Insurance frustration

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I usually get botox injections every four months, and my last injections were scheduled for late December. After meeting with the urologist in late November, we decided to delay it by a couple of weeks since I was doing much better than I usually am at that point in the cycle. Maybe a good decision, though I was starting to have some significant discomfort by the time my mid-Januaty appointment came around.

I was all set for that - I'd already squirted lidocaine into my urethra and was walking out the door to go to the appointment when the office called. They said that my insurance had not approved the procedure and we'd have to cancel.

I called the insurance, and they couldn't find any record of the doctor's office sending in the paperwork for a prior authorization. I ended up spending over three hours on the phone between the doctor's office and the insurance, trying to get them to work out whatever the issue was. It ended up that the doctor's office submitted even more paperwork to try to get it approved.

That was over two weeks ago. I called the insurance company yesterday, and again they couldn't find any record of a prior auth request. The customer service rep eventually looked deeper in the files and found that my particular coverage goes through a separate company for prior authorizations, and they're the ones claiming that botox isn't covered now even though I've been getting it for many years.

So now I'm stuck. There's some opaque company denying my prior authorization, and neither my doctor's office nor my insurance seems to he able to break through the problem. I haven't even been able to find out who to call to try to get it straightened out.

At this point I'm hurting badly, and it's getting worse quickly as the Botox from August wears off. Nobody seems to be able or willing to push through this problem, and I'm out of ideas for how to convince them to keep trying. I've wondered if I should call my company's HR department, but I'm not eager to tell them all about my bladder issues.

Anybody have any advice? I get the feeling that if I don't push on this it'll just get dropped, and it's one of the main things that keeps the painful spasms at bay.

 

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This is one of the pitfalls of modern day society @Itapilot. I unfortunately can resonate with your frustration of having to go through so many hoops to get things accomplished. Sometimes it feels like it never is.

Either way, I am going to send you good vibes and that things will work out - eventually, they do.

Blessings,
Honeeecombs

 

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Sounds like you need to speak a really good customer service representative for your insurance company and if they can't get through to the ghost company or if you just don't want to be strung along you need to have them get their supervisor to speak with you and find the path to the adjunct company door for you.

Maybe write a brief synopsis of the chain of events and that you are a prior recipient of the Botox.
The company is supposed to be a SERVICE YOU are paying for!

 

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Docs have to maximize profit on each encounter to pay huge overhead plus a a crushing burden of education debt. Fight to change the system.

Meanwhile, count your blessings. My neurogenic bladder is incurable on a medicare budget.

 

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@tripichick I’ve been told by other members here on the forum that Medicare pays for Botox. Botox treats *my* Neurogenic Bladder, as it does for several other members here who have Neurogenic Bladder, too. In fact, all three of the urologists I’ve worked with have said Botox works the best for those of us with Neurogenic Bladder than for those with any other diagnosis. Botox isn’t a permanent cure, but it dramatically decreases the pain in my urges, reduces the frequency of my urges while awake by 80%, reduces my daytime leaks by 98%, reduces my nighttime urges and awakenings by 50%, cuts my bedtime diaper wetting by 80% so I can reuse them and save money, and makes my diaper leaks onto my bedpads basically nonexistent so I can save money and mess there, too - not to mention having to launder my sheets as often. I highly recommend trying it! The efficacy of Botox for me slowly tapers off over six months. I try to get them every three months before they taper off too much. I’ve been receiving Botox for the past five years. The first few years I could only afford the copay once a year. But I’ve been able to get them quarterly now for 1.25 wonderful years of relief! I’ve been able to sleep a lot more, and I’ve been higher-functioning as a result of that.

@ltapilot I’m so sorry to hear about your dilemma. I literally feel both your physical and emotional pain. Here are some ideas, before contacting HR (which I’m really not sure would help because they’ll likely just tell you to call your insurance company - though they may know the name and phone number of the preauthorization company, which could help you):

-Are you positive your urologist has sent the paperwork? If not, change urologists.

