Health Organization for Pudendal Education

Hi Folks,

Hope everyone had a wonderful holiday season. I did a 16 hour drive on my back to see my dear ones and it was well worth it!

My question for you is about insurance. I have tried and tried and Anthem B/C ,B/S of Colorado will not cover the extra PT sessions that I need. My PT has written three times and it has been turned down for silly things that were not true. Is it possible that they are trying to deny everything because our COBRA is just about up?

Kate

Even if your COBRA is up they will have to pay retroactively for dates of service while you were still insured.

I have Anthem B/C B/S in Nevada but the denials I have gotten have come out of Colorado so we are dealing with the same dept.

I have had very good success writing nastygrams to their appeals dept. They play games. They send you a letter of denial saying you can appeal, but the phone numbers on the letter do not go to the correct department.

So I did an appeal in writing for the 1st denial and pointed out to them that the numbers were wrong. They sent me back an approval, then turned around and sent me another denial for a repeat of the same procedure...with same fake phone numbers!

The first approval letter was from a patient advocate in the appeals dept, so I contacted her and sent the next nastygram directly to her attention to pass along to the right people. I called them on their games and suggested that they were acting in bad faith. I have never been denied for anything since. That stuff scares them into thinking you will complain to a regulatory board.

Important in appeal: They will base their denial on a set of rules and regs. Call customer service and ask where you can find all the applicable rules and regs - they are posted someplace online and the phone rep can guide you to them. Base your appeal argument on why you were wrongly denied, in light of their own rules and regs. Unfortunately if they have played it by the book, you lose. But usually they are bending the meaning so they don't have to pay, and if you display a knowledge of their guidelines they will give in.

Wow, how can I thank you enough?!! I will follow your instuctions to the letter. You wouldn't have any idea if Anthem Colorado will cover surgery by Dr. Hibner, would you?

Kate

We might not be on the same plan; it is just that the Medical Review Dept. or whatever they call it, the people who reject claims, is the same Colorado office for both of us. Otherwise the plan I have is a Point of Service plan which means it covers everybody, without a referral, except that in-network is a lot cheaper than out-of-network. I haven't contacted Dr. Hibner's office so I don't know if he is in or out of network for Anthem.
PM me if you are having trouble composing nastygrams and I can send you mine as samples; they were about another issue (trigger point injections) but might help you get creative LOL.

Well they must have to pay for the dates you are insured over there but i guess you made your insurance plan with some fake insurance agency thats why they are not giving you any benefits now...

Kate;
I had the same problem with United Health Care. They deny EVERYTHING. Every state has a dept of banking, insurance, securities and Health care. Look on the computer for your states phone number. I haven't had to use them yet, but it's been close. I did the Her Majesty thing, plus reams of paperwork showing how more pt could possibly avoid a surgery. My PT wrote a few times also. Finally after me paying 100.00 / wk. out of pocket, they okay it.
Good luck;
Doreen