Please Advise

[Maureen Adele]

What is the name of your state? New York

My little boy has uncontrollable epilepsy, he's nine. He is scheduled to undergo evaluation at a hospital four hours away, where they will induce seizures in order to find out if he is a candidate for brain surgery. We are suposed to check in on Monday, Feb.10.

My HMO still has not approved this. I've been calling every day, have letters from three neurologists and his pedeatrcian recomending this treatment. The HMO has already shelled out 800 bucks for an initial appointment and evaluation. I was told yesterday that they have untill Feb 14, to decide because of "special circumstances", what ever that means. Right now the"Director" is reveiwing our case.

My question is how long can they keep us waiting, is this legal and what recourse do I have? I'm guessing they are going to deny the request, why else are we still waiting. Please help, time is running out, and this is way too stressful right now.

 

[ellencee]

You have today and tomorrow to get this resolved or I recommend that you do not accept admission and treatment on Monday, the 10th; you could get stuck with the whole bill if you do.

I recommend that you call the hospital where your son will be going and speak with someone in the admitting office. I'm sure they have a precertification method in either the admitting office or the preadmission office. Ask that someone in precertification call the insurance provider and speak to the director if necessary, but speak to someone and get a statement of approval of service and payment faxed to the hospital.

Sometimes, the precertification department can resolve this better than the individual can because of their ability to provide the correct billing codes, ICD-9 codes, etc. and because they can provide the anticipated charges, item by item, to the insurance provider.

You need to make the person in precert aware that if it is not approved by the close of business on Friday, 2-7-03, your son will not be admitted on Monday, the 10th. That way, they can make sure the schedule is freed-up for another person who may be waiting on testing availablity.

I hate to assume anything, but I assume you are asking if your insurance company denies this treatment to your child, do you have a claim of 'bad faith' denial of treatment. Is that correct?
If so, the insurance company would have to have failed to follow appropriate steps before making the denial--ie--failing to have MD input in making their decision, failing to advise you of your right to appeal.

If your HMO is through an employee health plan, the laws that apply to ERISA would have to be evaluated to see if the HMO breached their duty to you and your son. You would need to consult with an attorney that has experience in dealing with ERISA issues. (ERISA is Employee Retirement Income Security Act and applies to employee benefit plans, health plans, including managed care plans.)

I hope that in some way, the above information is of help to you.
Best wishes,
EC

 

[Maureen Adele]

Thank you for your prompt reply. I have been in touch with the pre-certification clerk at the hospital. She is just as frustrated as I am, and she has experience with the HMO as well. We will not go on Monday unless there is an approval, can't risk the life savings yet. I will try to seek out the ERISA laws, if anyone could provide a link that would be great. I will do anything in my power to help my little boy. Since when do insurance companies make medical decisions, and not doctors? What does the insurance company know about epilepsy? Sure is food for thought, no wonder the doctors are striking.

 

[ellencee]

Insurance companies do it when they can get away with it and they get sued when they can't get away with it. They can't make medical decisions and that's one area that lawsuits occur. The insurance company can have a physician review the claim and make a medical statement that the treatment wasn't needed (that's what they are paid to do), but you still are guaranteed the right to an appeal and the right to receive necessary diagnostic measures and treatment.

beth3 and cbg are the experts on ERISA; maybe ask them in Employment Law what to do next.

(I'm not in favor of healthcare workers going on strike, not even physicians or RNs. I'm not in favor of any public service provider going on strike, such as firefighters, airlines, etc. The general public is dependent on these professionals and I'm a little tired of regular folks paying the price of striking professions and workers. I've used your post to vent my personal opinion! Thanks for your tolerance and the opportunity!)

 

[Maureen Adele]

Just got word from the HMO, its approved!!!! Thank you again for your advice. We still have a long way to go, and I'm sure it will prove very usefull as we travel this path.

I'm with you on strikes by the way. I now have a greater understanding of what these folks are going through, and can empathsize.

 

[lkc15507]

MaureenAdele:

Just in case you revisit this thread and in case you may have future need for knowledge of approval procedures, I am posting some links that may be helpful. If your plan is in fact an ERISA plan (some group health plans are not--such as churches and governmental agencies, I have also run across some hospitals that actually qualify as churches) the US Department of Labor is the regulating body. Their general website provides much consumer information. The specific page I have listed has Q&A related to the new regs governing minimum requirements for benefit claims determinations. The next site I list is by a labor union that has provided a very user friendly table outlining the time frames a plan must follow when making benefit determinations. Please also be aware that what is contained in the summary plan description (SPD) of your group plan. The specific regulation is listed in the Code of Federal Regulations, specifically 29 CFR 2560.503-1 and can be found at the Cornell Law website along with many other places.

http://www.dol.gov
http://www.dol.gov/ebsa/FAQs/faq_claims_proc_reg.html

http://www.lhsfna.org/html/dol_claims_new.html

http://cfr.law.cornell.edu/cfr/cfr.php?title=29&type=part&value=2560

I am very pleased that your son's approval came through quickly. Best of luck to you!
lkc15507