Fighting for Medical Care the Hard Way

OMG, do squabbles with the health insurance company never cease?  How about fighting multiple health issues at once?

My History

I have moderate obstructive sleep apnea.   (OSA). "Moderate" refers only to my pressure setting (8.5), not the frequency of my sleep arousals. My arousals are, on average, every couple of minutes. By partner and personal observation, I know that they begin occurring at the transition between Stage 1 and Stage 2 sleep, and they are constant. Hence, I have no REM unless I'm so deprived that it starts in an earlier sleep phase. In fact, during a sleep atudy, I didn't go into REM until approximately 6:00 am!

My sleep arousals still occur wih BIPAP therapy, although I am supposedly properly treated (and 100% compliant) with BIPAP therapy. Tarousals are less frequent with BIPAP therapy (by partner and personal observation, on average, every five minutes). I still have serverely-delayed onset REM. I am still exhausted all the time.

Here's my total picture: moderately severe constantly disordered breathing, delayed-onset REM, parasomnia (speaking and teeth clenching severe enough that I've bitten through my orthodontic retainer), periodic limb movements, and long-sleeper syndrome.

Since sleep is a life-long issue and the "roto-rooter" surgery (uvula/adenoid/tonsil removal) has a pathetically low long-term success rate, my sleep specialist and I are pursuing the last option we can find . . .

God, but to be properly slept, properly REMed. --sigh--

September 2009

My sleep specialist "refers" me to an oral surgeon for the creation of a custom oral appliance that will hold my jaw in the proper place for my BIPAP to be most effective. This is the oral appliance that this oral surgeon invented, perfected, and of which he performed an NIH-funded field study. Note that this "referral" is on a PPO plan, so it's not an HMO-type referral, just a "go to this guy and get this item" referral. I leave the office without the referral info. No big, just fax the office and get it, right?

No joy. I call and leave messages for his nurse again and again. Maybe I'm not making what I need clear on voicmail. I ask the receptionist for the doctor's fax number. I fax, again and again, addressed sometimes to the nurse, sometimes to the doctor himself. I call again and again, saying what I need over and over, to anone who answers, but no one can tell me. His nurse isn't there or she's with patients. He of course doesn't take calls from patients any more than any other doctor. Months drag by. I just don't understand this, I've never had this much trouble with his office before. I keep trying.

I get busy at work. I am, as usual, criminally sleep-deprived and only barely able to maintain sanity with stimulants and an anti-anxiety prescription. I keep poking, faxing, calling, letting it ride, poking, faxing, calling. The holidays come. I'm pulling my hair out. By luck, an assistant eventually answers. She knows what I need. Apparently the size of the medical organization (something like 10 offices across town, hundreds of physicians, this thing is something between a hospital and a single-doctor practice) my sleep specialist is employed by led me to getting the wrong fax number, the wrong nurse's name, and calling the wrong location.

After a couple of weeks of chasing the doctor down, she gets him to decide for sure on the referral and then she gets me the referral info I need (name/address/telephone).

January 2010

I research the oral surgeon. I am impressed. I set an initial consultation.

The oral surgeon practices part-time out of another full-time dentist's office. Best I can tell, the setup is kind of like renting a chair in a beauty salon. I visit, he examines me, discusses my history, and is confident that his oral appliance can help me. He shows me a model one, explains how it works, explains why he thinks it will work, tells me about past case histories similar to mine and the results his appliance has achieved with them, and it all makes total sense to me. OMG, am I totally psyched!! Someone who believes me, someone convinced he can help me! As a 70+ year-old man practicing part time, he does this for the help it gives people. Yay!

He tells me that the PPO plan I have usually pays really well, that my dental plan, another company, does not. He warns me that he's only recently re-done his paperwork for my PPO, that he has come back from sabbatical to find out he had fallen off their rolls. There might be a "delay" while the paperwork goes through. The cost is $2.6K, complete.

February-March 2010

Week after week, I call the dentist's office back about benefits verification. The insurance girl can't tell me anything except that the PPO doesn't acknowledge the oral surgeon, that they won't cover anything, and that my out-of-network deductible is $2K. That my dental won't cover anything (yeah, that policy pays crap). Week after week, no additional info. I keep calling her, telling her what he told me about having completed his PPO paperwork, that they should pay. She doesn't care and/or is too incompetent to accomplish anything, or maybe both. I talk to others when they answer, and I keep getting referred back to her. I write detailed emails to the oral surgeon. No response, of course, doctors and dentists don't email with patients. I just want him to be aware, hoping maybe he will help from his side.

