The insurance company doctor that denied Punkinhead's March Synagis shot gave his reason for denial as "treatment not consistent with published medical evidence."
It's a TOTAL lie. Our state officially extended the RSV season here on March 8th because of..........VIROLOGY SUPPORTED HIGH LEVELS OF RSV!!!!!!!!! And the state published that info too.
All of Punkinhead's doctors say a March course of Synagis is needed and we even know that the health"care" company is approving shots for other babies all over the state so clearly they know it's needed. This is getting ridiculous.
Our last hope is that Buzzkill's company complaining that they paid for Punkinhead to be covered and that they're losing money with all the hours Buzzkill has to spend on the phone trying to get this fixed will get the insurance company to approve her shot.
HotMommy has been crying some hot tears of frustration today.
Showing posts with label healthcare. Show all posts
Showing posts with label healthcare. Show all posts
Friday, March 14, 2008
Wednesday, March 12, 2008
I'll go all 15 rounds if that's what it takes.
The latest on the Syngais saga....
Apparently, I've misunderstood the cost of this shot. It's about $1,100 a DOSE not a shot and Punkinhead is now getting THREE doses based on her weight. If we pay out of pocket that's $3,300!!!!!!
So lets add up what the cost would have been if we'd had to pay for all her doses October-February. $11,000
We were referred to a group that is run by the Synagis makers that helps people get the medicines their doctors tell them they need when the insurance companies say no. This group can really help put pressure on the insurance company and has helped our doctors billing office realize that the insurance coordinator won't return their calls because if they stall long enough, it will be too late for her shot to be effective and they won't have to pay. They gave them advice on how to get around the local representative that's stone-walling. Buzzkill and I also got some helpful tips. We went to Buzzkill's benefits person at work and explained what's happening so she can put pressure on the insurance company. Buzzkill's employeer is the insurance company's "real client" and they're much more worried about the company's business than they are about our individual complaints.
We've also been told by this helpful group that despite what the insurance company's local rep has told the doctor, our insurance company is paying for Synagis injections for March ALL OVER the state because our RSV season is longer!
HotMommy is determined this health"care" company is going to pay what they're supposed to! (Rocky theme plays in the background of my mind)
Keep those positive thoughts and purposeful prayers coming. They're greatly appreciated......
Apparently, I've misunderstood the cost of this shot. It's about $1,100 a DOSE not a shot and Punkinhead is now getting THREE doses based on her weight. If we pay out of pocket that's $3,300!!!!!!
So lets add up what the cost would have been if we'd had to pay for all her doses October-February. $11,000
We were referred to a group that is run by the Synagis makers that helps people get the medicines their doctors tell them they need when the insurance companies say no. This group can really help put pressure on the insurance company and has helped our doctors billing office realize that the insurance coordinator won't return their calls because if they stall long enough, it will be too late for her shot to be effective and they won't have to pay. They gave them advice on how to get around the local representative that's stone-walling. Buzzkill and I also got some helpful tips. We went to Buzzkill's benefits person at work and explained what's happening so she can put pressure on the insurance company. Buzzkill's employeer is the insurance company's "real client" and they're much more worried about the company's business than they are about our individual complaints.
We've also been told by this helpful group that despite what the insurance company's local rep has told the doctor, our insurance company is paying for Synagis injections for March ALL OVER the state because our RSV season is longer!
HotMommy is determined this health"care" company is going to pay what they're supposed to! (Rocky theme plays in the background of my mind)
Keep those positive thoughts and purposeful prayers coming. They're greatly appreciated......
Monday, March 10, 2008
Shot update
We're officially denied coverage for her March shot.
It looks like the CDC is saying for April no one needs a shot because this RSV season is ending early. Since we don't have to worry about coverage for an April shot, we're going to bite the bullet and pay for March.
We could quarantine on principle, but then I might go insane before the end of March, and really it's about what the Punkinhead needs more than anything.
She should get it tomorrow. Health"care" sucks. Pardon my language.
It looks like the CDC is saying for April no one needs a shot because this RSV season is ending early. Since we don't have to worry about coverage for an April shot, we're going to bite the bullet and pay for March.
We could quarantine on principle, but then I might go insane before the end of March, and really it's about what the Punkinhead needs more than anything.
She should get it tomorrow. Health"care" sucks. Pardon my language.
Tuesday, March 4, 2008
RSV stuff, this is long with no pictures
We got a call from Punkinhead's pulmonary specialist today that has us fairly concerned. As most of our friends and family know, Punkinhead was born about 9 weeks early and because of that has to get a monthly shot for RSV. We and all other families that have our same health"care" company and go to the same pulmonary specialist have been denied coverage for this shot for the month of March. The doctor's office tells us this happens from time to time and not to be worried because they negotiate the coverage back, but they've canceled her Thursday appointment and let me know that she has to have her next shot rescheduled no later than March 13 or we have to quarantine ourselves. The other option is to pay out of pocket and then negotiate for reimbursement from our stupid health"care" company. Yeah, right, we'd never see that money again.
