I Spent The Entire Afternoon on the Phone About Chianna's Health Insurance Today

How can anyone say no to her? Staywell Health Insurance sure is trying to.

After all of the back and forth today with the insurance company and doctors offices, my conclusion is that the insurance companies purposely make it impossible to get coverage so that the members give up and then they don't have to pay out.

Currently I believe what is happening is that the medical review division of Staywell that communicates with doctors, and only doctors (not members) has different information and does not communicate with the customer service division that I am only allowed to talk to.

The referral lady at our pediatrician's office gave me the phone number of the person she deals with in the medical review division. I called this nurse named Sandy. I first left a message explaining who I was and to please call me back because I am getting conflicting information. I didn't hear back, so I figured I'd call again since I really don't want to stew over this all weekend. I wish I had recorded the conversation with this woman, who has got to be one of the bitterest, evil human beings I have ever spoke to. Yes, you read that right. On top of everything I am dealing with, this woman decides to be a bitch. And I don't use that lightly, I wish I had recorded the spiteful tone coming out of this "woman's" mouth. And she is a 'nurse'? Pitiful.

Here is a summary of how the conversation went:

Me: Hi, is this Sandy? My name is Shari McConahay
Sandy: I got your message earlier but I didn't have time to call you back.
Me: I'm sorry to call again, but I am anxious to get this situation resolved.
Sandy: (cutting me off) Well, your daughter has already had A LOT of therapy.
Me: Ummm, no, she hasn't had a lot of therapy. That's why I'm calling.  
Sandy: She gets Speech and OT.
Me: No, she gets speech, but not OT or PT.
Sandy: Well then we are both misinformed because ATA says she is getting speech and OT.
Me: Who is ATA?

Sandy: The American Therapy Association, that is where you get your therapy from.
Me: No, we get therapy at All Aboard Therapy
Sandy: ATA is the one who approves it, we don't even do that here.

Me: And the referral dept at her pediatricians office said you said she only gets 24 speech sessions?
Sandy: Yes, and she's used them up, she doesn't get anymore.


Me: She is getting speech, but she hasn't has 24 sessions, so I don't even know why I am being told she has reached any limit.

Sandy: Well then good for you, she still has sessions left!
[Yeah, good for me, Lady!]

Me: I don't understand, why did the supervisor I spoke with at Staywell this afternoon (I provided name and reference #) tell me we get 24 session every 60 days and then it renews every 60 days? I confirmed that it does not run out.
Sandy: We aren't Staywell, we are Wellcare and she only gets 24 sessions it is not continuous coverage forever as long as you want.
(I still am not clear the difference between Staywell and Wellcare, but when I login to our account online, from Staywell, it changes to Wellcare. Her insurance card says Staywell Kids.)
Me: OK, well I am getting 2 different stories and it is not fair that I am stuck in the middle.
Sandy: Well I know what I know and that is you only get 24 sessions. I can't talk to you anymore because I am the only nurse here, and I have other phone calls to answer that are coming in right now.
Me: Well, I am having an emergency here and I need help. How do I find out about getting my daughter approved for out of network coverage for the occupational and physical therapies?
Sandy: We don't approve out of network coverage, that never happens. And there are providers in your area. I told the doctors office to write a prescription for physical therapy.
Me: There are not providers in my area, I actually sent in a letter detailing each of the providers that are listed on the website and the reason that they cannot see my daughter.
Sandy: (Cutting me off before finishing the sentence.) Yeah, I read that, but there are providers.
Me: Can I speak to a supervisor?

Sandy transferred me to a manager's voice mail. I left a message and I hope I can talk to the manager on Monday. I also hope she takes my complaint about Sandy and what an awful person she was to deal with.

I can not tell you the horrid, evil tone this woman had! And I feel I have to add, I was not rude to her at all, she must be upset with something that she deems it necessary to take out on others but she is clearly in the wrong profession.

I then called back the Staywell customer service division that I spoke to and ended up getting no where. They reassured me that "they know for sure" that she gets continual therapy, 24 session every 60 days and that I have to have the doctor's office call back on Monday to request a new authorization to go out of network. They assured me that they do approve out of network providers when it is necessary. It's like I'm talking to two different companies here - and they even call themselves by different names. The company is state run, and it is really messed up. They did tell me that I could have the doctor's office call them instead of the provider line. But I have a feeling that won't go well. We will see what happens on Monday.

In the mean time, I called the UCP and Easter Seals to inquire about advocates. I am calling our local news stations to tell my story. I have already wrote all my politicians, I'm doing that again. I am filing a complaint with the state board for health insurance too. Any other ideas, please let me know.

I don't know how long this is going to take to get my daughter the therapy she needs. It has already been 8 months since she has had the therapies recommended by her doctors. If coverage does run out, or I cannot get the correct therapies for her, the price to pay for them out of pocket is over $1,100 a month. I am going to look at fundraising money so that we can get her the therapy she needs. 


