I use to worry about this baby a whole lot less than I do right now. I spent way too many hours last night watching videos, and looking at pictures of her past three and a half years. I can now pinpoint the month that her face began to look more tired… and my goodness, sweet baby I’m so tired too.
Well it was another day of torturous phone calls that ended in a spiral of madness and incomprehensible insanity… all of it will prolong her pain.
Technically, the procedure that we need doesn’t require a pre-authorization according to our health insurance. So, technically there is nothing that YNH can get pre-approval for. (This is important.)
However, YNH pre-ensures coverage because they want to get paid.
Insurance told YNH they will not cover procedure, and not because of the procedure type, but because of the diognostic codes used to specify need. The only person who can change diognostic codes is ordering physician – who is not back into hospital until hours before surgery.
It gets better…
The insurance didn’t technically deny procedure because there’s no formal pre-auth needed, and so no one had to technically deny coverage. As a result, there is no formal appeal process we can begin to engage in.
Yes, follow that insanity.
YNH calls HBHC to double check coverage, but doesn’t actually need pre-auth.
HBHC says no pre-auth needed, but we won’t cover it.
Me: Well, I want to appeal that.
HBHC: You can’t because there hasn’t been a formal denial. You can technically still go have the procedure that doesn’t need a pre-auth, and then formally appeal when we deny coverage.
Me: So put my family at a financial risk?
HBHC: Well you still have the procedure and then appeal.
We could self-pay and tell YNH that we don’t have insurance, and receive care for only several thousand dollars, but if we do that we can never appeal to insurance.
Or we can risk it. Get procedure done for 3x the non-insured rate, and hope we win appeal process.
Or cross everything that the doctor gets more creative with diagnostic codes, hours before scheduled surgery.
Or when we inevitably miss original procedure date (6/21) the doctor figures out a way to squeeze it in before they leave for sabittical on 6/30 (yes, let’s add to this insanity).
Meanwhile, we agonize over the health and safety of a super sweet tiny human. We get to sit with worry and panic, because everyone leaves at 3pm on a Friday.