Aik - what in the world kind of company do you work for? And the insurance company has to provide you with the formulary info, if not online then in writing. Start an email bombing campaign, it will document your requests for bills and updated formulary. Email them every few days and mail a copy to the company every week or so, certified mail, so someone has to sign for it. There is your proof, acceptable in court. Get your employer benefits person on this. They should have easier access to the insurance company; at least a sales person there who will be more likely to get you a human contact. Something does not sound right about this. Ask your employer for another copy of the insurance handbook, say you lost yours. That should give you all their rules on claims and timeframes you must adhere to. If you have to get your dr to resubmit your claim and med records, get a copy for yourself. You only have so many days to get this done. Normally if they deny a claim, they need to notify you within x amount of days leaving you with plenty of time for you to appeal. Are you going to in network drs? That makes a difference. Out of network can be a whole different procedural process. You may have to follow different rules and submit your own claims. Doctors offices sometimes can make lots of mistakes and fall behind on the process if it is not a run of the mill ins co or an out of network claim. Some of the billing people are fresh out of a school that will pass my Kitty as long as the govt paid the tuition. You sound like you are pretty experienced with this process, so I am probably telling you things you already know.
Are you in Tucson or are you more north and closer to the Indian lands and artist community towns. I know there are a few up in there. And I know you told me this before and I looked through some old posts and could not find it. I forget stuff fairly frequently, my fault. I would love to come visit, but I don't think DH would go for it. And I do not know if I could take Tucson heat with my heart. I feel fine, but in the heat I have trouble breathing and my heart gets wonky. I am not a delicate flower but seem to be on the wiltin side of things.
All I can say is there are reason's why attorneys won't touch this with a 10' pole. Yes, there are laws on the books and there is no enforcement, no penalties. Half the time when I push it, a few months later, something gets approved as a "technical change" so they don't have to do it - like accepting medical records from outside of network. They don't have to anymore. That's state law now. Essentially a person needs to be born in network. That appeared when I was trying to get my cancer monitored in network, but because it was treated out of network, no records were accepted and no monitoring. You could say that for any chronic condition. This is what I mean that states control the insurance - at least the ACA will eventually standardize some of that. There are also contridictory laws - like giving you all the treatment options. Then further on, another statute says that if you are referred out of network (i.e. no specialist in network) the doctor can be held financially liable. I think that's pretty standard in most provider contracts now. So who is more likely to enforce? The patient that wasn't given their treatment options (if they know it) or the insurance when a patent steps out of network? The result is that doctors don't give treatment options that they know insurance won't cover.
Part of the problem is utilization. This insurance uses Million Robertson (I think that's the name) M&R. It's based on insurance standards - what most insurance covers and doesn't cover, not medically based standards of care. So that ends a lot of arguements right there. Medical neccessity standards don't apply and they don't get me anywhere. I have to be able to translate EVERYTHING into a legal standard. That's all I got. I am pretty sure a lot of people's insurance does the same but unless they bump up against it, they wouldn't know since insurance considers utilization to be propietary.
If insurance is employer supplied, there is this thing called ERISA that prevents taking them to court or so called "tort reform". Insurance claimed all these misc. court cases cost them too much money and convinced AMA, etc. that premiums would go down. Well, premiums didn't go down and were still stuck with ERISA. That's federal. Again, unless people bump up against it, they probably wouldn't know it's there. Most sick people aren't good at waiting and jumping over all the hurdles that insurance can throw into their way. Yes, there's a grienvence line but no requirement that they answer it and they don't - so it's unreported. Yes they publish a formulary, my scripts were on it. There's no requirement that it's online and who knows where my "notification" went. I may get it before next year. I'd have better luck with a lottery ticket.
My first appeal took over 4 years to get to administrative hearing (which is non-binding anyway). That time I did FINALLY get an attorney to feel sorry for me. They filed a motion of continuance and within hours, once they saw an attorney, my doctor got a call from the medical director saying, "I can't defend this" and approved treatment, It was the FIRST time he even looked at my file. There is also another law saying denials MUST go through medical personal and directors office. Yea, right. Not many conditions can be held off for that long until treated. The next time, I couldn't wait. Insurance never has responded to repeated requests for expedited approvals, never given me written notice, doesn't follow regulations at all. So what. There's no penalty.
It's pretty clear to me that because I did win the appeal again -after I had gotten treatment (not reimbursed) that my medical records disappeared. Some of it was because a doctor got investigated and cleared. He gave me a pathology report saying my tumor was benign (which I have) and sent one to the cancer center, same date, saying I had invasive cancer (which I also have). The doctor was going to let me die because he knew insurance wouldn't treat it and they wouldn't have (no specialist in network). He also stalked me for awhile (another story). Since then, I can't get squat, no medical records etc. That's a problem with the old boy network.
I'm going to U of A medical school, thinking a teaching orgainization would be above the old boy network and I think they are. They are doing medical records, requesting them, etc. It's the insurance throwing monkey wrenches in. I don't have a recourse until they bill/deny care and they aren't doing that until it's too late. Pretty simple.
It's a book that's not my favorite. It helps to blow off steam.
I took a quick look at private insurance (web form) all they know is age and sex. $10,000 deductable with $170/mth payments. $5k deductible with $300/mth payments. Unreal. Give me Medicare - and they are older and sicker and use medical standards. Go figure.
