Insurance questions

Cora11
Cora11 Member Posts: 173
in Esophageal Cancer #1
As we start to get all the EOB papers in the mail I am wondering if anyone has experience with appealing claims. I know that after this is over - meaning when surgery is over, I'll have a huge file of EOB's that say that did not pay the full amount for UC ( usual and customary). If any of you have a good system for appealing to insurance companies I'd like to hear about it. Or, did you get an attorney to help you. What are some of the experiences you all have had if you are willing to share. Also, did any of you get on SSI/disability? I hear there is a form that is called "compassionate allowance" and that EC is on there. If you did get that, did it affect your own personal disability policy if you bought one. Just wondering about all these crazy things that should not be in the way right now but they are starting to accumulate.
Thanks,
Cora

Comments

  • jojoshort
    jojoshort Member Posts: 230 Member
    #2
    SSDI Disability
    Yes, Cora, esophageal cancer is one of those "quick decision" diseases that allow for a very short decision time. You will want to fill out that form ASAP. You can print those right from the SSDI website, too. Remember that they will wait for 5 months before a check is cut to you. They will figure that 5 months from the date you put down as unable to work. Your doctor will also have to fill out info on that form.
    Medicare doesn't go into affect until 24 months after SSDI gets approved, however.
    I do believe that your private insurance will look again at your claims if you protest within 60 days of the EOB. So you will want to look at that stuff quickly, too.
    Also, your insurance may have a "catastrophic" out of pocket limit. Luckily, for us, that was after $5,000 was reached, so once we paid $5,000 out of pocket, all medical bills were paid in full, leaving nothing for a patient balance.
    Lee and Chantal have national health insurance, and they will look at these numbers and be very surprised. Some who don't have ANY health insurance here in the U.S. will lose their homes because they got sick. I know that Steve's chemo treatments, "list price" were nearly $10,000 PER TREATMENT. He had 8 treatments. Thankfully we had health insurance through my work, or I'd be losing my house, too. Yikes.
    Jo-Ann
  • Daisylin
    Daisylin Member Posts: 365
    #3
    jojoshort said:

    SSDI Disability
    Yes, Cora, esophageal cancer is one of those "quick decision" diseases that allow for a very short decision time. You will want to fill out that form ASAP. You can print those right from the SSDI website, too. Remember that they will wait for 5 months before a check is cut to you. They will figure that 5 months from the date you put down as unable to work. Your doctor will also have to fill out info on that form.
    Medicare doesn't go into affect until 24 months after SSDI gets approved, however.
    I do believe that your private insurance will look again at your claims if you protest within 60 days of the EOB. So you will want to look at that stuff quickly, too.
    Also, your insurance may have a "catastrophic" out of pocket limit. Luckily, for us, that was after $5,000 was reached, so once we paid $5,000 out of pocket, all medical bills were paid in full, leaving nothing for a patient balance.
    Lee and Chantal have national health insurance, and they will look at these numbers and be very surprised. Some who don't have ANY health insurance here in the U.S. will lose their homes because they got sick. I know that Steve's chemo treatments, "list price" were nearly $10,000 PER TREATMENT. He had 8 treatments. Thankfully we had health insurance through my work, or I'd be losing my house, too. Yikes.
    Jo-Ann

    Cora,
    As Jo-Ann said, we have national health care coverage here in Canada, so I can't offer any advice. I have often complained here about the care we've received, it sometimes seems as if we're denied tests and treatments which seem to be standard in the States. however, I an so very grateful that we don't have the added stress of financial ruin, paperwork and endless appeals to file. I honestly don't think I could manage any more than we already have on our plate. I'm sure Lee can rest easier also knowing that I won't lose the house, or face bankruptcy because of his treatments. I would gladly sell everything I own for a cure, or even some quality time, but I guess it just doesn't work that way.

    Lee and I watched the documentary Sicko a few years back, and it has really reminded me how fortunate we Canadians really are. lee and I often have talked about just how lucky we are. Lee researched the costs that we could be facing, and it's right in line with what Jo-Ann said. That's not to mention his medications, feeding tube, feeding tube formula, hydration, home nursing care and countless other things. One of the nausea meds was not covered by Lee's drug plan, and it cost $150.00 for a 2 week supply. I started complaining of the cost, then reminded myself how very fortunate we are, for that to be our costliest expense of the last 8 months.