A lot of you have asked questions about this RSV thing, so I thought I'd put something up to explain it for those interested. Don't feel obligated to read it, it's kinda boring medical stuff, but please everyone, just say a prayer that the awesome folks at her doctor's office can negotiate quickly and easily and we can get her next shot ASAP!
I’ve borrowed a lot of the information in this blog with gratitude from another blog mommy facing some of the same challenges.
For those of you unfamiliar with RSV (Respiratory Syncytial Virus) let me do my best to explain. Like the flu or common cold, RSV is a seasonal virus. It starts in October and continues through April. It's common and easily spread infecting nearly all children by the age of 2.
Most kids (born at full-term) develop moderate - severe cold like symptoms, but due to preemies fragile, less developed lungs and lower immune system they are at increased risk for developing severe RSV infection leading to severe lung infection (ie: pneumonia), life-threatening breathing problems, hospitalization, etc.
The common complicating risk factors include: Premature birth (35 wks or less),
Low Birth weight (less than 5.5 lbs), Heart disease, Lung Issues, Being Around Other Children, Family History of Asthma, Exposure to tobacco smoke, Multiple Births
Punkinhead had the first two risk factors, but luckily none of the others apply and we can control her exposure to other kids. A lot of people have a hard to getting their insurance to cover the treatment (a shot of Synagis once a month), but because Punkinhead was born before 32 gestational weeks weighing 2 lbs 14 oz, up till now we didn't have issues being approved for it.
Synagis is the only approved medicine to protect from the severity of RSV, which is the #1 cause of hospitalization in babies under one year. However, if we paid for the shots on our own it would cost us about $1000 dollars per month for a grand total of over $8,000! It so expensive because it is actually NOT a vaccine, it’s the an antibody injection. A vaccine is a small amount of a dead virus that your body reacts to by developing antibodies to it and then it is prepped to fight the live virus when you encounter it. There is not a working vaccine for RSV so Punkinhead is given a ready-to-fight antibody that requires a “booster” dose every month. The first dose was only one shot, but once she was over 15 lbs, it’s a LONG needle in each leg every time to give her the right dosage.
Our health"care" company's purpose in cancelling ALL our pulmonary specialist's patients for the month appears to be an attempt to rid themselves of a few patients. They cancel us all, make us beg for it back, make us worry about our kids, and then make some money by cancelling coverage for a couple of kids whose risk factor is on the borderline at the end of RSV season. It's sick and makes me want to move to Canada.
A lot of you have asked questions about this RSV thing, so I thought I'd put something up to explain it for those interested. Don't feel obligated to read it, it's kinda boring medical stuff, but please everyone, just say a prayer that the awesome folks at her doctor's office can negotiate quickly and easily and we can get her next shot ASAP!
I’ve borrowed a lot of the information in this blog with gratitude from another blog mommy facing some of the same challenges.
For those of you unfamiliar with RSV (Respiratory Syncytial Virus) let me do my best to explain. Like the flu or common cold, RSV is a seasonal virus. It starts in October and continues through April. It's common and easily spread infecting nearly all children by the age of 2.
Most kids (born at full-term) develop moderate - severe cold like symptoms, but due to preemies fragile, less developed lungs and lower immune system they are at increased risk for developing severe RSV infection leading to severe lung infection (ie: pneumonia), life-threatening breathing problems, hospitalization, etc.
The common complicating risk factors include: Premature birth (35 wks or less),
Low Birth weight (less than 5.5 lbs), Heart disease, Lung Issues, Being Around Other Children, Family History of Asthma, Exposure to tobacco smoke, Multiple Births
Punkinhead had the first two risk factors, but luckily none of the others apply and we can control her exposure to other kids. A lot of people have a hard to getting their insurance to cover the treatment (a shot of Synagis once a month), but because Punkinhead was born before 32 gestational weeks weighing 2 lbs 14 oz, up till now we didn't have issues being approved for it.
Synagis is the only approved medicine to protect from the severity of RSV, which is the #1 cause of hospitalization in babies under one year. However, if we paid for the shots on our own it would cost us about $1000 dollars per month for a grand total of over $8,000! It so expensive because it is actually NOT a vaccine, it’s the an antibody injection. A vaccine is a small amount of a dead virus that your body reacts to by developing antibodies to it and then it is prepped to fight the live virus when you encounter it. There is not a working vaccine for RSV so Punkinhead is given a ready-to-fight antibody that requires a “booster” dose every month. The first dose was only one shot, but once she was over 15 lbs, it’s a LONG needle in each leg every time to give her the right dosage.
Our health"care" company's purpose in cancelling ALL our pulmonary specialist's patients for the month appears to be an attempt to rid themselves of a few patients. They cancel us all, make us beg for it back, make us worry about our kids, and then make some money by cancelling coverage for a couple of kids whose risk factor is on the borderline at the end of RSV season. It's sick and makes me want to move to Canada.
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