Our First Insurance Struggle

Sometimes, I look at other bloggers and I think, “Man, she has really got this stuff figured out.”  I am not one of those bloggers.  I blog in hopes of one day figuring it out.

What I’m trying to figure out right now, is what I could have done differently to have not been taken by this much of a surprise.  Here’s a little recap of the surprise phone call while I was at the park with the boys last week.  It was from a very nice woman whose name completely escapes me because my memory could barely take in the latter half of the conversation.

Me:  Hello, this is Tatum

Her:  Hi, I am [insert name here], I work in billing at Pediatric Home Service (PHS) and wanted to let you know that Owen’s invoices have begun getting rejected from insurance because they say you have reached your DME max for the year.  I just wanted to make sure you’re aware that we are going to start sending you some invoices.  We don’t want you to be surprised.

Me:  Oh.  What exactly falls under DME?  (See, I’m still trying to figure this out!)

Her:  DME is Durable Medical Equipment, it’s everything we do.

Me:  Everything?!  So, his oxygen, oximeter (monitor), all the oxygen tubing, feeding bags, feeding pump, nebulizer equipment…and everything else? (It’s a three page order list)

Her:  Yes, everything.  Did you know that your insurance dollars ran out?

Me:  No.

Her:  I was afraid of that, that’s why I wanted to call to see if I could answer any questions.

I was at the park with the boys and another mom, who is also a customer of PHS (a great company, by the way) so, I cut the conversation short, but obviously had to go back to it later because I had a-whole-lot of questions.

The next morning, I called the insurance company first.  Another really nice woman was very reassuring as she begin to pull up our account that, “something must be wrong because oxygen and feeding supplies are medically necessary” and then she paused and said, “oh…you have a $Xthousand per year maximum”

So, I asked, “when did that run out”.

“The first couple days of August.”  Was her reply.

Deep breaths!

So, here we are, two months into it, finding out that we are going to be paying 5/12 of the year on all of Owen’s oxygen and feeding equipment and no, it does not go towards our annual out-of-pocket max.

Let’s just say, we hadn’t budgeted for it.

Really deep breaths!

All I could think was, what did I do wrong?!  No, I never read our insurance policy, but even if I had, I didn’t know what DME was so I’m not sure it would have helped.  I guess, I never imagined a scenario where oxygen and feeding equipment wouldn’t be covered.  I knew to call on the helmet and therapies, but oxygen and feeding equipment …  I mean, the alternative is being in the hospital?  They prefer us at home, right?

Our conversation ended with me politely asking the process for filing an appeal.  Wish us luck!

I know that’s an abrupt end to the post, but that’s as far as the story goes.  I’m writing about it now because I hope that others can learn from our mistake.  I can promise you, the 2013 insurance manual will be read and I will be on the phone with the customer service person until I understand every possible out-of-pocket expense.  As one of my grad school professors used to say, I will know that manual in “excruciating detail”.  (I didn’t like that prof much, but I don’t really like details, especially the excruciating kind).

Just a couple of things before I end:

1)  I’m not sharing this to ask for money or donations of any kind.  I’m only sharing, because I know I’m not the only person that’s been taken by surprise and if someone else can not get in this situation, than it was worth sharing.  However, if you have advice on insurance appeals – I’m all ears!

2)  Healthcare costs are a hot topic in the political landscape.  I, personally, find politics fascinating and love to debate them.  However, this blog is not a political blog.  It’s a blog about Celebrating, Connecting & Healing in relation to premature births and special needs.  If a comment is made that is politically minded and goes against Celebrating, Connecting & Healing, or even sort of suggest telling others who to vote for, I will delete it.  That’s not because I don’t think healthcare costs or this election should be discussed, it’s that I think there are better venues than this blog to do it.



© Copyright Tatum, All rights Reserved. Written For: Ain't No Roller Coaster

14 thoughts on “Our First Insurance Struggle

  1. Eric’s friend’s friend worked at a health insurance company. It was their policy to deny appeals a minimum of 3 times, so don’t be easily deterred…not that you would be anyway. Eric’s mom had to appeal several times as well. Good luck and how does that lady think she wasn’t already surprising you?

  2. Yes, don’t be easily deterred. Call lots. And do you have a friend/attorney who could write an official letter for you and help you with pointers? That is always helpful. We had one issue with a bill for my $20,000 helicopter ride. It was eventually settled, but it was a pain, we were worried, and took a few months to get it figured out. I am sorry. I don’t handle any of the insurance stuff, so I wish I had more to tell you. Jon does all of that and he is much better than I. Good luck!

