Friday, August 19, 2005

Adventures in Code Cracking, Part 2

The latest round in "Insurance Wars": The Mother Strikes Back.

The doctor who presribed Ethan's stander, Dr. JJ, called me yesterday. He got my message, but he was confused. What was this "procedure code" I was asking for?

I explained what AMANDA had told me and he seemed baffled. "This isn't a procedure. This is a piece of equipment. I could give them a 'procedure code' if I was actually performing one. I don't have any code to give them." He asked if he could call someone at Cigna. Based on past experience, I didn't want to send him through the maze of phone prompts blindly. I told him I'd try again, and hopefully they'd call him directly if they had questions.

"Try to get someone who'll give you a last name," he said. I had to laugh. Last name? People in Cigna-land don't have last names. Why would they need them? They're droids.

So I called Cigna again. Call number 3. JULIE.

JULIE asked for all of my information again. Apparantly, the call history didn't document much. I explained what AMANDA had told me and that my doctor didn't know what a procedure code is.

"Well that's beside the point. We still need the procedure code."

This is the part where I tried to explain to JULIE that, hello?, if my doctor doesn't know what it is, how is he going to give it to her?

JULIE put me on hold while she called Dr. JJ. After a few minutes she came back on the line.

"That doctor... he was really starting to get rude with me." I wanted to laugh at her, but I thought that might be over the line. Instead, I just said, "Oh?" No sympathy here JULIE.

"He kept saying that he didn't have a procedure code, and I said 'We need one anyway!' and he said we'll have to get it from the place that provides the equipment, not him. I don't know who that doctor was. But. He was very rude!"

I tried to reign JULIE in. Big picture, JULIE. My doctor doesn't have the code. Who has it?

"Well, you must have to get it from the company supplying the equipment."

Big. Sigh. Then I started. If she thought Dr. JJ was getting rude, I can only imagine what she thought of me.

"So JULIE, where does this put me? Because my original phone call with Cigna started out this way. A month ago. Someone told me my first step was to find out who supplies the equipment. They were going to find out and then get back to me. A month ago.

I'm going to ask you the same question I asked two days ago: 'What do I have to do to get this stander for my son?' AMANDA's answer was to get this code from the doctor. Obviously that isn't working. So what do I have to do??"

JULIE said I had to call the different Cigna providers and find someone who carries the equipment and order it from them. They would have the code and could send it to Cigna.

But JULIE, "I thought this equipment might not even be covered? Why would I order it if you might not cover it? Then I'll have to pay for it myself, won't I?"

JULIE thought a minute. "Yes, I guess that's a bad idea. You probably shouldn't order it."

Good thing one of us was thinking.

She then started reading me provider names and phone numbers. I finally stopped her after the eighth one and asked how many I was expected to call. She said, "That's up to you." Yeah. Right.

I tried to explain my past experience to JULIE. When we tried to order Ethan's special stroller, I was forced to call all of these same numbers, and none of them carried that type of equipment. I ended up getting an out-of-network place - who we were trying to use the whole time - authorized. She didn't want to hear it.

"Just because the name says something else doesn't mean they don't have it. They might be able to order it." Fine. So I humor JULIE and say I'll call them all.

I call every place on the list. I explain what I'm looking for. Every. single. person. says, "What's that?" I explain again. Can they order it? No.

Once I've exhausted the entire list, I call Cigna back. Number 4. JANELLE.

My first question to JANELLE is - Do I have a case manager? Someone I can deal with one-to-one? Every time I call, I get a different person and a different story. JANELLE thought for a minute, and finally said, "Mmm. No. You don't. Sorry!"

JANELLE was awfully cheery about all of this.

So I give JANELLE the short version of the story. I explain that I called all of the places JULIE told me to call, but no one had it. I know of a place that does carry it. But they are out-of-network. What now?

JANELLE tells me that I need to talk to Intercorp, the pre-certification area. They can get me authorized to use this other dealer. Fine. She transfers me.

Cigna representative number 5. JAMES.

JAMES listens to my story and says, oh, no. I am in the wrong area. I need to talk to someone in the Medical Department. He'll transfer me. Before he transfers me, I shout, "No! Wait! I was just transfered from the Medical Department!" He insists that's who I need to speak to .

I try to explain JANELLE's reason for transfering me to him. "So, see? I need this pre-certified. That's what you do. You're the precertification department!" JAMES explains that no, they only deal with medications, not equipment. He has to send me back to the Medical Department.

By this point, I'm starting to wonder if this is everybody's first week on the job or something. Because clearly, none of them know what they're doing.

My call is picked up back in the Medical Department. Number 6. FRAN.

I quickly explain to FRAN that I have been passed around a lot and I'm getting tired of it. I just want to get this equipment. She promises she won't pass me around. She's actually pretty nice about it.

FRAN listens to my story. Again. She asks if I have called Gentiva yet. They are the main equipment company contracted with Cigna. I vaguely remember speaking to them in the past, but not about this. FRAN tells me that they are the ones I should have called in the first place. Nice that no one else knew about this.

FRAN puts me on hold while she calls Gentiva. She gets back on the line and says that Gentiva can get the equipment. We have to do the following steps:

1. Dr. JJ has to call Gentiva and order the equipment
2. Dr. JJ has to send Gentiva the Medical Necessity Notes.
3. Gentiva will forward the Medical Necessity Notes and the procedure code - Ah! - to Cigna.
4. Cigna will review the Medical Necessity Notes. This could take up to 15 days.
5. Cigna will decide whether or not this piece of equipment is actually "medically necessary".
6. Cigna will notify Dr. JJ and us about their decision.
7. If by some miracle they approve it, then we order the equipment.

After hanging up with FRAN I called Dr. JJ back and left another message with his new instructions. I haven't heard back from him. Yet.

My face was practically purple from frustration. I was on the phone for almost two hours. Only to find out that it will still be at least another couple of months before we get this stander.

That's if we get it at all. Sigh.

But, oh! Good news! If it gets denied, we can always go through the Appeal Process!

More fun with Cigna! Yippee!

2 comments:

erica said...

Oh god, what a nightmare.
I'm having flashbacks to dealing with the eeee-vil bank a couple of months ago, and that wasn't even over anything half as important as this.
I hate corporate america.

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