J
jrotier
Guest
Ok, so I don't post very often, but wondering if anyone can shed some light onto my dilema.
I've been having some insurance issues latey. I feel I am prety well-versed in the insurance world, my mom works for a doctors office and her job is to prior auth surgeries, I work in health care as well. I am well aware of the need to get doctor's orders, the prior auth approval process and so forth.
I'm running into issues where my CF center / Doctor obtains the prior authorization, I get the test / medicine, then my insurance turns around as says it's not covered for whatever reason.
The first was a bone density scan I had (obviously, recommended for CF'ers). The test even demostrated osteopenia, but my insurance company said since I did not have any of the "recognized" risk factors, it was not a covered benefit. To me it seems that if I have osteoepnia, I obviously have a risk factor, seems like common sense. I had to take it all the way to an independent medical review and am still awaiting the reult.
The latest is coverage for Levaquin. I just got a letter stating it's not medically necessary, yet they aproved the prior auth.
I realize a prior auth does not guarantee coverage, but I though the whole idea of a prior auth was a situation in which the information provided demonstrates the medical necessity, then, the insurance tells me it's NOT covered because it's NOT medically necessary...
I just don't know where to go from here. It's not so much that they won't cover it, their guidelines are their guidelines and I can't argue with that. But how can they prior approve it, then turn around and deny it.
Any recommendations how to fight this? I live in CA if that makes any difference.
Thanks for any advice!
I've been having some insurance issues latey. I feel I am prety well-versed in the insurance world, my mom works for a doctors office and her job is to prior auth surgeries, I work in health care as well. I am well aware of the need to get doctor's orders, the prior auth approval process and so forth.
I'm running into issues where my CF center / Doctor obtains the prior authorization, I get the test / medicine, then my insurance turns around as says it's not covered for whatever reason.
The first was a bone density scan I had (obviously, recommended for CF'ers). The test even demostrated osteopenia, but my insurance company said since I did not have any of the "recognized" risk factors, it was not a covered benefit. To me it seems that if I have osteoepnia, I obviously have a risk factor, seems like common sense. I had to take it all the way to an independent medical review and am still awaiting the reult.
The latest is coverage for Levaquin. I just got a letter stating it's not medically necessary, yet they aproved the prior auth.
I realize a prior auth does not guarantee coverage, but I though the whole idea of a prior auth was a situation in which the information provided demonstrates the medical necessity, then, the insurance tells me it's NOT covered because it's NOT medically necessary...
I just don't know where to go from here. It's not so much that they won't cover it, their guidelines are their guidelines and I can't argue with that. But how can they prior approve it, then turn around and deny it.
Any recommendations how to fight this? I live in CA if that makes any difference.
Thanks for any advice!