Tuesday, December 22, 2009

Hell Hath No Fury

I have heard over the years stories of insurance company evil - we all have heard them. I was always thankful that I didn't deal with that kind of company. Surprise! Our turn came around.

The Girl has an appointment on January 4 at a clinic that specializes in developmental disabilities. The clinic has been doing this for 60 years so one can assume they've got their act together. The doctor heading up the Girl's evaluation is a developmental psychologist who is affiliated with Stanford's Lucille Packard clinic for children. She is a graduate of McGill, did her residency at Yale, is board certified in developmental disabilities, and actually teaches seminars on how to diagnose speech disorders. In other words, she is exactly what we are looking for.

Sadly the developmental clinic does not take insurance. We will need to get reimbursed by our insurance company for the very expensive daylong evaluation ($3700!). In order to get the reimbursement we must get a preauthorization for it. The request was sent in to the insurance company by our pediatrician with the important details. Yesterday the insurance company informed us they were denying the authorization, saying that there are doctors in our network we can see and so we can not see one that is "out of network".

I called the insurance company and asked for a list of of developmental psychologists that were "in network". The woman I spoke to, Christy, put me on hold and after a bit returned and gave me the name of a psychiatrist. I told her that was not the same thing - we want a developmental psychologist. Christy put me on hold again, longer this time. When she came back she said that she was certain that Children's Hospital in Fresno had one on staff and I should call them. I asked her for a name. She said I would have to call Children's, that it wasn't their job to find me a doctor. I said that since they were the ones claiming there was a doctor "in network" they should prove it to me by giving me a name - it was impossible for me prove a negative (that there weren't doctors in network) especially without a list; it was their job to prove there were. She said she did not have access to a list; only their medical director did and he did not speak to patients. He only spoke to providers. I told her that was nonsense since she had just given me the name of a psychiatrist with no problem. She essentially told me, tough - call Children's.

So I checked. Children's hospital is a first rate facility dealing with many issues and we have availed ourselves of their services before. However, even though they have four psychologists on staff, none of them are developmental psychologists. In fact there hasn't been a developmental psychology department at Children's for five years. Some additional investigation showed there is only one developmental psychologist in our entire area, and she only takes patients assigned to her by the state. That's it.

Insurance company lied. End of story. They compounded their lie by covering it up. This little sham of theirs is the equivalent of me needing heart surgery, them having no cardiac surgeons in network and so requiring me to see a general surgeon for my bypass... or a dermatologist. And they would claim the general surgeon or dermatologist was a cardiac surgeon.

They are scum of the first order.

Though I can fight them, it won't be in time as, sadly, by the time I do ultimately win the appointment will have taken place and they will be able to deny the claim because it wasn't "pre-authorized". Nice little scam they've got, huh?

We are dealing with my child here so mark my words: You don't want to mess with my kid.

I'm coming for you and, to quote a movie, I'm bringing hell with me.

The battle royal began this morning with phone call after phone call to no end. Recommendations for child psychiatrists were the best thing offered. Finally I was provided with the phone number of the CEO of the insurance company. He took my call and listened patiently as I told him the story from beginning to end. He asked me two questions and when I had answered them he told me that he would approve the payment and it would be taken care of within the hour.

I was stunned for a moment and then, through my tears, I thanked him and told him to have a merry christmas. I don't think I have ever said it with more sincerity.


Patricia E. Kefalas Dudek said...

I appreciated this realistic story with a happy ending (nice for a change)!

Maybe you can consider sending the CEO a thank you letter and posting to your blog again if he really followed through with what he promised?

arlopop said...

Actually checked in with authorization department this afternoon and indeed, it has been authorized (I have the authorization # to prove it), so I think he really did do as he said.

I should add some details...
the two questions he asked me were, how much would the evaluation cost, and he shrugged off the cost. The second question which he prefaced with an apology if it sounded cold was, did we plan on using the clinic for services once the evaluation had finished. His concern being that once they approved it the first time they could be on the hook for it afterwards as well. Once I assurred him that the five hour drive to the clinic all but precluded any additional services and that we were only seeking a diagnosis he was satisfied.

He admitted that children's health issues were near to his heart and was aware that services were very limited in our area. It was utterly understandable to him that we would need to go out of network to get what we needed.

His human and utterly concerned response really did move me to tears. A good man.

Blaize said...

Thank you for your Christmas miracle story. The Scrooge of a company became human, with a human face. I'm so glad you are going to get a diagnostic evaluation.

(P.S. I would have cried like a baby.)