    • Jessi, Yikes, that’s a bill I’d never want to get in the mail! I’m glad it worked out in the end. Kyle and I divide tasks a lot in our house, but we tag team on insurance. He deals with his company and pushing HR,etc and I deal with the insurance company. In other words, where it takes political savvy, Kyle’s much better at the job than I 🙂

  3. Tatum- we have had insurance issues with Sonoma for the past few months and believe me, there is nothing you could do. The whole insurance situation is SO confusing. Before Sonoma’s surgery, she actually went through “prior authorization” where a team of people are supposed to look at her policy and clear her for the surgery and all associated with it. Every time I look into insurance they use such mumbo-jumbo that I feel like I need more than an MBA to understand it and that they are trying to trick me. So I called that group about 10 times to ensure we were set. They said we were and it is their JOB to be right about that. Well, turns out we weren’t. They declined her wheel chair one month into needing it and then they declined her physical therapy starting last June. When we appealed, they declined that too and determined they were going to count all of her hospital therapy towards her allotment (she had 7 therapies/day in the hospital). Insane- we keep fighting and they keep denying. At some point, we just gave up because I didn’t understand the system and could deal with the stress anymore more (all these case managers that asked how they could help but just gave me a bunch of jargon back with no real answers). For us it is more complicated since General Mills self insures so while health partners might approve something, GMI might decline it. All I would say is please don’t blame yourself or look into the past- nothing you could have done. After that, continue to fight and appeal! One option we used is when you start to appeal, find out who the insurance medical director is on your case and have your doctor call him/her directly. That usually works (unless you are under a self insured policy like GMI- then I found that they don’t really care because the company, not the insurance company, makes the decision). Hang in there and let me know if I can help…

    • Michelle,

      Thanks for sharing – but man, that’s awful. She had spinal surgery and the wheel chair gets declined? And, I always thought a benefit of being in the hospital was that you weren’t changed for things, like therapy. My head is shaking. But, I’m definitely going to ask about how our insurance works. From our initial interactions, I am pretty confident that we’re dealing with the insurance company and not the employer, but now I know to make sure….You would actually think that the employer would be more generous (especially with your family) than the insurance company. And then there is the question of how hard you fight with your employer. Awkward. I’m sorry that happened to you.

  4. Your comment about Owen needing the oxygen and supplies or the alternative is the hospital is exactly it – they would much rather have you guys home. It made me think about a situation we had with our son Henry. Henry was born in Billings, MT and at 3 weeks he was flown to Denver for his PDA. We were only suppose to be there 7-10 days but it turned into 8 weeks because he was so sick. Meanwhile my husband’s job changed in his company and he was transferred back to MN. He was flying to Denver every weekend to see us and then flying back to MN to work during the week. It was really difficult for our family so once Henry stabilized we asked if we could transfer him to a hospital in the Cities. Insurance denied it even though it was months and months yet in the hospital for Henry and meant our family wouldn’t be together. An amazing case worker in the Denver hospital had the idea to break down the cost of a day of care in the Denver hospital and a day of care in the Cities hospital and I kid you not we were on our own private jet within 48 hours flying to Henry’s NICU home for the next few months in MN. All because someone thought outside the box for us. So my suggestion would be to try and see if you can price out the cost difference for home vs. hospital care and that should be enough of a reason to continue coverage on medically necessary equipment. I hope you can get it all sorted out without too much added stress.

    • Wow, Henry was a really well traveled sick little boy! Thanks for your insight, it’ll definitely help with the appeal.

      I have to ask, and you can answer privately if you prefer – did Henry and Owen share any days in MN? I remember a few of the nurses always commented that Owen looked a lot like another baby named Henry. Just wondering if this is the same, apparently very handsome, Henry. If so, do they still resemble each other?

    • Sarah! Not sure if you’ll ever see this comment, but I never had a chance to say “thank you” for sharing your story with me in the family waiting area. I remember you showing me pictures of your little ADORABLE Henry and talking about oxygen flows. I want to give you a belated thank you for giving me hope…and the strength to keep going after loss. I never got to tell you how much I admired you. I hope Henry is doing well!

  5. Tatum, once when we were having problems with our company-sponsored insurance program Howard called the person in HR who managed the insurance (to what degree, I don’t know.) Howard told him about the run-around we were getting from the ins. company and he advocated on our behalf and we finally got the records we needed to settle the problem. Good luck! I think the ins. companies try to wear you down so you’ll give up.

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