Health Organization for Pudendal Education

OK. I am just complaining because sometimes I have to do that.

Right now we have Anthem BCBS through my husband's employer, at no charge to us. This is what I have going at this time to try to get well:

1. I have an appeal in to Anthem, which took me a lot of time and effort, to overturn a denial get me botoxed. I believe very strongly I will win it, they have no leg to stand on. Their review of the literature in making their argument against botox, does not include anything published after 2002. Among other things, I sent them everything that has been published since then. They received my appeal May 11 and have 30 days to review it.

2. I have a phone conference pending with Dr. Feigenbaum in Kansas City, to see if I am a candidate for tarlov cyst surgery. His assistant told me he reviews charts and calls patients every Wednesday, at an average of 3 patients per Wednesday. I am now #7 in line, but he is on vacation until June 20. So I can expect a call in the 1st half of July. They take my insurance which is a Point of Service plan.

Today I got surprise news from my husband. The city he works for has decided to switch insurance providers as of July 1. He doesn't know the name of the company yet, but was told it is an in-state HMO with an option to use it as a Point of Service plan instead if we pay a premium of approximately $300 per month. So how does that effect me?

1. Assuming Anthem uses their full 30 days to answer my appeal, I will be informed after June 11. Even if they approve my appeal, there is no way I will be able to get a hospital procedure scheduled and done by July 1. So the whole process will have to be re-started with a new insurance carrier, and maybe a new provider.

2. My phone conference with Dr. Feigenbaum will not happen until after July 1. His office took all my insurance info so I think they bill for it. I know Dr. Feigenbaum's office won't take the HMO, but if we pay for the POS it is a crapshoot whether they will happen to take that or not. Then, since he has a long wait list for surgery, I have to magically come up with $300 per month for insurance, for quite awhile. At the same time as my husband is taking major pay cuts because the city is broke. That's why they went with some low bidder insurance company too. It will be interesting to see where that extra $300 per month will come from.

So, looks like it is time to start from scratch. I will have to go down to Human Resources next week with a typed list of questions to find out where this is going to leave me. I love the group of providers I worked so hard to find and am dying to find out the name of our new insurance company to find out if any of my local providers and most important, Dr. Feigenbaum, accept this insurance. if Dr. Feigenbaum does not take the new insurance but thinks I am a good candidate for the surgery, I will if necessary pay out of pocket and go deep into debt to do it. Am wondering if I could keep the Anthem BCBS under Cobra instead as that would be less expensive overall, but I don't know if I am entitled to COBRA since new insurance is being offered to me.

This is horrible news to me. I have given it to you wonderful people who have bothered to read it, and now I am going to give it to God and chill out about it. Could not have come at a worse time, huh? If you got this far thanks for reading my rant

Oh HM this is horrible news. I'm so sorry. I know how hard you worked on that appeal. Some days it just feels like life wants to see how many hurdles we will jump over. UGH!! At least you are on the right track. Listing your questions is a great idea. I tend to forget what I want to ask if I don't list them.

Good luck and keep us posted.

Tracy

HM,
Sorry to hear about your developments. At least you have the POS option. Maybe that will work for Dr. Feigenbaum. Whats the point of POS if you can't pick your providers ? Another example of working people taking it on the chin while the rich get richer. And now the Republicans want to turn Medicare over to the insurance companies so they can take can take care of everybody (as in a mafia hit). Hope things work out. Good Luck .

Best Wishes,

Don

Thanks guys, Tracy & don you have both been so supportive of my insurance mess. While I understand that I am blessed in many ways and have no business accepting good if I am not willing to also accept trouble (Book of Job, my fave!), sometimes a girl just likes a little sympathy
Since I don't know the name of the insurance company yet, for all I know it might be a change for the better (although with the low bidder thing I kind of doubt it!)

I'm sooooo sorry, HM. I wish there was some way to put you at the head of the line while you still have your current insurance, but of course I know the world doesn't work that way. These horrible changes you describe are happening all over and there is nothing good about it. I wish you every possible hope as you go forward. ((((hugs))))

Awwwww...thanks Celeste Even us non-cuddly-seeming people love hugs!

HM, so sorry to hear of your struggles. The good news is: you still have insurance at a great rate! I pay twice that for just myself, I am extremely thankful for that as I purchase my insurance through my old job because of my long term disability status and pay the full rate myself. I have a friend that where she works people pay around $1,000/month for a family plan. I' m just trying to help you see the bright side of a very disappointing and disheartening change in your insurance, you still have insurance.

Hey, HM ...
How very upsetting! I also work for municipal, although my insurance isn't free. I pay $200/week for the BC/BS PPO. The Town I work for sends out bids to insurance companies every fall, so there's always the potential I could have a different provider each year. So far, I've been lucky, but ... there's talk about them completely doing away with the PPO plan this fall, only offering an HMO. I fully understand the devastating effect having your insurance change has on trying to get proper medical care. Especially when you've got all kinds of things in the works!
I'll be keeping my fingers crossed for you, hoping this new insurance has minimal impact on your treatments.
Please keep us posted!
Hugs,
Karyn

What a nightmare!! Insurance is so frustrating I feel like between my medical issues and my sons that I sound half my life fighting with the insurance company! Hopefully this is just a temporary setback and the pos option will work in your favor in the long run. My insurance is pos and it gives me 3 levels of coverage - HMO, ppo and out of network. This gives me much more flexibility to see drs that are out of the network - although it is more expensive to do that. Hang in there I'm praying this will be a positive change for you in the long run!


merrie

Thanks everybody

My husband did tell me, with his typical level of attention to detail, that he thought the plan was "something like United something-or-other", so I am hoping and praying it is a United Healthcare plan because I looked them up last night and they do have an excellent POS which is in-network for Dr. Feigenbaum and all our family's other current providers.

United has so many different plans, I couldn't even locate an HMO that has a network in our city, but I think the HMO is out of the question anyhow. While it will be hard to find another $300 per month, what I REALLY can't afford is to go into a managed care structure right now.

We have so many bills and then the pay cuts looming...but I think I did figure out a way to save some money for the payment...I'll go on a starvation diet to take off all the weight I have put on since I got disabled and went on meds! One less mouth to feed has got to make some kind of difference

BTW don, the deal with POS plans and in-network vs. out-of-network providers, is that to see an out of network Doc with a POS you pay a deductible and coinsurance (my current POS is $250 deductible and 30% of the bill as coinsurance)...and then since the insurance company does not have a contracted price with the provider, they scrutinize the bill to see if the prices are what they consider "usual and customary", and pay 70% only of what they deem "usal and customary". So the patient has a probably potential to pay significantly more than 30% of the bill. That's why even with a POS, I did not want to get my piriformis injections done by Dr. Filler: he charges so far above what the insurance companies consider "usual and customary" that he maintains a financing department to deal with the patients' costs.

The biggest catastrophe would be if Dr. Feigenbaum is not in-network for whatever plan we get. If he's in-network, I'll find a way to live with whatever comes our way. This would actually be our 4th insurance provider since my husband started working for the city 8 years ago, I should be used to it except Anthem BCBS lasted the longest (it's been at least 4 years, maybe 5), so I got complacent I guess