Daughter with PWS:insurance woes - Vascular Birthmarks Foundation Forum
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Old 04-15-2007, 10:44 PM
momofAddie momofAddie is offline
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Question Daughter with PWS:insurance woes


I was wondering if someone had some advice for me. My daughter is 4 months old and was born with a PWS on her face. I have been jumping through insurance hoops and my insurance company, as well as, the company I work for have decided to cover laser treatments, but at my out of network benefit. This benefit is 70%, as opposed to my in network benefit of 90%. After 3 weeks of the insurance company "researching" in network physicians, they were unsuccessful (as anticipated per me..my pediatrician and I had already researched) in finding one. They are in agreement that there is no in network physician, but state my company has it set up this way. I work at a VERY well known facility (world wide). I have a meeting with the benefits director there, but I'm sure she will say the same thing--no exceptions. I believe my company is doing my child an injustice. I am mortified that they, of all people, are not willing to cover my child's treatments at the 90%. As most of you know, this is a life long issue. We have already had a treatment because we did not want to delay any longer because of insurance. Does anyone have any advice? What to say to my benefits department, etc? Do I get an attorney? Any help would be greatly appreciated!
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Old 04-15-2007, 11:03 PM
Dodge
 
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Can you please tell me how you got 70%? I think I got a kaiser insurance HMO , and they cover 0% and say its all cosmetic. I live in california, bay area btw. Where do you file with insurance and what do you say etc?
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Old 04-15-2007, 11:26 PM
momofAddie momofAddie is offline
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Default Insurance woes-help

My daughter goes to Dr. Lisa Buckmiller at Arkansas Children's Hospital. She had to send A LOT of information to my insurance company, including a letter of medical necessity. I had to send pictures. A lot of insurance companies try to make PWS a cosmetic issue, but it is absolutely not! PWS will eventually grow, cobblestone, and can cause some major health issues. Most doctors who deal with PWS know exactly what to say to the insurance companies. Also, it is part of my companies benefit to provide 70% for out of network physicians. You really ought to try Linda Shannon's book: Birthmarks A guide to hemangiomas and vascular malformations. It has a whole chapter dedicated on insurance. Hope this helps!
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Old 04-16-2007, 05:24 AM
heyjude heyjude is offline
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I have Aetna insurance and Jude's laser treatments are just covered, no questions asked. However, I have run into your exact problem with it being out of network. GET THIS!!!!!!!!!!!! The doctor that I use is in network but the hospital that Pulse Dye Laser is at is not in network so therefore I have to pay 40% of all the charges. To use the room that the laser is in is $700 alone, without insurance!!!! Its a nightmare. I was so thrilled that we were covered with the treatment but 60/40 is a total rip off.

I don't know what to do either. We are spending $600-700 dollars every 3 months on his hosptial bills alone. That does not include his anethesiology bills and my dermatologist bills either. We are a young couple that are barely making ends meet but we like you cannot take the risk of not doing treatments for the sake of Jude's birthmark getting worse. We cannot afford to do it but how can we afford to stop? So if someone has an answer let me know!!!!!!

Kennan!!!!!!!

p.s. did i mention i hate hospitals and insurance companies?
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Old 04-16-2007, 10:34 PM
nickbar nickbar is offline
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Please read thru the sample letters on msn (and the msn back up site)... I believe we have an example of an appeal to pay out at the higher rate. worth checking out.
You are welcome to copy any of the letters and adapt to your own situation.
Corinne
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Old 04-17-2007, 04:03 AM
Aussie legs Aussie legs is offline
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I have read quite alot of letters saying about insurance not covering PWS removal I think things might me different in Australia as when I first wonted to get my PWS removed about 11 years ago I went and seen a doctor, he asked me if I really wanted it removed because it would cost around $20,000 to remove as it is quite large, any way after the test treatment I went back to him and I had a Health Care Card (Low income card) after having baby number 3, he told me that he runs the laser clinic at the Childrens Hospital and I could have it done there and it would'nt cost me a cent, well 11 years on I think I would of been well over the $20,000 he said and I am very thankful that I happened to go see the right doctor and he is treating me for free, the costs are covered by Medicare in Australia so I'm not sure how it is worked out because I know their are people in Australia that they wont cover., I dont have any medical insurance either. So it their are anyone from Australia, Medicare Care cover my costs, so I hope this helps someone out.
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Old 04-18-2007, 11:29 PM
momofAddie momofAddie is offline
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on this website? what website do I go to? thanks!
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Old 04-19-2007, 12:51 AM
missy missy is offline
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On this site:

http://groups.msn.com/vascularbirthm..._whatsnew.msnw

You have to register and wait to be approved, but it doesn't take Corinne very long to get you approved.

Missy
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Old 04-19-2007, 03:49 AM
nickbar nickbar is offline
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as soon as msn gets me the notice... Jules (my asst.) or I will accept you...just make sure you say something about "birthmarks" so we know you are for real.

Corinne
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Old 04-20-2007, 04:22 PM
momofAddie momofAddie is offline
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Update. I met with my benefits director at my company. She states that we fall in a "gap" in our plan. No exceptions will be made. The out of network rate is to assist those that choose to go out of network. She understands that I have no choice, but says no exceptions can be made. Any suggestions?
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