digging in

The reason why I have procrastinated so much in making new appointments for Tristan for September is because we have a NEW doctor we have to go to. I spent the better part of 2007 getting permission (aka referral authorizations) from my insurance company to go to all these specialists. 6 doctors might not sound like a lot, but when each one comes with weeks of work, it really adds up. Plus there is the added bonus that the insurance may turn us down and we did all that work for nothing.

Here is how the system should work.

1. your PCM (primary care manager) tells you that you need to see a different doctor - usually it is a specialty doc (like derm)

2. You call your insurance company and they give you a list of all those types of doctors in your area, you pick one, the PCMs office faxes a request and with in a week you are making your appointment.

Here is how the system works for us.

1. Your pediatrician tells you that you need to see a specialist because what he has noticed in your son is beyond his practice of care.

2. You call your insurance company and they tell you that there is NO doctor with in 150 miles of your treatment area (home) that is ' in network'.

3. So, you are now left with trying to find a doctor 3 hours away who has the ability to help your son. (fortunately our pediatrician knew of one that he told us about)

4. you call your insurance company to see what steps are need to be taken to get approved.

5. they tell you that your PCMs office will fax a request for approval and then they will review it and let you know. They also tell you that the referring doctor needs to submit 'proof / reasoning' as to why your child needs the care that you are requesting.

6. once you have all that you wait on the doctors office manager to actually submit the referral request.

7. wait a week and call the insurance company to see if the request has been received.

8. call doctors office to let them know that the insurance company didn't receive the request ask said office manager to re -send the request.

9. repeat steps 7 and 8 a few times.

10. finally receive word from the insurance company that your referral has been received and denied because it was filled out incorrectly.

11. go back to step six and repeat steps 7-9

12. finally after 100 calls back and forth to each respective agency receive word that your request has been approved.

13. fall to your knees in prayer and tears.

You might be wondering what would happen if I didn't keep following up with Tristan's doctors office. Well, I found out. In May Tristan started receiving speech therapy. Before I made the appointment I called the doctors office and requested a referral.... even the agency that was seeing Tristan requested one too! 2 times! For some reason it didn't get done.... the office manager either sat on it, forgot about it or was abducted by aliens.
Finally in July the requested was sent and approved.... and now I am fighting to get the referral backdated so that I don't have to pay out of pocket for 2 1/2 months of therapy!

We need to see a geneticist in September. I have contacted 2 of Tristan's doctors to write letters to accompany the referral request. I have contacted the PCM office to let them know that we are requesting a referral and that the letters need to be attached.

Now I wait. and I call. wait, call. wait call. I fax and I email, I fill out forms, and I send letters... and I wait and call.

Every time I call the office manager tells me that she has sent the referral request in... and each day I check with the insurance company to find out that it hasn't been received. Back and forth....

With every request that I make, I provide written proof with a date, so that I can keep track of the whos, whats and wheres.

I shouldn't have to do this. The office manager should just send it in when she gets the request. She should check to make sure her fax went through and then follow up with a call to make sure the insurance company gets it.... but she doesn't..... she lies to me and tells me its done.... and I wait.... and wait. It has become so bad that I have contacted the officer managers managing agency to help me... not sure what they can do, but I felt like they should know what was going on.

Today I got up the energy and courage to start on this marathon. Guarding my emotions, making sure I don't cry when I get asked over and over again about Tristan's condition. Making sure I don't get angry and yell at the people who (in my eye) keep dropping the ball. And always, keeping my hope in check... not wanting to put all my faith that the next doctor will be 'the one' with the answers and the one who can end this race.


Tracey said...

I sincerely hope so! I can imagine all the frustration and do not envy you. I really hope this works and ends for you soon. I know when I've had to deal with several doctors all at once it was very frustrating for me and it wasn't one-tenth of what it sounds like you're going through. Good Luck.

Leah said...

Its awful. Your blog has me now on the phone with our in common ped's office to make sure Salem's cardiologist referral got sent. UGH. I'm sorry. It does suck. Hang in there. Call me if you need me.

Williams Family said...

I'm so sorry. I battled that for myself, not my kids. I assume it will be trouble when my doctor says you'll need to request a referral. But hey, praise God for health insurance.