My appeal rejection letter states the following: "Upon review of available information, WHP has determined that the above-mentioned services are experimental/investigational and not a covered benefit. Therefore, the charges for the above-mentioned services will remain your financial responsibility."
Blah, bla, bla. [grits teeth] Blah, bla, bla. It goes on to say: "If you disagree with this decision, you may request an additional level of voluntary appeal before the WHP Grievance Committee. You must notify WHP, orally or in writing, of your request for this additional voluntary internal level of appeal, within 180 days from the date you are notified of the first appeal decision."
Allllrighty then! Let's break this down, shall we? My supposed date of procedure was Nov. 18, 2010. And thus like a good girl should I attempted pre-authorization as is recommended to do. And guess what? DENIED. When exactly? Well I'm glad you asked. I was denied the very same day we were packed up and leaving for ATL. Anyways, old news.
So we go anyways. Surely there'd be a payment plan. Remember? Right? People don't just have $10,000 layin' around. $550 for the scan. $200 for the consult. And everyone else's insurances had paid - NO PROBLEM! Fine. We can appeal and reschedule. Or take out a very high interest rate 'medical loan.' Yikes! So if everyone else's insurances are doing it. Hmmmm. Maybe with a little hand holding, peer pressure, being shown the money they'd save . . . Just maybe they'd come around.
Y'all know the Welborn Health Plans billboard up on the Lloyd Expressway? Makes me literally sick to my stomach to see the smiling faces on there. Turn off the expressway then Angela before you wreck. Noooooo! There's one on 41 too. Bastards! It's a lie I tell ya. A lie! If they truly are the "BEST" . . . Lord please have mercy on us all. Ahhhh, but I digress.
So I launch an appeal. I even shared it with you. Remember? Took some re re re re-writing to get it to a 'G' rating but I got 'er done. No cursing even. Look it back up. I think you'd be proud. Anyways. Bottom line was savings. Costly monthly drugs vs. a one time procedure. Simple economics. Plus me feeling better = less medical expenses overall, etc. etc.
Screw it all. The hubs wasn't waitin' and the good docs appointment book was fillin' up fast. Before we left the office I was rescheduled for Dec. 10, 2010. That was to be my new birthday come Hell or high water. And we had both remember? Sure woulda been nice if I could have been LIBERATED in November. Just sayin' . . .
So you know the story. Nearly a month and $10,000 later (which we'll be paying on for 5 years by the way) I AM LIBERATED! Upon our return home we admittedly don't find opening the mail is a top priority for us however within a week to 2 weeks from our return we discover a letter from WHP. Yippee. A reversal of their initial denial perhaps? Hah! Laughable! Try a rejection of my appeal - this one dated Dec. 8, 2010.
And the wording. HILARIOUS! "If you disagree with this decision . . ." Now what pray tell could have happened that would have changed my mind in less than a month. Oh gees, if you say it's experimental Mr. big bad insurance company with smiling faces on billboards, then it must be experimental and scary so I MUST NOT WANT TO FEEL BETTER AFTER ALL! I mean really?!? If a couple of docs paid by Welborn Health Plans deem something experimental am I supposed to be okay with that?
Am I supposed to give up feeling better? Standing to brush my teeth? Washing my hair with my head tilted back? Baking? Walking? Staying up late? Getting up early? Feeling like going out? Playing with my boys? Thank God my husband could get a loan fast and easy. But what about the poor souls who have to listen to the billboard monsters? This sickens me. Seriously sickens me. Whilst I'm doubled over in angered despair riddle me this: Is this everyday procedure only experimental because I have MS???? Bastards!?!?! Forgive me.
Where was I. Ahhh yes. Today's oral requestfor "this additional voluntary internal level appeal" because NO, OF COURSE I HADN'T CHANGED MY MIND! So why had I waited so very long to notify WHP of my plans to go in front of this so-called Grievance Committee? Again, dear readers, I'm sooo glad you asked. I, as an Orth, a Spindler, an Angela, hahem (clears throat), I don't do anything half-assed. PERIOD. I wanted all my ducks in a row should they answer my request with a "come in to see us in an hour."
Preparation. I wanted all my clinical notes together. I wanted the disc of the procedure. I wanted before and after videos. I wanted a professional, well thought out plan of attack before proceeding. Up bright and early this morning. 2+9=11. Just a coincidence, but whatever. Today was gonna be the day. At least I'd be put down for wanting to take this to the next level which would catapult me into finishing all I would need to stand in front of this Grievance gang. As many times as I've typed 'grievance' in this entry I can't help but think of General Grievous. Just sayin' . . .
So at 9:25 a.m. this beautiful Wednesday morning I call. As per the letter ORALLY to me in these circumstances means I can call and or show up at their Evansville office and say: "I wanna take my appeal to the next level and go in front of your Grievance Committee." Or something calm and cool and curse word free like that. So I get a very nice CSR Sarah who gives me to Steve in Appeals. "This is Steve," he answers.
Whoopity doo. I thought. I gotta name too. It's even longer and more impressive than yours. Ha. Ha. Ha. Okay. I wasn't at all bitter at that point. Nervous maybe. Apprehensive sure. But I wasn't the pi$$ed off Angela you all know and love until much later on in the brief one sided conversation. Long story short - I'm well aware you have already denied me. And in both rejection letters it mentions different levels of the appeal process. Thus,
"All I'm wanting today kind sir is to notify you orally as per your last letter that I want to heighten this appeal to the next level which is to go in front of a Grievance Committee as I understand it sir." Welllll maybe I didn't use 'Sir' so much but I was civil and kind. My Momma raised me right. His Momma? I dunno. Anyways he says I cannot make such a request orally. Fine. His letter says I can, but WHATEVER.
I undestand trying to make it hard on someone. I mean ya can't just give $10,000 to anybody who just calls in and asks for it right? I was prepared to jump thru a few hoops. And you know what? Thanks to LIBERATION I even felt like jumping. Anyways. Anyways, back to the story. He tells me I must submit the request in writing. No problem. Whatever. His address right in front of me I verify it with him. 1. It's always good to do. And 2. I wanted to show him I had all my shit together so to speak.
An arrogant answer to follow I kindly retort "While I've got you could you tell me a little bit of what to expect going in front of this committee?" Blah, bla, bla. Doctor this. Specialist that. Vote this. All very formal, legal and scary sounding. I retort, "Should I bring legal council at this time then?" Whoa! Phone silence. Verizon guy, you there? Can you hear me now?
"No. No," he says. "This evening meeting is to be quite informal." Huh? We'll see about that. Again per the letter (that apparently doesn't mean beans): "You will have the opportunity to represent yourself or designate another person to represent you . . ." So ummm, yeh, I was a member of Drama Club in high school and I'm wondering if for show's sake I shouldn't rep myself and have about a dozen or so friends and family speak on my behalf as well. Any takers?
More to come my friends. After lunch I'll get to this billboard man actually calling me back. Actually telling me not to bother 'cause I'd been cancelled. What the #@*%???