-Ask your insurance company for the name and phone number of the intermediary agency that handles your pre-auths. If they’ll only tell you their name, hunt the company’s phone number down on the Internet. Then you should try calling them, and if they don’t respond to you, have your doctor himself/herself call that agency. Ask them to confirm that Medical Botox is no longer covered. Make sure you tell everyone you talk to that you’re not referring to Cosmetic Botox, just Medical Botox. If they say that benefit has been canceled, ask why. Ask for them to confirm that in an email or a written letter. Make them nervous.

-Get nasty with your insurance company. Insist on speaking to a manager/senior and if that person doesn’t help, ask to speak to the next higher up manager. Send them copies of your past bills from your doctor’s office indicating that they have indeed paid for your Botox before. Even better, try to find your EOBs from your insurance company from your prior Botox and send them back in their face to prove to them with their very own paperwork that they’ve paid in the past.

-If none of that works, ask HR for help. If the Botox coverage truly is canceled, they should have sent you a letter about that. Then, alas, your only options will be to pay for it yourself or to start buying the very pricey public healthcare platinum or gold plans available through the Affordable Care Act. But that insurance, over a year, might cost you more than just paying for the Botox yourself. And, unless you have a change in life status, you won’t be able to enroll in a public healthcare plan again until November of this year, for coverage in 2024.

Don’t panic yet and try to ignore your pain as much as you can so you can work on this nasty project. I think you’ll get through this and get your approval after all; this sounds like a mistake to me. If your Botox coverage truly is canceled, I’m going to be worried about my own and furious on your behalf. Maybe, though probably not because they seem to barely exist and don’t have any full-time staff, the NAFC would be willing to talk to your insurance company to advocate for continuing Botox coverage. It probably wouldn’t work, but NAFC should do activist work like that for us.

I’ll be thinking of you and hoping you achieve success in this matter. Please keep us posted!

 

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enjoy your privilege. I'm followed at the county medicare clinic, a very affordable option which I think most Americans should be required to use. Medicare paid for urodynamic testing which revealed incurable post-stroke motor and sensory damage. Told to self-cath bid but my stroke-clumsy hands couldnt find my urethra with Google maps!

 

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I’m sorry to hear about your issues with your insurance company. We’ve probably all been there to some extent. From my own experience I suggest when you actually get a person on the phone, start off by asking their name and telling them that you are recording this call! There are apps that make this possible and it seems like they are more willing to listen and try to help you rather than just trying to get you off the phone. I personally had an ongoing problem for eight months. It gets exhausting having to explain to each person you get on the phone what the issue is, having to provide all the background information relative whatever it is you’re trying to get resolved. As soon as I used this approach the problem was magically resolved. Don’t know if this will help, but may be worth a try. Prayers for better days ahead.

 

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Check your state government directory for the insurance department. Every state regulates insurance companies, and those departments often also do consumer protection on a case-by-case basis. I had a denial-of-claim reversed after filing a complaint with my state insurance department.

 

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@tripichick You should absolutely ask if they’ll try Botox.

 

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@ltapilot You can also ask each person you talk to for their direct phone number, extension, or email, so you can try to continue working with the same person to avoid having to start over every time.

 

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Thanks for the suggestions.

I think what really upsets me about the whole thing is that they waited until right before the appointment to decide that they're not going to pay for it, leaving me hurting with cramps and spasms. The appointment has been scheduled since last August, and if they'd made a more timely decision I could have worked through these issues when I was feeling good.

 

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I was thinking the same thing, they don't take into account that a sick person is not in the best position to calmly wade through the red tape.
Bureaucracy!!!!
I think Diane's suggestion for finding the direct contact with the insurance company is the shortest route to the source.

 

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You know, I was just thinking about this as the program that I am in for Indepdent Housing for those with Mental Health Issues - in order for myself to get an income prior to going back to school and working part time - requries temporary assistance from Social Services.

Temporary Assistance is something myself and my former significant other had trouble getting when we were living together. Any type of Insurance or Government help i feel like is a process that you are 90% going to "lapse out" of unless you have some sort of case manager or peer advocate. I feel that is set up that way for people to purposely fail.