    Cora, I hope you are able to navigate the system easily, and be able to maintain whatever financial security you are accustomed to.
    Chantal
  • jim2011
    jim2011 Member Posts: 115
    #4
    SSD
    I applied for SSD compassion program. EC is included on the list. Worked great and have it for 3 years and then will be re-evaluated. Important to remember the waiting period and make sure that you answer that question correctly.
    My private insurance costs about $880 per month and I may need to give that up soon. I know that Medicare is a 24 month waiting time. What about medicaid?? What is that all about??
  • unclaw2002
    unclaw2002 Member Posts: 599
    #5
    Cora,
    What type of insurance
    Cora,

    What type of insurance do you have? An HMO, PPO and through which company? Does it require pre-approval? Do you have to use certain medical providers, go to certain approved hospitals. The hospital you are considering using, or the cancer center, should have a social worker and I would recommend calling and asking for help in navigating this complicated mine field we all call insurance. As another post said is there a maximum out of pocket cap on what you have to pay in a calendar year?

    You don't want to worry about money as you are trying to get the best care --- but you should try to proactively manage the health insurance coverage and obtain approval for the procedures before you have them done if at all possible.

    If you recently purchased disability insurance --- they may not provide coverage for a pre-existing condition read your policy and the exceptions carefully. No need to pay for something that won't provide you coverage.

    As to SS disability as others have said you should apply for a compassionate decision as soon as possible.

    Cindy
  • Cora11
    Cora11 Member Posts: 173
    #6
    Daisylin said:

    Cora,
    As Jo-Ann said, we have national health care coverage here in Canada, so I can't offer any advice. I have often complained here about the care we've received, it sometimes seems as if we're denied tests and treatments which seem to be standard in the States. however, I an so very grateful that we don't have the added stress of financial ruin, paperwork and endless appeals to file. I honestly don't think I could manage any more than we already have on our plate. I'm sure Lee can rest easier also knowing that I won't lose the house, or face bankruptcy because of his treatments. I would gladly sell everything I own for a cure, or even some quality time, but I guess it just doesn't work that way.

    Lee and I watched the documentary Sicko a few years back, and it has really reminded me how fortunate we Canadians really are. lee and I often have talked about just how lucky we are. Lee researched the costs that we could be facing, and it's right in line with what Jo-Ann said. That's not to mention his medications, feeding tube, feeding tube formula, hydration, home nursing care and countless other things. One of the nausea meds was not covered by Lee's drug plan, and it cost $150.00 for a 2 week supply. I started complaining of the cost, then reminded myself how very fortunate we are, for that to be our costliest expense of the last 8 months.

    Cora, I hope you are able to navigate the system easily, and be able to maintain whatever financial security you are accustomed to.
    Chantal

    sicko
    That movie sure got it right about corporate health care. I worked in an HMO and it was all about the bottom line and that is often in conflict with patient care. You are very fortunate over there. I do hope we get some changes here. We self0-insure through a group plan but we still had a 30k deductible which we met in about one day. Hah! So, now I see the EOB's that give "explanations" as to why they did not pay the full amount. I think they hope you cave and just pay. Seems like if it is something this big, they would just negotiate with the clinic if they really thought it was too high. They want the patient to do that, and guess what- I'll do it.. but every letter will certainly have an attorney's signature on it. Not gonna play the game laying down that is for certain. If anyone else is at our stage, also watch for the fact that most appeals process have a limit of 180 days, so watch for those deadlines.
    Thanks again
    Cora
  • Cora11
    Cora11 Member Posts: 173
    #7
    unclaw2002 said:

    Cora,
    What type of insurance
    Cora,

    What type of insurance do you have? An HMO, PPO and through which company? Does it require pre-approval? Do you have to use certain medical providers, go to certain approved hospitals. The hospital you are considering using, or the cancer center, should have a social worker and I would recommend calling and asking for help in navigating this complicated mine field we all call insurance. As another post said is there a maximum out of pocket cap on what you have to pay in a calendar year?

    You don't want to worry about money as you are trying to get the best care --- but you should try to proactively manage the health insurance coverage and obtain approval for the procedures before you have them done if at all possible.

    If you recently purchased disability insurance --- they may not provide coverage for a pre-existing condition read your policy and the exceptions carefully. No need to pay for something that won't provide you coverage.

    As to SS disability as others have said you should apply for a compassionate decision as soon as possible.

    Cindy

    insurance
    WE have a big catastrophic plan that negotiates prices with hospitals and providers. Of course, they don't give us a handbook, anything like that to say who they have arrangements with. They pretty much say you can go where you want, but if we don't like what they charge, well then we'll slap an UC code on there for usual and customary meaning they don't want to pay some of it and then that is when appealing comes in. So, if I have to go to the mat, I shall GO TO THE MAT !! I have been told most of the time they work it out between the clinic, or provider and don't give it to the patient. So, we shall see. But it is frustrating as I said, I paid my 30K now you pain for my husband's new esophagus, ok? We purchased disability years ago when Keith graduated medical school so that policy is really helpful. THanks so much for all the great suggestions.
    Cora

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