Commonwealth of VA - REFUSES TO COVER CGMS

[jpb286]

Commonwealth of VA - REFUSES TO COVER CGMS (NOW COVERED!!!)

I spent all morning on the phone with Anthem BC/BS and they told me they will not cover any CGMS product, because my policy is under the Commonwealth of Virginia, and the Commonwealth of Virginia states that they will not cover it. I was told I cannot appeal because this is not Anthem refusing to cover it, but the Employer refusing to cover it.

I have been trying to call the Commonwealth of VA Human Resources Dept. all afternoon, but no one has answered the phone. Not to be outdone, I call the Governor's Office to inquire why no one was answering the phone during normal government business hours (M-F/ 9a-5p), and they said they didnt know why, and that they "must be in a meeting" or something. I politely asked them if they could ask Governor Kaine to please hire someone to answer the telephone when all staff members are in a meeting, since we had a 1 billion dollar surplus the last time I checked. I told him this was a government matter of the highest importance, and the fact that no one was answering the phone was unacceptable.

Now I don't know where to go with this. Anthem told me that I couldnt appeal. They also told me that the state would not change their member benefits because of one person. (I don't care what they said, I am trying to schedule a meeting) I politely told them that they should strongly consider it if that one person was costing them $80,000 in hospital visits and associated follow-ups a year.

Now, Where should I go from here?:eek:

[rmccully2000]

It sounds like you may have to make your appeal to your employers HR. I would draft the appeal just like you would for the insurance company. I would also recommend getting a case manager at Patient Advocate to assist you. They have been helpful to us when appealling for medical benefits.

http://www.patientadvocate.org/

We were able to get our employee to change their policy and cover some dental work related to a cleft palate.

Good luck!
Becky, Mom to Mason, 7, Dexcom, Iport

[EmmasMom]

Yikes! That sounds like an uphill battle, but I agree that it's still worth fighting! I don't have any particular advice, but wanted to wish you luck!:cwds:

[jpb286]

I made great strides today. I have been talking to the wrong people(Anthem). The state is who I needed to talk to as they write the policy, they can decide what is approved and not approved, NOT ANTHEM. If the state says to pay and Anthem refuses to pay, go to court and get a court order ORDERING Anthem to pay. If they refuse they are found in contempt of court and fined up to the maximum allowed by law.

9:02am EST: I call from Anthem, and ask them why they wont approve it. They tell me that the state writes their policy, so I have to get approval from them.

1:06pm: I call the state.

3:04pm: They call me back with the decision that "they have no problem approving this" and to call Anthem.

3:12pm: I call Anthem and tell them to approve this and they refuse to.

7:02pm: I contact a legal advisor who states to:
1) Get a letter from Anthem stating "the state is responsible for deciding"
2)Get a letter from the state saying "we have direct Anthem to pay for CGMS"
3) Forward this letter to Anthem and when they stil refuse to pay the claim "get a copy of their refusal letter".
4) Take copies of all 3 letters to court and get a court order "Ordering Anthem to pay $XXX.xx for CGMS.
5) If Anthem still refuses they will be found in Contempt of Court and assessed up to the maximum penalty by Virginia law.

Tomorrow: Get all letters together and take Anthem "to the cleaners."

[rmccully2000]

Yeah!! The important part was getting your employer to approve the coverage :) With self-funded insurance plans, they get to call the shots. I'm so happy the state is on board. Now that you have them backing you up, you are in good shape!
Best of luck tomorrow :)
Becky, Mom to Mason, 7 Dexcom, IPORT

[Boo]

You Go Paul!! ;)

[MLH]

I am sorry you are going through this. I just fought Aetna to cover the cgms and won. I really think the reason I was successful is because I FINALLY got through to the right person. It took me hours and hours to do it, but here is how I did it.

I found AETNA's home office on the internet. I also found a phone #. I asked to speak to the CEO. I asked over and over and over again. Finally, the CEO's operator put me through to a supervisor. Amazing, she actually knew what she was doing and got me a case manager. If you can get a case manager with a medical background you at least have a chance of her understanding what a cgms is. I also had an awesome letter of med. necessity from my endo. It described my daughter as a brittle diabetic who checks 15 times a day and still misses lows. I had all this with me and faxed it to the case manager right away so there was no waiting. I also had tons of info from minimed about the cgms and I did research on the internet and copied articles right from CWD about the cgms. I was planning on faxing all this stuff everyday until I got what we needed. I was being hysterical. My mother insists that can help!

So, maybe if you ask to speak to the gov. and the CEO of the company where your insurance comes from it might help.

I know this is hard, but you are the only one who can be an advocate for your child. Don't let them get the best of you!!! We will support you and give you extra strength to win this battle!

Good Luck and keekkp us posted.

Michele mom of
AGH 9 dx'd 5 pumper and
LMH 6 nonD

[jpb286]

I know this is hard, but you are the only one who can be an advocate for your child. Don't let them get the best of you!!! We will support you and give you extra strength to win this battle!
Michele mom of
AGH 9 dx'd 5 pumper and
LMH 6 nonD

Lol, I am the adult trying to get authorization in this case, no kids here! :D

[MLH]

:o Sorry Paul, my bad. My kids were talking to me this morning and I guess I didn't read the end too closely! Either way, I wish you the best in trying to fight the system. I am hoping if enough people start asking their insurance companies for this, they will have no choice but to cover them, just like they cover the pumps now.

