Spasmodic Dysphonia Bulletin Board

Insurance Denial
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Posted by: Faye Casanova ®
10/31/2007, 20:39:18
Hi,
I am a teacher who has received botox injections for the past 2 years. My state teacher's insurance company, Blue Cross Blue Shield, has covered the injections. Suddenly with no explanation, they are denying coverage. I have not received a response from the company. My school district personnel suggests retirement. I have asked my local senator to help me. What else can I do? I feel like suing them. I can't teach without a voice. Why can't they just tell me why this is happening? I am considering applying for disability retirement. Any advice?



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Re: Insurance Denial
Re: Insurance Denial -- Faye Casanova Top of thread Archive
Posted by: Hoarse Whisperer ®
10/31/2007, 21:51:29
1. First, get your doctor involved. This happened with Blue Cross Blue Shield (BCBS) in Texas recently. The doctor involved (Dr. Barbara Schultz at the University of Texas Southwestern Medical Center) took up the fight and provided BCBS with medical necessity documentation and got coverage reinstated. Interestingly, while some claims were denied, others were still being paid. Anyway, Dr. Schultz is a hero around here.

2. Get help directly from Allergan, the pharmaceutical company that makes Botox. I've heard they are terrific at working with insurance companies and helping them understand the difference between cosmetic Botox and therapeutic Botox, which is used for certain neurological conditions.

www.BOTOXReimbursementSolutions.com
Toll-free phone: 800-44-BOTOX, Option 4 or 800.530.6680
Toll-free fax: 877.530.6680
Hours: 9am – 8pm ET (Mon – Fri)

3. File an appeal with BCBS. Your rights and the instructions how to appeal their decision should be listed on your Explanation of Benefits (EOB) form. Or you can call and ask them how to file an appeal.

4. File a formal complaint with your State Department of Insurance. I don't know what state you live in, but each state has a department that deals with insurance issues. The names may be a little different from state to state, but essentially they do the same thing - help customers with disputes against insurance companies. Many states, like Texas, allow you to file and monitor your complaint online.

5. Get your school district or teachers' union involved. Whoever your insurance is contracted through should have a human resources person who can help with claims that have been wrongly denied.

6. If you know of others that have been denied, this might qualify for a class action lawsuit. An attorney may be willing to take this on a contingency basis. Even a letter from an attorney threatening this may be helpful.

I would use every single one of these suggestions and hit BCBS from all directions.

Most importantly, don't give up! There are many resources available to help you get the medical treatment you need and that you pay insurance premiums for.

Good luck!

Lori
AB/SD and VCD since 2003
Dallas, Texas




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Re: Insurance Denial
Re: Re: Insurance Denial -- Hoarse Whisperer Top of thread Archive
Posted by: Faye Casanova ®
11/01/2007, 18:29:31
Thank you for the advice, Lori. My doctor did appeal, and BCBS upheld the denial. I am waiting to hear from some other contacts. Most people I've talked to don't seem to care. I will follow your advice. I've not given up, yet. By the way, I live in Mississippi.



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Re: Insurance Denial
Re: Re: Insurance Denial -- Faye Casanova Top of thread Archive
Posted by: KellyAnn ®
11/02/2007, 12:35:18
I had a similar experience where I was denied. After numerous phone calls getting no where, I followed the formal appeal process for my then insurance company. It literally took almost a year of back and forth between my doctor and insurance company, but ended up that I never paid a dime. I would persevere until resolved in your favor. I just never gave up and never took no for the final answer.



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Re: Insurance Denial
Re: Insurance Denial -- Faye Casanova Top of thread Archive
Posted by: anneL ®
11/22/2007, 20:30:19
I also am a 27 year veteran teacher in Alabama with SD diagnosis. I have received Botox injections for 1 year. Though it helps, it is very difficult and not fair to students to continue teaching. I am about to apply for Social Security disability. I was wondering if you've had any success yet or any suggestions for me?
Thank you, anne



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Re: Insurance Denial
Re: Re: Insurance Denial -- anneL Top of thread Archive
Posted by: Cocoacat ®
11/26/2007, 22:03:03
I've been teaching for 18 years and only 1 year SD diagnosis and Botox injections. I agree with you that it's not fair to the students. Out of 3 months time, I'm whispery for a month, decent for a month, and then deteriorate for a month. I only feel like talking during the middle month. I can't see myself doing this until retirement age. It's taking a toll on my mental health as well. Is this something that can qualify us for disability retirement from the district? Also, my insurance (Blue Cross)doesn't cover Botox unless the injections are at least 3 months apart. One time, the doctor's office talked to the insurance company and had an exception made for 11 weeks injections instead of 12 since school was about to start and I have to travel 6 hours away to get the injections. Other than that, I haven't run into any problems with insurance.



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