Here is the latest on where we are at to get HBOT insurance approval...
Last Thursday, the medical director of The Wound Care Center at St. Vincent Hospital approved KK's case and information was sent for prior authorization to our primary health insurance, Harvard Pilgrim Health Care.
HPHC was closed on Monday for the holiday, so I did a google search while I waited not-so-patiently to see if I could find out whether or not HPHC covered HBOT. I found that some insurance companies do cover HBOT for radiation necrosis, but HPHC does not. So when I spoke with a representative on Tuesday, I heard what I already knew: HBOT does not need prior authorization as long as it is for certain diagnoses. She did say that the provider should have received a reply from them...though she did not tell me whether it was approved or denied.
I called The Wound Care Center and they said it was denied. I asked if they had heard anything from KK's supplemental insurance, Mass Health, and they said they did not.
So I made more calls.
First, I left a call back request with Mass Health.
In the meantime, I called HPHC to see if there was any way they would repeal their decision. They said that the provider would need to call the provider line and ask for a peer-to-peer review; if it was still denied then I could appeal the decision (which could take up to 30 calendar days).
Instead of waiting for Mass Health to call me back, I called them again. After explaining our case, the representative said that it should be approved if the provider applies for prior authorization.
I called The Wound Care Center back and explained to them all that I had learned. I was told that the provider does not call the insurance company -- that the insurance company calls them to set up a peer-to-peer review. I was also told that it is not their policy to apply for prior authorization from a secondary insurance company. She would not listen to anything I said. I was so frustrated.
I called HPHC and told them that the provider would not call the provider line for a peer-to-peer review, so the representative immediately mailed an appeal application to me.
I then called Mass Health again and cried as I tried to explain the situation. The representative was so helpful and set up a conference call with HPHC to get a copy of the denial letter. After being on the phone for over an hour (the first 25 minutes of that was spent waiting to speak to a representative), I felt like we were making headway when my cell phone dropped the call just as we connected to the HPHC representative.
Once my signal was strong again, I knew I would never get the same representative at Mass Health, so I decided to call HPHC now that I knew I needed a copy of the denial letter. The representative said that he didn't have that, but he offered to call The Wound Care Center to get a copy of it. He just needed me to get a fax number so he could send then send it to Mass Health.
So I called Mass Health again. After waiting for a representative for about 20 minutes, my phone died. As soon as I got home, I called from a fully charged landline. When I connected once again with a representative, she told me that I needed the enrollment center. I asked if I could give her my number in case we got cut off. She said they can't make outgoing calls, but she did give me the number to call the "direct line" in case I got cut off before transferring me.
Around 4:45, after being on hold for about 35 minutes, a recording said that call volume was high and that I should call back between 8:45 and 5:00 tomorrow then hung up. I called Mass Health back and finally got a representative again around 5:20. He also told me that I needed the enrollment center. I asked if he could at least give me a fax number. He said the enrollment center might want me to send it to a different fax. I conceded that, but I asked for the one he had so I could at least do something tonight and assured him I would call the enrollment center at 8:45 tomorrow.
By the time I called HPHC back, the representative that had the denial letter was gone for the night. Thankfully, he left extensive notes for the next representative and stated that he would fax the letter to Mass Health at 8am tomorrow.
I am praying that the fax will make it to the right place between 8:00 and 8:45 tomorrow morning and we will get the approval we need for KK to start HBOT at The Wound Care Center.
