Friday, June 29, 2012

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. . . . .

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What's Wrong With Health Insurance in the US?



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.

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