Here is Part 1 of This Insurance Problem


Part 2 of My Insurance Problem


Part 3 of My Insurance Problem

Please share my story.
Thanks,
Shari McConahay
Mama Bear

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Update:

After yesterday, I realized that it will take too long to sort out this insurance crap, and Chianna has already gone 9 months without physical or occupational therapies. We are going to have to get Chianna her therapy without the insurance. But we need help in order to do that because it will cost over $1100 a month. Any small amount will help. Please share our story. Thank you. 

http://igg.me/p/153715?a=799470

Trying to Get Chianna Therapy

The reason I called Staywell today was partly because of another reason: I received a phone call from the referral dept at Chianna's pediatrician's office telling me that she can't receive anymore speech therapy because she has used up the 24 visits she has for her lifetime! When we first were put on Staywell I called them and asked what type of therapy coverage they had and they told me it is 24 visits per 60 days, but I specifically asked and they confirmed that it is renewed every 60 days. Now they are telling the doctor's office one thing. When I called today they supervisor assured me that is not the case and the they do cover 24 sessions per EVERY 60 days. I have been back and forth on the phone between her pediatrician's office and Staywell and we are each speaking to a different department that the other is "not allowed" to speak to and getting a different story. Someone, please help!

My Next Post on This Topic is:

I Spent The Entire Afternoon on the Phone About Chianna's Health Insurance Today

Previous Posts on This Topic:

Trying to Get Chianna Therapy

What's Wrong With Health Insurance in the US?

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Update:

After yesterday, I realized that it will take too long to sort out this insurance crap, and Chianna has already gone 9 months without physical or occupational therapies. We are going to have to get Chianna her therapy without the insurance. But we need help in order to do that because it will cost over $1100 a month. Any small amount will help. Please share our story. Thank you. 

http://igg.me/p/153715?a=799470

Staywell Insurance Problems - Out of Network Coverage

So, I am currently on hold while I type this with Staywell health insurance, the insurance that covers my daughter. Since I last wrote, I have been going through Herculean efforts in attempt to get coverage for out of network therapists through Staywell for my daughter's physical and occupational therapy. They first asked for a letter from her pediatrician. It took me a month of back and forth with the doctors office to get the letter. Then Staywell tells me that they don't need a letter, they need the doctor to call to get the necessary forms they have to fill out. It took several phone calls and several hours for her doctor's office to do this.

To digress, my daughter has Cerebral Palsy and needs speech, physical and occupational therapies to give her a chance at a better life, to help her learn to use the weakened right side of her body. The longer she goes without therapy, the more her muscles stiffen and the less help the therapy is. Although C.P. is not progressive, without the necessary therapy, she gets worse.

Staywell does not have enough providers in our area for therapy. Since the doctor's office submitted all the information Staywell requested on June 14, 2012, I have called Staywell several times to check on the status. My last call to them was on Wed. June 27th. First they told me that the Dr. had to call again because they are missing information. I asked what information is missing and she tried to tell me the doctor's office had to call. I explained that they are making it impossible for my daughter to receive the therapy she needs because the doctor's office cannot continue to call spending hours on the phone. She put me on hold, came back and said she was sorry, she saw the doctor's office did send in the necessary info and that the case was in review. She said it should only be a few more days since it takes about 14 days.

So I called today to check the status. First I was told there is no record of any request. After I told her there had to be since I have called about it several times, she found it, and tells me that they need more information and for the doctor's office to call. I freak out and ask to speak to a supervisor. She tried not to get me a supervisor, but did after I threatened to show up at the office with attorneys.

Now I am speaking with the supervisor, and they are telling me that the medical review division closed out the case on June 20th with the reason "no authorization was necessary". She is telling me that the doctor's office needs to call back because that department doesn't speak to members, only doctors. That the information on the original request didn't say the request was for an out of network specialist. WHAT!!! It definitely did and my letters to them and the doctors information did as well. They purposely give people the run around so that they will give up because no one can spend the time on the phone and on hold and calling the doctors offices, insisting that they help me.

She told me that the only thing to do is have the doctor's office call back and submit a new request, make sure it says out of network coverage and ask for expedited, it will take only 3 days.

We will see. To be continued. . . . .

Next posts on this topic:

Trying to Get Chianna Therapy

I Spent The Entire Afternoon on the Phone About Chianna's Health Insurance Today

Previous Posts on this topic:

What's Wrong With Health Insurance in the US?

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Update:

After yesterday, I realized that it will take too long to sort out this insurance crap, and Chianna has already gone 9 months without physical or occupational therapies. We are going to have to get Chianna her therapy without the insurance. But we need help in order to do that because it will cost over $1100 a month. Any small amount will help. Please share our story. Thank you. 

http://igg.me/p/153715?a=799470