Insurance appeal question - advice?

[riley2008]

I thought I was usually pretty good at keeping up with the different requirements for all of our different insurances. Our medical (BCBS) allows annual exams within the same month annually or two weeks prior to the 365 days anniversary date. That I know from experience.

Well, not so with our vision insurance (they only do reimbursements). Our VI allows visits "only one year to the date" according to Jacqueline in customer service. OOPS! A quick review of my policy does not state "to the date" and uses the same wording as BCBS - "once in a 12 month period". My problem - we all go to get our annual eye exams on the last Friday before Christmas right after school gets out. We've done this the last four years! Apparently we went on Friday 12/20/09 and then returned on 12/17/10! According to Jacqueline "that's one business day early". UGH!!!!!!

I filed the on-line appeal, but haven't heard anything within their "one business day to reply" - it's been three full business days. I want to write an appeal, but not sure how to plead my case. Suggestions? Lost cause?

 

[LaurenLC]

I thought I was usually pretty good at keeping up with the different requirements for all of our different insurances. Our medical (BCBS) allows annual exams within the same month annually or two weeks prior to the 365 days anniversary date. That I know from experience.

Well, not so with our vision insurance (they only do reimbursements). Our VI allows visits "only one year to the date" according to Jacqueline in customer service. OOPS! A quick review of my policy does not state "to the date" and uses the same wording as BCBS - "once in a 12 month period". My problem - we all go to get our annual eye exams on the last Friday before Christmas right after school gets out. We've done this the last four years! Apparently we went on Friday 12/20/09 and then returned on 12/17/10! According to Jacqueline "that's one business day early". UGH!!!!!!

I filed the on-line appeal, but haven't heard anything within their "one business day to reply" - it's been three full business days. I want to write an appeal, but not sure how to plead my case. Suggestions? Lost cause?

From my experience battling with my insurance company and trying to appeal was pointless and a total waste of my time. I called, made verbal statements and written statements and it made no difference.... I hope you have a better outcome!

 

[quentina]

I have had great luck with the appeal process. Not sure if your case would qualify however; we have had lab tests fall in the "not medically necessary" line and I have appealed and gotten them reversed.

It's worth a try, you got a 50/50 chance of getting them to say yes.

 

[LilyWDW]

I thought I was usually pretty good at keeping up with the different requirements for all of our different insurances. Our medical (BCBS) allows annual exams within the same month annually or two weeks prior to the 365 days anniversary date. That I know from experience.

Well, not so with our vision insurance (they only do reimbursements). Our VI allows visits "only one year to the date" according to Jacqueline in customer service. OOPS! A quick review of my policy does not state "to the date" and uses the same wording as BCBS - "once in a 12 month period". My problem - we all go to get our annual eye exams on the last Friday before Christmas right after school gets out. We've done this the last four years! Apparently we went on Friday 12/20/09 and then returned on 12/17/10! According to Jacqueline "that's one business day early". UGH!!!!!!

I filed the on-line appeal, but haven't heard anything within their "one business day to reply" - it's been three full business days. I want to write an appeal, but not sure how to plead my case. Suggestions? Lost cause?

Well, it does say "once in a 12 month period" which would mean that only once within that 12 months. If you went on 12/17/10 you were still within that 12 month period. Any time after 12/20/10 would have been okay because the full 12 months would have passed... which also would have been a year to the date.

I guess I don't see the issue in the wording.

 

[allison443]

Well, it does say "once in a 12 month period" which would mean that only once within that 12 months. If you went on 12/17/10 you were still within that 12 month period. Any time after 12/20/10 would have been okay because the full 12 months would have passed... which also would have been a year to the date.

I guess I don't see the issue in the wording.

I agree with this...the wording seems clear enough
You may as well try to appeal though. I hope it works out for you

 

[allison443]

I thought I was usually pretty good at keeping up with the different requirements for all of our different insurances. Our medical (BCBS) allows annual exams within the same month annually or two weeks prior to the 365 days anniversary date. That I know from experience.

