What an interesting title, right? It’s like “MORE COWBELL”, but totally different.
O.K. I’m calming down over here.
First off, I must thank SO many of you for mobilizing and reaching out with great advice and insight in order to help me get the $23,000+ medical helicopter ride covered by Anthem Insurance. If you are just tuning in, you can read the back story HERE.
I have taken all of your advice and have begun to act on as much as I can. I am learning that living with a complex medical condition is itself, a full-time job. Not the day-to-day living, but the management of all of the snafu’s that come with an EMERGENCY. It would be awesome to simply spend entire days fighting the big insurance companies, but most of us out there (me) also work full-time, have families and would like to spend free time doing things that are more fun than being on hold at Anthem. These things that are more fun could include: digging out my eyeballs with a plastic spoon (also not covered by insurance), counting to infinity (only Chuck Norris has done that….twice) or watching a coffin warp. (coffin warping is also not covered by burial insurance, but maybe a rider?).
Well now I am just being silly. So let’s get to the fun. The NH Insurance Bureau is helping me. The Boston MedFlight people are helping me, and hospital doctors and staff are helping me. The Anthem Insurance people had this to say when I called this morning:
(After going through 4 voicemail prompts, I get a human. Very nice woman.)
Me: (Giving all claim numbers and explaining that I am looking for more information as I am going to file an external appeal in writing) “I am looking for the written policy from the company that was used to deny my claim. In addition, I do not want a name, but can you provide me with the area of medical certification that the listed M.D. has that was printed in your second level denial letter, received by me on January 14 of this year?”
Anthem Rep: “I can show you how to access the policy online. All of our policies are online and are free to download. Are you able to visit http://www.anthem.com?”
Me: “Yes, thank you, please walk me through that process so I can access and download the policy.”
Anthem Rep: “No problem.”
We do all that and I now have a copy of the words that have been written to deny my life saving. medical flight. I again ask her about the medical doctor’s area of expertise and she asks me why I need that information.
Me: “Well, I am living with a complex neuromuscular condition that is pretty unknown to doctors unless they specialize in that area of care. If the person reviewing my claim doesn’t have the knowledge of treating anyone living with muscular dystrophy, I am not sure if they were/are the best party to make the decision. Again, I certainly don’t need a name, just the background specialization.”
Anthem: “I understand. There is someone that worked on this. Let me see if she is available to speak with you. Can I place you on a brief hold?”
Me: “Sure. Thank you.”
I hold for about 3 minutes and the rep. comes back on telling me that the person that outranks her “does not speak directly with members, but the doctor who reviewed my claim is board certified in medicine.” I press on and am told that Anthem can provide no further explanation.
Me: “O.K. Are we on a recorded line?”
Anthem Rep: “Yes.”
Me: “Excellent. I want to have it on record that I am asking for a medical review of a life threatening claim that has been denied, but you cannot or will not provide me with the fact that the doctor reviewing the claim may or may not be certified to render a judgement as they have no medical or care training in adults with neuromuscular conditions. Is that a correct statement?”
Anthem Rep: (pauses) “Yes. All of our reviewers are board certified and they do not work directly for Anthem. All of them are medical doctors, but we cannot tell you about their specific training.”
Me: “Thank you for your time, and also providing me with the policy. I will be filing, in writing, an external appeal and you will be receiving that soon. I also asked, in my second level appeal, if Anthem had checked with the ground ambulance companies to see if they were otherwise engaged on the evening of 1/2/24 and/or if the level of care ground could have provided would have been equal to the emergency care that I received while in the air ambulance. Were these questions addressed? They were not mentioned in my denial letter from Anthem.”
Anthem Rep: “I can mail all of the notes associated with the appeal to you.”
Me: “Please do that.” I then verified that she had my correct address, thanked her one more time and then hung up.
Now, just for fun…..here are ALL of the criteria that must be met for the company to pay for an air ambulance. I am copying and pasting directly from the document and you will be happy to learn that if the person dies en route, or is pronounced dead on arrival at the hospital, Anthem will cover the cost. Funny. I spoke with a dear friend recently whose mother was airlifted and, unfortunately passed. He told me that Anthem still tried to deny payment even after the poor woman had left the Earth. This is madness and I will keep you all posted as long as you’re still interested. Thank you, I love you all.
CG-ANC-O4 AMBULANCE SERVICES AIR AND WATER.
Medically Necessary:
The use of air and water ambulance services is considered medically necessary when all the following criteria are met:
- The ambulance must have the necessary equipment and supplies to address the needs of the individual; and
- The individual’s condition must be such that any form of transportation other than by ambulance would be medicallycontraindicated; and
- The individual’s condition is such that the time needed to transport by land poses a threat to the individual’s survivalor seriously endangers the individual’s health*; or the individual’s location is such that accessibility is only feasible byair or water transportation; and
- There is a medical condition that is life threatening or first responders deem to be life threatening, including, but notlimited to, the following:
- Intracranial bleeding; or
- Cardiogenic shock; or
- Major burns requiring immediate treatment in a Burn Center; or
- Conditions requiring immediate treatment in a Hyperbaric Oxygen Unit; or
- Multiple severe injuries; or
- Transplants; or
- Limb-threatening trauma; or
- High risk pregnancy; or
- Acute myocardial infarction; if this would enable the individual to receive a more timely medically necessaryintervention (such as percutaneous transluminal coronary angioplasty [PTCA] or fibrinolytic therapy).
*Air transportation may be appropriate if the time between identification of the need for transportation until arrival at the intended destination for ground ambulance would be at least 30 minutes longer than air transport.
Mileage associated with an air or water ambulance service is considered medically necessary up to the distance required for transport to the nearest appropriate facility.
The use of air and water ambulance services to transport an individual from one hospital to another requires that:
A. The above criteria must be met, and
B. The first hospital does not have the required services and facilities to treat the individual.
The use of air and water ambulance services for deceased individuals is considered medically necessary when the above criteria are met and when either of the following is present:
- The individual was pronounced dead while in route or upon arrival at the hospital or final destination; or
- The individual was pronounced dead by a legally authorized individual (physician or medical examiner) after theambulance call was made, but prior to pick-up. In these circumstances the response to call is considered medically necessary.
Remember kids. ALL of the above must be met. That’s a lot of hoops. I guess I will write out the points one at a time. Anyone want to help me edit when I’m done?
First I need to call my cardiologist and get a letter. Then my pulmonary guy. Then I need to visit the first hospital that made the call and get a letter from them (I’ve called twice but got nowhere, so I’ll just pay them an in person visit. Nothing like wasting the ER staff’s time right? They’re not busy….
Oh, the places I’ll go.
How about national TV? I’m down for the talk show circuit. I’m funny too.
Patrick moeschen 