Thursday, May 14, 2009

De-Nied...Again

*This is me a few weeks ago on one of our friends little quads. Didn't go very far or very fast, but it was a nice sense of freedom. Some fun I can have sitting down.*

You know that airline commercial when after some uncomfortable situation is put in front of someone they go out with the tagline, "Want to get away?" Well yep that's me today.

I wish I was out in the desert all alone riding around, releasing some aggression. I know weird right, me the prissy girl. But that's how I feel.

After the "lost" fax last week, I patiently waited for today to come. The day that I would get an answer to the referral request to see the Dr. in San Diego about the option of a continent ostomy. I was confident that this consult would be approved, I mean how could it not be, it's just a meeting and it was made clear that I will NOT be seeing the two jerk surgeons in my network. Guess who was wrong once again!

Well when the mail arrived today, I saw the envelope and as soon as I felt how much paper was in in I knew it was a denial. When you are approved you get one piece of paper with the auth number and info to make an appt. When you get denied you get four pages that describe the denial and all about the grievance and appeal process to dispute it. 

And yes, once I opened the envelope that's exactly what it said -- denied. It stated that elective colorectal surgery would not be approved out-of-network and that there were colorectal surgeons in the network that could provide the services I need. (This is a paraphrase, but not an exaggeration.)

First off, elective? Really, yes I'm electing to have some sort of ostomy because by sphincter was damaged beyond repair during my first surgery. Yes please sign me up, I'll volunteer....NOT. I mean it's not like I'm asking for a face lift of lipo-suction out-of-network. GRRRR.

So while crying and after talking to my hubby and my mom, I left a message for my PCP who wrote the great letter and sent the request asking him to call me back. I also left a message for my GI, who I saw last week, she told me to call her if things didn't work out and that she would band together with my PCP to figure things out. 

After more crying, a brow wax and a hair cut, I got home and called the IPA (Health Network) and asked to speak to the top lady who I've unfortunately had to speak with in the past. She wasn't available so I talked to her assistant who went through everything with me and said that they do have another colorectal surgeon they contract with that's affiliated with UCI Med Center and she sent me an auth to see him. But she did say that if I wanted to appeal the denial of the consult to the SD guy I would have to do that with my HMO. Seriously, how does that make sense, the IPA is the one that made the decision. GRRR.

So I took her authorization and then called the HMO, talked to a supervisor about the appeal/grievance process. He was so nice, I told him I'd already filed a grievance against the original surgeon and explained that I would not be going to anyone in the network, that I wanted to see the top guy in these surgeries, etc, etc. He took all this down and submitted it. He explained that since this is not life threatening it couldn't be sent as an expedited cause and that it would be up to 30 days before I hear the final ruling.

So now what you say? Now we wait to hear back from my PCP and GI and see if they can do something on their end. We wait for the appeal to go through the HMO and hear back from them in June. And we research this other surgeon to at least have in our back pocket, however I don't believe he specializes in the K-pouch so at most he'd be able to do the permanent external ileostomy. 

Oh yes and one more denial came in this week too, denied again for Social Security benefits. Yep according to them I can totally walk or stand for 6 hours in an 8 hour day. I laughed. Now I have to go to an appeal hearing. First step talk to the law firm that is representing me in early June and then set up the hearing.

Bottom line, more waiting and more researching. Until then, it's just one more week until we leave on our cruise, so we will be getting away very, very soon. I can't wait to escape day-to-day life for a while and just be with my hubby. I do have another very exciting thing to look forward to next week. But that will be for another post next week sometime. I'm working my way to having one of these back on my face...

2 comments:

Aim said...

Grrrrrrrrrrrrrrrrrr! Thank God for the much needed cruise!

The Quick's said...

Allison - I feel your pain about the insurance companies, it is total and complete bull shit. I get fired up reading your post because I have been there. All I can say is keep forging ahead - it may take time but perserverance does pay off and you have to be your own advocet - unfortunately! hang in there!