as prior to starting therapy, our benefits were verified by the team.  Thing was, some days they paid for the second hour and some days they didn’t and, in fact, it was only 10 specific days of physical therapy charges for which I was being billed for.  All billed days fell within the 6 week period that Drew received therapy at this provider.  I was advised to contact the insurance company.

Ugh, there are no words uttered to parents of children with extensive medical needs that causes more dread or anxiety than those.

So, I mentally chug three Monster drinks, blare Survivor’s “Eye of the Tiger”, warm up my phone dialing fingers a la Rocky Balboa, and psych myself up for what will probably be an exhausting experience.  I literally had no idea that nearly a year later, I’d STILL be battling this very same issue.

First, after the representative’s multi-week investigation into the matter, the explanation was that they had paid for 30 sessions as agreed per our insurance plan.  A quick back-story: we used our 30 sessions in Florida, we returned to Kentucky and continued physical therapy and these sessions, since we’d reached our limit with primary insurance, in Kentucky were billed to Medicaid.  The representative claimed that they paid for all thirty sessions, 20 of them in Florida and 10 of them in Kentucky therefore they’d paid all claims appropriately and have met their requirements.

Only, this infuriated me as regardless or not that they covered 30 sessions of physical therapy, it meant that my out-of-pocket expense was greatly increased due to how they were covered.  Obviously, I balked and insisted that they resolve the issue by paying for the 30 sessions from Florida and undoing their coverage of the Kentucky therapy (as, the 10 sessions of therapy in Kentucky that they paid for could be paid for by Medicaid).

But, nooooooooooo….they can’t do that.  Desperate to find a loophole or a company error to exploit, I had the representative investigate each individual claim and advise me of the date that which it was submitted hoping that they were submitted appropriately strengthening my stance that these charges should not be my responsibility.  And, luckily for me, they were all submitted by the provider in a timely fashion proving that the insurance company made an error in only paying for 20 sessions out of the 30 submitted. This caused me to unknowingly seek additional PT at home which were billed to insurance (process is to bill insurance before billing Medicaid – so, since I mistakenly had 10 sessions left in my coverage, those 10 were paid for by insurance.)  It appeared as if insurance had just randomly selected 20 dates to cover, paid for those, when I returned home (thinking that I had used up all 30 of my insurance-covered sessions), underwent PT (which I understood to be billed to Medicaid as I had reached my insurance limits, however, much to my dismay, they were paid for by insurance.)

I hope this all makes sense.  It’s a lot I know.  And, maybe you haven’t even gotten this far in reading…..perhaps this is a long boring post outlining boring insurance procedures and you’ve moved on mid-paragraph two.  But, none-the-less, I’m going to document this experience as a real-life happenings of a special needs mom for sentimental purposes and maybe this post will help me remember how things went down to make it easier to explain to my future lawyer.

Obviously, I was quite unhappy with this answer because due to their ill decisions, my out-of-pocket expenses were now dramatically increased.  I refused to back down and insisted they do something because I would not be letting this go.  So, she reassured me she’d get this to the resolution team and would call me back after some investigation.

In the meantime, I could tell something was being done as every month the statement was different and not in a good way.  Now, there were ADDITIONAL dates of service that I wasn’t previously being billed for.  And, big surprise, a major insurance company did actually call me back.  After a couple of months of investigation, the same representative called me back with new information.

This time, the explanation was that the dates for which I was being billed for had already been paid by the insurance company and the provider was mistakenly double-billing.

Okaaaaay….so, great….sounds like ya’ll still have a lot of work to do!!??  Thanks for the update ??? I’ll….uh….let y’all carry on because this is obviously not my problem.

Several more months go by.  Same representative.  Yet another explanation.  This time, it’s,

Them: “You signed a waiver in which you agreed that you were responsible for any charges that exceeded your coverage limits.”

Me: “Uh….yeah…but I didn’t exceed my coverage limits.”

Them: “Well, if I were you I would contact the provider and work this out with them.”

Me:  “Uh….isn’t that what y’all have been trying to do for nearly a year?”

Them: “Yes, but…”

Me: “And, exactly how am I, just a patient with no access to your’s or their systems or policies/procedures, supposed to get this resolved when y’all have had escalation groups, intimately educated on billing and insurance procedures, haven’t been able to in a year?!?”

Them:  “Uumm…”

Me: “…”

Them: “…”

Me: “Soooooo….you’re saying that y’all are just washing your hands of this?  That..uh..I’m just fending for myself now?!?”

Them: “…”

So, yeah.  Insert dramatic outburst here.  I used to work in a call center so I first assured the representative, who has actually been really polite and kind, that what I was about to say wasn’t personal towards her, but rather an attack on the company itself, but I advised her of my never-ending frustration and dissatisfaction with them as a company.  Then poor husband happened to call me shortly after and got the brunt of my frustration before barely saying “Hi”.  And, he listened to me whine and complain about it for the remainder of the day.

It’s apparent to me that the insurance company is trying desperately to skirt these charges.  It’s clear to me that I am in no way responsible for these charges:

  • Our plan covers 30 sessions.
  • Drew underwent 30 sessions.
  • All 30 sessions were billed to insurance in a timely manner
  • All 30 sessions were billed PRIOR to any therapy that occurred in Kentucky therefore it is evident they had 30 claims, disregarded 10 of them, chose 10 sessions billed at a later time from Kentucky, and called it “covering your 30 sessions per your insurance plan.”

It appears as if they insurance company is trying excuse after excuse hoping to find that one that will appease me or cause me to just wave the white flag.  But, what they don’t know about me, is I’m very spiteful and stubborn.  That I will spend an equivalent amount of money that is these physical therapy charges to combat them and win my case simply for the sake of the principle of the matter.  I will not be letting this go.  I will go all the way to the top with this.

So, the trade-off for an uneventful and routine three months away from doctor’s offices and complex medical procedures is a shit show with the insurance company.  I can’t honestly tell which one I hate worse.

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