If I was going to advocate for my child, Grace, I had to know and understand exactly what steps to take! The very first thing I did was double check what diagnostic code the ordering doctor used. International Autoimmune Encephalitis Society’s website makes it easy because they give you the correct code in their information. I compared it with the code the doctor used. There it was. Just as the website reported that the most common reason for receiving a denial was that the wrong diagnostic code is used, the coding for Grace’s diagnosis was not for autoimmune encephalitis. The doctor or a staff member in their office had made a mistake and used an incorrect code. Having identified the problem, I now knew that it could be corrected.
I immediately called the doctor’s office to make them aware of the situation. But I was faced with the next challenge. They had received the same denial letter from our insurance company prior to us receiving ours and instead of double checking their codes, they wrote an immediate appeal and attached 45 pages of notes stating WHY my daughter needed the treatment. They informed me we would know in 72 hours if it went through.
I checked back in with IAES and updated them on the situation. I was quickly informed that the doctor’s office or whoever was in charge of doing the prior authorizations in the doctor’s office were making ANOTHER mistake by appealing the denial. “You don’t want to appeal a denial when the wrong diagnostic code is used! A NEW prior authorization with the correct code must be submitted.” They explained.
So, I got back on the phone with the doctor’s office and gave this information to them. The answer I received from them was, “Well, the doctor wrote the appeal and gave 45 pages of evidence and it should take 72 hours before we know if they will accept it.” I again insisted that they should not appeal due to the incorrect code. She said, “oh ok, I’ll just let them know about the new code.”
Oh boy, I started getting a little irritated. To top it off, I had been told the doctor had left town for two weeks. Clearly, I was getting nowhere in getting the office staff to understand what actions needed to be taken. I knew that their efforts would result in a denial of the appeal. So, I decided to contact the hospital nurses in the infusion center that are in charge of submitting prior authorizations. I went over all the information with the nurse. She agreed a new prior authorization was needed and would contact the insurance company to get it done. Thinking I was out of the woods, I relaxed a little.
The next day the infusion nurse called to let me know the insurance company told her she could NOT submit a new authorization for 6 months. Ahh! What?! I knew this simply was not true and I demanded she contact them again. She said she would try.
I updated IAES and we decided it would be easier to go over the situation on the telephone. I learned that the insurance company appeared to be under the impression the patient was being given a different diagnosis and not addressing this as a clerical error.
“If you need a lifesaving treatment, and pay good money for health insurance, do you really thing the insurance company is going to tell their customer: I’m sorry but due to a clerical error we can not give you your lifesaving treatment? I’m afraid your life will have to be cut short?” She explained that, “Most infusion nurses are really wonderful and want to help, but there are times when you will sense that you have to be pushy. Be confident, you are informed now. If you have to, be pushy. At times, it’s appropriate.”
I followed up with the infusion nurse the next day. I was being pushy, and I was learning that with that and my sense of confidence I was getting the job done. We only had 2 days left until my daughter’s treatment was scheduled. I was feeling the urgency of getting this accomplished. At this point, the insurance company accepted the new prior authorization and the nurse told me she marked it as “urgent” and “high priority”. At the end of the day we should have an answer.
– – But no… that’s not what happened. The nurse called to check the status of the authorization and the insurance had NOT put it as high priority. She said it wouldn’t get looked at for another day or two or maybe up to 14 days. This was not acceptable. The insurance company had already made one mistake by telling us we had to wait 6 months, now they don’t push it through when marked urgent?
While problem solving on the telephone with IAES, I was told that when a clerical error is made and a delay created from their mistake a new prior authorization with the correct code could be faxed to the insurance company and the person who submitted the corrected prior authorization could then ‘walk it through’ explaining to the insurance company that it was their clerical mistake. That in situations like this, the correction could be made in a matter of hours or by end of day. In fact, I was advised to give them a time limit as to when I expected to have it approved and let them know I expected a call back telling me the mistake has been corrected.
So, I called member service on the back of my insurance card and told them I need to make a member complaint and asked to speak directly to a member services supervisor. This is what got the ball rolling. They were apologetic, offered as much assistance as I needed, and they even got the authorization labeled high priority. I wrote down the supervisor’s name and direct contact number. I told her I would call in the morning and make sure it went through.
Friday morning: the day of Grace’s infusion. The Nurse at infusion center called to let me know the prior authorization had NOT gone through and was still pending review. I put my big girl pants on and called the supervisor and said, “My daughters treatment is scheduled to take place in 45 mins. THAT’s how long you have to get the authorization through or I’m going above your head.”
My daughter and I showed up at the appointment, waited about 15 minutes and the nurse walked over to tell us the authorization was approved. Hallelujah!!