Need to Vent

chynabear

I am so upset. Not only is going through cancer bad enough but on top of it we have to battle the insurance companies, the lack of competant staff at the doctors offices to correctly submit claims and so on.

Just when I think that I have finished my fighting, here we go again.

I just received a letter from the insurance company informing me that they will not cover my PET/CT done in July. Informing me that I owe $4,700. I DON'T HAVE $4,700. My husband and I are struggling very hard to climb our way out of debt due to him being laid off in 2004 and me not working because of treatment and because of some bad decisions we made when we thought we had money. I'm trying to find a job in a town where job's are slim. I have a college degree and I'm not even finding a job as a grocery store clerk. Then, on top of all of the other crap, it just seems like when it rains, it pours. House repairs, doctor bills, vehicle repairs, etc. I am so overwhelmed.

So, I call my insurance and say, "I don't understand. They pre-approved this claim and now it is being turned down." Turns out that the insurance views PET's as "experimental" and "investigatory" where Colon Cancer is concerned. That they will cover it only after all other avenues have been taken; i.e., MRI, CT, ETC. I say, this was a PET/CT. I didn't have an MRI. The doctor's apparently never submitted any documentation as to why they feel that I NEED a PET/CT. Why it is medically NECESSARY. All that was submitted was the results. Now, I'm trying to get ahold of the scheduler because she is trying to schedule me for a PET/CT this month. I also need to have the DR send a letter to see if we can get the insurance to change their minds.

The only up-side is that the lady I spoke with was very understanding. Her husband is a cancer survivor as well and she vowed to help me through this. Gave me some "key words" that need to be included in this letter.

I am so frusterated.

Anyway, thank you for letting me vent.

Depressingly,

Patricia

kangatoo

Depressing....thats downright sick Patricia! I find it incredible that such a life threatening disease is thought of so minor by your insurance companies. Any suspicions of re-ocurrance should be checked with whatever technowledgy available. We have medicare(public health paid by a levy on our taxes) here in Australia but I have often said here that I think the more expensive disgnostic procedures are not used when they should be. My scans consist of ultrasounds only...I think because MRI'S, PETS, CTS are expensive to do and if we have no private insurance the govt. is reluctant to spend $$'s on public medicare patients unless abolutely necessary. It sucks and it all revolves around some company making a buck! I am sad to hear of your dilemma Patricia. The powers of this world like to line their own pockets...always the weak, the less fortunate suffer...tsk!, tsk!
huggs from oz, kanga n Jen

mwomack

I really believe the Dr. should be able to straighten it out. But,I post on another website and a guy is going through the same thing. Some recommended that he contact patientadvocate.org to help him fight this with insurance.

I am not familiar with them, but I have seen them recommended several times.

We were fortunate in that our Onc. has always gotten the tests pre-approved. On my husband's only PET scan, it was originally denied by our insurance. They said they only allow PET scans for suspected reoccurances (rising CEA). Somehow he got it approved for the staging phase a couple of weeks after surgery. My husband's pre-surgery CT showed nothing and I was questioning the accuracy and reliability of them. The Onc. said well we will do a PET scan to make sure it has not metastisized.

After chemo, he ordered another PET because the 1st one did show a hypermetabolic (4.7 SUV) iliac lymph node that could be post-op inflammation or carcinoma. The onc. thought he could get a repeat PET based on the 1st one, and he could not. They did allow a CT scan.

My husband was Stage IIIC. I really don't think the Stage IV has much trouble getting PET scans through our insurance but I really don't know that. It seems like Stage IV's get PET scans pretty frequently according to my readings.

taraHK

You are so right. I have thought, more than once, that what every individual diagnosed with cancer needs is a full-time 'secretary' (assistant, advocate), just to deal with all the paperwork, forms, insurance, etc. It is so overwhelming! Like we need this......
I wish you all the best in sorting out the insurance issue as well as your other job/financial issues.....
Tara