Well, not so with our vision insurance (they only do reimbursements). Our VI allows visits "only one year to the date" according to Jacqueline in customer service. OOPS! A quick review of my policy does not state "to the date" and uses the same wording as BCBS - "once in a 12 month period". My problem - we all go to get our annual eye exams on the last Friday before Christmas right after school gets out. We've done this the last four years! Apparently we went on Friday 12/20/09 and then returned on 12/17/10! According to Jacqueline "that's one business day early". UGH!!!!!!

I filed the on-line appeal, but haven't heard anything within their "one business day to reply" - it's been three full business days. I want to write an appeal, but not sure how to plead my case. Suggestions? Lost cause?

Something is off with your dates...12/20/09 wasn't a Friday like you said...it was a Sunday
I definitely understand going the same time of year every year...but why do you always go on a Friday? Eventually that is going to mess up the one year thing.

 

[mjkacmom]

I think it's a lost cause. I know when I book the kid's checkups, they check to see when they were there last, and add a little padding, just in case. If it's even one day before, the insurance company won't pay.

They're tough - it took me almost 2 years to get my insurance company to pay for a failed induction (told me it wasn't related to my pregnancy ). Had to get my congressman involved.

 

[Pamlur]

Here is the link to a calendar for Dec '09; going by that, it looks like you should be okay in your 12-month thing.

http://www.timeanddate.com/calendar/monthly.html?year=2009&month=12&country=1

Maybe they just updated the chart on Sunday and used that date instead of Friday's date.

 

[riley2008]

Now I know I have a right to appeal!! Thank you! Thank you!! (I was repeating what customer service told me about my DOS for 2009.)

I had to do some digging, but found my calendar and my reciepts from last year.

THANK YOU!!!

 

[allison443]

Here is the link to a calendar for Dec '09; going by that, it looks like you should be okay in your 12-month thing.

http://www.timeanddate.com/calendar/monthly.html?year=2009&month=12&country=1

Maybe they just updated the chart on Sunday and used that date instead of Friday's date.

How does that show it would be okay? If they went on Friday in 2009 like the OP said, they went on 12/18. Then in 2010 she said they went on 12/17. Isn't that within a 12 month period? Like the insurance person told her, she went one day too early, unfortunately.

 

[bettyann29]

Ive worked many years in health insurance and Ive done my share of appeals personally with my insurance company.. but honestly, most likely you wont get a favorable outcome for the scenario you are explaining.. Those types of things are pretty cut and dry..

For medically necessary denials, that could be backed up with a dr appealing and submitting medical records.. denial based on dates and the way your policy is written isnt generally up for change..

but if you dont appeal you'll never know..

 

[kaytieeldr]

How does that show it would be okay? If they went on Friday in 2009 like the OP said, they went on 12/18. Then in 2010 she said they went on 12/17. Isn't that within a 12 month period? Like the insurance person told her, she went one day too early, unfortunately.

I think so too, unfortunately. My doctor's office won't let you make an appointment for a physical (covered once per calendar year on the typical insurance plan, and they deal with many) less than a year-and-a-day from your current one.

Yes, December 17 2010 is fifty-two weeks after December 18 2009 - but it's not a calendar year later. The OP can try pointing out that the insurance company always covered this scheduling in the past, but there's a good chance they're simply cracking down, interpreting their own policies more strictly.

 

[DopeyDame]

Alas, I agree with the PPs who say you are probably out of luck. There isn't much wiggle room with the wording - it's once per year, and you had two checkups in a year. However, it certainly can't hurt to appeal - you never know! If you do appeal, check with your State Attorney General's office. They almost certainly have a insurance protection or consumer protection division whose sole job is to help you with things like this. When we appealed, that office wrote a letter on our behalf, and within a week (after much yelling and getting nowhere on my own!) we had a successful appeal response.
Good luck!