I eventually become agressive with the insurance girl, "Insurance is your JOB. What is the PROBLEM here?" and she snaps back, "We're a DENTAL office. It's not like we do MEDICAL insurance EVERY DAY, you know!" I remind her what the oral surgeon said about filing under the medical insurance, that it was HIS instruction, not mine, and that the PPO pays really well. She responds, "Well, I don't know WHY he told you that, we don't even DO that!" She made it clear she was done dealing with me unless and until *I* could get the PPO to put it in my file so that she can verify that the procedure codes are covered.

I call the PPO, they show him as a dentist on the dental version of their plan (which is not the dental plan I have). I call her and tell her this. Her response is, in effect, "So?" She gives me the medical codes and tells ME to get them approved in a way she can verify. "Maybe they'll work with YOU. They won't work with US." This, even though she still can't tell me anything, at all, that they've told her except the fact that it's going to come out of my pocket, and there's nothing she or I can do about it. I write another detailed e-mail to the oral surgeon, hoping he can help from his side.

I wait.

April 2010

I've received no response from the oral surgeon (as expected), and also no call from the insurance girl (as I'd hoped). She's intimidated me with the insurance and the practice for which she works. I realize that this is just done. I cough up $2.6K or remain sleep and REM-deprived forever. Who has that kind of money on hand? I sink into digusted resignation. Maybe he'll give me a cash discount? Or maybe that insufferable woman will say, "We don't DO that!" again when I ask. Try to save money? Yeah, that's likely.

May - June 2010

Joe keeps pestering me about this oral appliance, and I keep putting him off. Things are tough at work, and balancing foot problems, GI issues, recurrent unexplained staph skin infections, and anxiety (along with the sleep deprivation), I already miss work more that I should. Visiting my boyfriend in another city (where he lives, a 5-hour drive one-way), I miss even more, son when I'm at work, I'm both tired and have a full workload. When I come home, I'm brain dead. I research the medical codes, then realize that I can't face fighting the PPO on this. I can't admit this to my boyfriend because I'm ashamed of the intimidation, resignation, and depression. I later come into a bit of unexpected cash as the result of a class-action lawsuit against a former employer. I begin trying to decide if I should go ahead and do this $2.6K out of pocket, because the settlement will cover it.

July 2010

Still trying to decide if I'm going to pay out of pocket, I begin to lean towards "God works in mysterious ways," but then something in me roars in defiance at the injustice of the annual $8-10K PPO gets in insurance premiums for my policy while not paying for the oral appliance that I need to make my life support device as effective as it should be.

I call PPO customer service. I explain the situation, and I give them the medical codes. All but one is covered. The other requires a Predetermination Request filed (then approved by the PPO) by the physician making the diagnosis before it will be covered.

("Covered" = In-Network paid at 80% after $400 deductible, Out-of-Network paid at ?% after $2K deductible)

Also, in order to have the PPO cover the services at the In-Network (i.e. 80%) rate, I have to escalate an Out Of Network Referral Request via a differet PPO group. This will be assigned to a nurse (a NURSE, omg!) for approval/denial. There is no possibility of after-the-fact negotiation with the PPO on this -- If I don't have this approved before services are rendered, they will not pay anything. I was warned that because there ARE other oral surgeons in my area, this will be a difficult approval to obtain.

While on the telephone with them, I made sure the PPO customer service was very clear on who needs to complete the Predetermination Request form, that the diagnosing physician will not be the provider of services. She insisted that the diagnosing physician should complete it. I download the Predetermination Request and it seems to say that the provider of services has to complete it. The form also says that approval is no guarantee of payment.

So, I talk to the assistant at the sleep specialist's office to obtain the OSA diagnosis code, complete most of the Predetermination Request form, and fax it to the sleep specialist's assistant for her to chase and complete. I talk to the insurance girl at the oral surgeon's office and also fax her a mostly-completed Predetermination Request form. On both cover sheets, I ask them to fax the completed forms and required supporting documentation to ME, that I will send them to the PPO and keep a copy since I have to drive this. The insurance girl said on the telephone she won't be doing anything until the oral surgeon returns to the office next week.

I hate that useless woman.

So, here I am, chasing the completion/approval of Predetermination Requests for both a diagnoser and a provider for an oral appliance that is currently not covered at all, only to have to then chase an escalation for approval of an Out of Network Referral Request that a nurse will decide upon, hoping that a random nurse understands the meshing of the medical and the dental a hell of a lot better than the insurance bimbo in the oral surgeon's office.

If both items are approved, I pay $520 for the appliance (20% of total since my deductible is already met). If not, I have a $2K out-of-network deductible + 20% of the remaining $600, for a total of $2,120.

What a *(&^%# nightmare.

~Riot.Jane