CAMaura

Hi Patricia -
I am so sorry that you are experiencing any of this; I have often thought of a new book title: instead of "it ain't about the bike", we could write, "we know, it is about all of the other crap".
Oddly enough, I had great treatment by my insurance company thoughout my ordeal; they supported my testing/treatment 100%. My onc's office, however, had charges up the ying-yang "just because they could"; a little sick, but I do live in a very pricey area.
But, more importantly, I would ask you to take all of this slowly. Bills send our emotions flying -- especially when we are not working or able to deal with another stressor. At this point, I would set yourself limits -- and strongly stick by them. I really mean this; make, maybe, two calls on your behalf and then let it go for the day and think about you and your husband. The life and love that the two of you have together is very important. After a few days have passed, make another few calls.
It seems as if the authorization process (?) became a bit messed up.....and that is in the hands of the Medical Group. The Radiology dept. or the doc''s office could be at fault for going ahead with scheduling without the needed paperwork -- but I am certainly no expert.
I really appreciate your posting and your candid thoughts. It is frustrating...and few know the full spectrum of stressors which we encounter.
Do hang in there and try not to forget to take good care of yourself. The recuperation process is not a quick-do....
Here is the deal: you are not stupid, you are not shurking responsibility, and you have NOT forgotten the American work ethic; you were, however, diagnosed with a disease which has kept you you from being an active, providing member of the salary-force in your family. It is nothing to feel ashamed about -- yet, we do...
Life is very funny. If it is at all possible -- if and or when you might read this -- take a deep breath, and know I write all of this in hindsight. I have NOT achieved some great amount of Zen from cancer yet (maybe a wee-bit)...and nobody - NOBODY - who I have come in contact with in or around this site has truly mastered it either. But that is okay; we are human first!
As long as you can say that you have the intention to do your best each day, you are doin' just fine. Love your husband and let him know that he does not have to hold the weight of the world on his shoulders and the two of your will work all of this out -- and I sincerely feel that you can and will. Rome was not built in a day.....and you may not find your solution today -- but that is just fine.
I am no Pollyana; but having endured and risen from a few really crappy, BS-driven months -- April, May, June, July and part of August -- I do think that we are stronger, better, and more capable than we, or others, ever dreamed. Patricia, this is just a 'blip'. I know the $$$ amount sent you reeling.......but don't let it. You and your husband will be okay!!!!
All the best - Maura

oes620

Patricia,
Yell, scream, stamp on desks to get the *Letter of Medical Necessity* from your doctors. My take is that dealing with the insurance companies is WORSE than having cancer(DAMHIK - don't ask me how I know)! I got 26 weeks of anti-nausea meds($6K) and 6 weeks of Xeloda($3k) for $25 each by getting these aforementioned letters. Now, I'm in for a PET scan($7K) and I'm hot on the trail of another letter. With the US privacy act(HIPAA), I am the only one who can deal with the insurance! Like I have the energy. You CAN do it! Stay in close contact with the insurance lady you mentioned. She probably knows all the routes around the big problems as she has probably had to use them.
A question: was the PET/CT done before surgery or after? PET and CT are completely different tests. Which did you have?
There are times I wonder if not having insurance might not be better......

Good luck and keep after the insurance claims folks.
Harriet in Texas

well

oes620 said:

Patricia,
Yell, scream, stamp on desks to get the *Letter of Medical Necessity* from your doctors. My take is that dealing with the insurance companies is WORSE than having cancer(DAMHIK - don't ask me how I know)! I got 26 weeks of anti-nausea meds($6K) and 6 weeks of Xeloda($3k) for $25 each by getting these aforementioned letters. Now, I'm in for a PET scan($7K) and I'm hot on the trail of another letter. With the US privacy act(HIPAA), I am the only one who can deal with the insurance! Like I have the energy. You CAN do it! Stay in close contact with the insurance lady you mentioned. She probably knows all the routes around the big problems as she has probably had to use them.
A question: was the PET/CT done before surgery or after? PET and CT are completely different tests. Which did you have?
There are times I wonder if not having insurance might not be better......

Good luck and keep after the insurance claims folks.
Harriet in Texas

> "Pet and CT are completely different tests"

I had a combination PET/CT done, (after an CT scan and multiple MRIs.)

Perhaps they also had this combination style testing?