Re: PLEASE HELP! |
First of all your sister needs to know why the Botox was not covered. Sometimes it is automatically assummed it is for cosmetic purposes(It is given at least 3 times more often for that and is not covered). Sometimes the doctor's office has coded it incorrectly or the insurance won't pay for it except in certain settings.(My doctor can't give it to her patients in her office. She has to schedule it at the hospital outpatient surgery center). Sometimes it is because that doctor is not on your provider list and special permission has to be given ahead of time or you have to find someone who is on the list in your network of approved providers.(Many people have to get letters written saying there is no expert on their provider list and a board has to approve going out of network.) Sometimes the injections are given too often (According to Medicare in TN at least, you can't get it more often than 91 days....not 89, even if you need it every 60 days). My husband's insurance covers medications for a very small fee...I have had the doctor write me a prescription for Botox and paid $3.00 for it because if I got it from the doctor it cost from $460 to $800 a vial. You have to set this up with the pharmacy ahead of time and pick it up within a very strict time frame and handle it carefully and go straight to the doctor's office or clinic or where ever they give it. It comes frozen and must be mixed with non preservative saline carefully and shelf life is very very short....a few hours and it can't be saved. That is why many docs give it only if 2 people come in at the same time.(Too bad if you need it before you can find a partner). Sometimes they just hope you want fight back and go quietly into the good night. NOT! There are probably many more excuses the insurance can come up with for not covering it, but the point is, your sister has the right to know why and then the right to appeal the reason. I have dealt with this for 3 years and it amazes me how many times and how much energy I have had to expend to get the insurance company to do the right thing. So far I haven't lost a battle. It gets old, but you have to do it anyway. It's not fair, but you have to do it anyway. They hope you'll get tired and stop, but you can't, even if you have to go as far as writing letters to Congressmen, Senators, Insurance, Doctors, Drug Co. etc. Hope this helps.
--modified by Delaine Inman at Wed, Jan 30, 2002, 09:47:30
Re: PLEASE HELP!
Delaine, you are right about having to do things exactly according to the insurance companies policies. I was considering switching to a doctor who required that I pick up the botox in advance and the insurance company stated that they would not pay for it that way. You'd think it wouldn't matter, since they cover my medical and drug expenses both, but there's no figuring out their reasoning, if there is any.
Virginia in AL
Re: PLEASE HELP!
Check out www.botox.com They have a patient help department that deals with this very thing all the time. Tell your sister not to give up or give in to the d@#$ insurance company. Get a letter from the doctor and go to the BEBRF site and get a definition of blepharospasm and send that to the Insurance company also.
Dee in OR
Re: PLEASE HELP!
I am with an HMO and Medicare (age 67). There was no neurologist giving Botox included in my HMO network. My primary care physician stated such and referred me, due to that reason, to one out of network. HMO approved it then. This doctor accepts Medicare consignment, which is considerably less than his normal fee. Medicare pays their 80%, then my HMO picks up the other 20%. I've been very fortunate that this went through rather smoothly, but I did take care to jumpcarefully through the proper hoops.
Good luck to your sister in getting approval, which I'm sure she has a right to. Delaine has a good thought, that it might have been coded as cosmetic, which is becoming quite well-known to most people.
Sally in North Idaho where it is snowing and beginning to blow a bit.