Luckily, i've got a case manager thats helping me go through all these steps for help - but the system is definetly rigged not in the favor of the commonwealth or people who are struggling.

It's extremely sad as we give millions of dollars in corporate welfare to the nations corporations but when it comes to a person who is getting back on there feet - the government does everything it can to deny you rather than assist you out of that rut.

I'm so excited to be able to go back to school and work part time - so that i can get more money coming in. But i heavily sympathize with you @Itapilot, because the light at the end of the tunnel is there - but its just hard to get there.

Blessings In Christ,
Honeeecombs

 

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@ltapilot I agree; that was asinine.

 

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I talked to both the doctor's office and the insurance today. The office says that the appeal was denied and there nothing more that they can do. The insurance, meanwhile, says they have no record of the request or the appeal.

The guy I talked to with the insurance called the doctor's office, and for a wonder got the insurance processor on the phone. He had me on hold, so I didn't hear the conversation (I wish he'd done it as a theee-way call, but no such luck) but he told me that he told the insurance processor how to file it, and that she wasn't happy about it. That makes me wonder, despite them getting this covered multiple times before, if the doctor's office is filing the wrong paperwork, or filing it with the wrong company.

We'll see if this is really progress, or just more time wasted on the phone. I spent an hour on phone calls today, on top of three hours last week, which is time out from my workday that I really can't afford to spend.

Meanwhile, I looked up my policy, and it explicitly covers botox for overactive bladder, but only to to 100 units. I've been getting 200 units for a long time now, though I suppose that may be something that they can get authorization for.

 

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Good WORK!

 

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@ltapilot Fingers crossed that today’s call will help move your appeal forward! Sorry to learn the insurance company only covers 100 units; I need 200. I hope the next appeal can get you the extra 100 you need. But even if you can only get 100, it’s better than nothing. Thanks for keeping us posted about this matter. We all wage wars with insurance companies here and there and it’s good to share tactics!

As a tip, whenever I want a pharmacy or doctor to talk to an insurance company, I offer to do the three-way call on my iPhone. Nobody has ever said no. That way I can act as a referee between the two, or help either side clear up details with the other side, plus I get to know what’s said. Perhaps you can also try this method in the future. Make sure you know how to initiate a three-way call on your phone before trying it with doctors. Practice first with, say your significant other, and a friend. First I get the doctor (or administrative assistants) on the phone, then I add the call to the insurance company. Or vice versa, if I’ve first called the insurance company.

 

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@Maymay941 I love your new teacup image!

 

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Coffee Snow! But thank you! I work for a dog rescue.i figure the photos are a way of sharing something about ourselves that is not incontinence as we all are much, much more than that.

You may now answer with a straight face. "oh really Maymay? That Depends!"

 

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I finally got the call to schedule my botox appointment on Friday. It's not until a week from next Wednesday, nearly six weeks after the original appointment that they canceled, but at least I have it now.

After thinking I had the insurance thing moving forward, it stalled again. I messaged the doctor twice, the first time asking if there was anything else we could do in the meantime and the second time asking if he could refer me to a doctor outside his organization who might be able to do the botox injections and get the insurance paperwork done. After the first message he called in a prescription for Uro-MP (which my pharmacy hasn't been able to get), and after the second I got a message from a different person in the admin side of his office saying that she was working with a surgical scheduler to try to get the insurance issue resolved. After that it took about three days to get the prior authorization.

I need to talk to the doctor about how to make sure this doesn't happen again. They should have been able to get the prior authorization in a few days, and they had plenty of time before the appointment to get that done. My insurance explicitly says they cover botox injections in the bladder, so the claim that they made earlier that it was being denied simply doesn't hold up. They were filing the paperwork incorrectly, plain and simple.

The biggest thing that angers me about all this is that I feel like I've been treated like I just didn't matter very much to them. I don't appreciate that at all, and it erodes my trust in my doctor's entire practice. If the doctor recommends something else and my insurance doesn't want to cover it, how can I trust that it's true? Do I have to spend hours and hours researching everything to see if I'm being lied to?

At least I get my botox this time. Hopefully this doesn't become the battle I have to fight every time.