And…
Although we begged to pay out of pocket, the providers said no every time. (As I’ve shared in previous posts, we’ve been told this is to protect the consumer, and if so, that is a good thing. However, consumer protections need to go further. Which one day I will share our initiatives that we are working on concerning this.)
In ME’s case, the denial went further than the initial denial of care discussed in this article…
When our doctor sent in the 120 pages of documentation in the fall of 2022, for the off label process, these documents did not make their way to the specialized pharmacy for the off label process until mid December of 2022. (A Cigna employee and an Accredo employee each gave me their contact information. They said they’d gladly confirm this with anyone who would want to investigate.)
We truly were stuck in the middle of bureaucracy.
There was absolutely no doubt that ME was the one paying the price for that bureaucracy.
Let’s get back to the article…
What is the take away from this article?
One of the first lessons I try to teach those who contact me is this…
Once you get that first denial, begin the appeal process immediately. Do not wait. Do not be intimidated. The article states only 5% of all claims that go through this algorithm will appeal.
95% are likely, much like I was, afraid to appeal.
Thankfully, Dr. Hoy led that process, because, as he said to us, he needed to do what was right for his patient.
This low percentage of appeals is likely due to employees not realizing that they can and should appeal. This, along with lack of education and of transparency by benefit plan administrators and HR, and you have a recipe for disaster for many who pay into the health benefit plan.
Fear of retribution from appealing is definitely a factor for many as well.
You get the gist.
Hopefully this article helps my readers grow in that confidence.
Make sure your doctor/provider is following through on the appeal process,.
Many providers don’t want to or do not actually even do an appeal, because that added layer is so expensive and labor intensive for their practice.
Which, is incredibly ironic and hypocritical, since corporations are using the algorithm to deny claims due to the fact that a physician actually reviewing it would be too expensive. (File this under “things that make you smack your head”).
However, they think nothing of the medical provider actually having to pay employees, along with the physician’s time and money spent in the appeal process. Again, as I’ve stated in other posts, this is a system set up to pit a physician against their patient.
Next, absolutely call the Department of Labor for guidance on your rights within your plan.
This article is everything that was said to me by a local physician who was trying to help us throughout ME’s denials and care.
This provider shared with me that these physicians who do these mass denials for Cigna and other companies make $200 or more per denial.
Read the article I’ve attached here, and then do the math.
This physician shared this with me about two years ago. I don’t even think I fully understood what he was teaching me until it got to the off label process and the 120 page document was with held.
I’ve told anyone that will listen about the lesson this physician imparted on me. Many who believed what he said to me went on to get their much needed care approved after following the steps I learned along the way to desperately seeking care for ME.
Thankfully, this article gives me hope that now others are speaking out.
This is long overdue.
Read this article, and by all means share this post.
Perhaps one day these companies will be held accountable for what so many of us have experienced.