FYI The dr. that approved mine in his letter stated that the cost of the cgms was still cheaper than 1 visit to the ICU for a severe low or DKA. I think he gets it!:cwds:


Michele mom of
AGH 9 dx'd 5, pumper and
LMH 6 non D

[jpb286]

I got a somewhat unexpected phone call on my cell phone as I was at lunch. It was Brian Hamman from the office of Insurance Benefits at the Commonwealth of Virginia who contacted me yesterday to arrange a conference call with Anthem for today to get this sorted out. He was so helpful throughout the process, I am going to write a letter to the Governor, and copy the Director of the Office of Insurance Benefits.

We had been having back and forth communications with Anthem, and they(Anthem) didnt understand that they had little say in the grand scheme of things. We did a conference call, and they said "they didnt understand why it was necessary to have a conference call" and I told them that if they had handled this process at their end correctly from the get-go, this call WOULDNT be necessary. I told them because it is a self-service policy, Mr. Hamman's office has to authorize it and he has, which means you are obligated to pre-authorize the medical equipment; and I want to get pre-authorization for this while all of us are on the phone.

I get put on hold, and get patched through to a staff physician who I explain the situation to (DKA related hospitalizations, frequent hypoglycemia, etc...) and he says that "it's no problem, and to stand by a minute." About a minute later he comes back on the line and gives me my pre-authorization number to file the initial claim good for 30 days.

Anthem granted pre-authorization at 80/20 for any CGMS Claims I file.

So the device will be $375 (80/20= $75) + 175(80/20= $35) for the sensors, so out of pocet annual cost will only be around $400. I am SO HAPPY!!!!

POLICYHOLDER: BISHOP, JAMES P
DOB: 11/18/1986
ID: XXX-XXXXXXXXXXX
GROUP: 12000000

Pre-authorization GRANTED for JAMES P BISHOP for DME (continuous glucose monitoring system) and DME ACCESSORY (replacement sensors) per __________ at Anthem BC/BS as of 04/06/07. This preauthorization will remain in effect until 05/05/07. Please don't hesitate to contact Anthem at ____________ if you have any questions or require further assistance.


The process I ultimately had to go through:
1) Call anthem, get denied.
2) Call employer, no answer.
3) Call the Governor's office to inquire why no one is answering a government phone during normal business hours.
4) Recieve a phone call back the same afternoon from the Insurance Benefits office at the Comm. of VA. They give the OK for the CGMS.
5) Call Anthem, tell them employer says ok, and here is Mr. Hamman's phone number. Anthem denies coverage again.
6) Receive call again from the Comm. of VA to set up a conference call with Anthem to explain to them they have to authorize it if the employer is actually the one paying out the claims(via Anthem). Anthem puts physician on the phone who okay's the pre-auth.
7) Pre-authorization granted for CGMS and related supplies.

[rmccully2000]

HOORAY!!! I'm so happy for you too :)
Good work Paul.
Becky, Mom to Mason,7 Dexcom, Iport

[badshoe]

That is moving at the insurance and government bureaucracy equivalent of lightspeed. Congratulations.

[jpb286]

Bishop: 1, Insurance Company: NOTHING!!!!

[jpb286]

That is moving at the insurance and government bureaucracy equivalent of lightspeed. Congratulations.

Its amazing what you can do if you call the Governor's office and use the right terms. I got the Commonwealth of Virginia and a National Health Insurance Corporation to go from denied, to bypassing any medical review panel, to approved in record time.

Call to Governor's Office:
Me: "I can't get anyone to answer the phone(at the HR dept). I have a government matter of the utmost importance that needs to be handled immediately."(Well this IS true, since the ins. is through the Comm of VA, it IS a government matter, and it IS of the utmost importance to me!)

Call with Insurance Dept. at the Comm. of VA:
Me: "Anthem refuses to preauthorize a $600 device that may have prevented you from paying for 3 hospitalizations in the last 12 months."
(he punches up total absorbed cost of 3 hospitalizations, followed by a whistle of shock)
HR: We have NO problem authorizing this, let me set up a conference call since they dont seem to be able to understand how to do their job here.

Conference Call with Anthem:
Me: This is James Bishop, I have Brian Hamman from the Comm. of VA on the phone.
Anthem: Who is he?
Hamman: I write the insurance policies for the Comm. of VA, and this gentleman has my authorization to be able to file a claim for a non-covered item, that apparently you refuse to handle, despite authorization from us.
Anthem: Okay, well we cant authorize a non-covered item
(Hamman interjects)
Hamman: Thats why I am on the phone with you now. Do it. (the pre-auth)
Anthem: But we cant cover this...
(Hamman interjects)
Hamman: You dont have any say so, we(state) pay the claims, not Anthem; we can do whatever we please. Do the preauthorization now please!
Anthem: Okay, hold on......Okay here is the pre-auth number_____.
Me: Thank you Mr. Hamman, and you madam.

I WIN. GAME OVER.

[Noel]

I am in awe! Congratulations!