 

[Tink-aholic]

Keep in mind that the insurance companies have no incentive to want to change this for you or anyone else. They deliberately make these policies because they hope that people make their appointments the way you do. That way, they get out of paying.

You have to watch them like a hawk in order to get your benefits maximized, unfortunately. You would be surprised how many people do exactly what you do and figure that it is close enough. Next time, make the appointment a week later and the following year a week after that, etc. Never give them the opportunity to deny you benefits again.

If you don't win this appeal, I would take them for exams right when school lets out for the summer. Yes, they will have two exams within six months, but only one that insurance will have paid for AND you'll now have summer months for making those appointments.

Good luck.

 

[Disnydad]

We appealed twice when my wife was going through her cancer to go outside the network. We won both times. It was actually pretty easy.

With the OP's issue I don't see being successful though over timing.

 

[3boymthr]

Has your policy renewed yet since September 2010?

If yes, and you're not on a grandfathered plan as part of NHCRA there is a new external review on appeals for claims that is now in effect. Most carriers are also putting this into effect for grandfathered plans as well but it's not guaranteed. This means that after two levels of appeal, not only BCBS has to hear your review but an outside third party does as well.

 

[cheshireqt]

We have successfully appealed based on medical necessity. Insurance puts us through the appeals process every 2 years for a necessary but expensive medicine for one of my children. We have documentation two inches thick now from specialists, tests, previous appeals, lawyers letter etc. So far we have won each time, going through it now and the stress of the possibility of denial is always huge in our minds and it makes me very grumpy for about 3 months while we wait for the process to chug along.
In your case you made a decision to go on that particular date and the policy said it would not be covered, so not sure the dr will support you with documentation that it was required? You might want to call the dr/dentist office though and see if they will offer any assistance, they really should have flagged that for you. My Dr office and Dentist office both always have the dates ready for me for when I can book and be in the proper window.

 

[Tink-aholic]

I train students to work in doctors' offices and I worked in many offices for years myself. With all due respect, why is it the office's responsibility to track the patient's visits a year apart? We are dealing with adults here who are capable of a) keeping track of the date themselves or b) calling to find out when their last appointment was and making an appropriate decision based on that information. But I think that expecting a doctor's office to keep track of and not let patients make appointments until they are within the appropriate window is expecting too much. Some offices may offer that service as a courtesy, but patients should be responsible for their own appointments.

 

[luvthatdisney]

Our eye doctor's office staff do keep track of our visits and will know what date to schedule past to make sure we wait the year as required by our plan. I assume it is the computer software they use as when I call to make appointments they know right off the date of our last exam and tell me the date. It is a great help to me and one thing I like about that office.

That being said, I too worked in medical insurance for many many years. Appealing things like medical necessity can go in the patient's favor, I have seen it happen many times. Often these types of reviews go to a panel of doctors/nurses who will review documentation provided by the treating physician and exceptions can be made. The issue about the 12 month lapse between eye exams is written in the policy and exceptions usually will not be made. I agree that there should be a week or so grace period, but still it is the patient's responsibility to keep up with that kind of thing.

I would recommend calling the doctors office and see if they would be willing to offer some type of discount since the insurance wont be paying. Many will as you will become a cash patient. Call and ask you might be surprised what they say.

 

[kaytieeldr]

I train students to work in doctors' offices and I worked in many offices for years myself. With all due respect, why is it the office's responsibility to track the patient's visits a year apart?

Oh, it's not at all - but some do. My previous and current doctors' offices "know" that most insurance companies won't cover (for example) more than one physical per calendar year; plus you need to schedule a year in advance for the doctors anyway. So they're very helpful like that - probably in part because they want to get paid

But you're absolutely right. I'm an adult, it's ultimately MY responsibility to know what my insurance covers and at what intervals. Example: my vision insurance covers one eye exam annually and one pair of glasses every other year. My (new) health insurance also covers an eye exam annually. I'm going to have the best vision in the world this year... or at least the best-checked.