michellep Posted July 7, 2009 Share Posted July 7, 2009 I need your advise please. My husband has stage 3 (possibly 4 depending of further testing). Our insurance company (an HMO) has denied home health care as well as a social worker. The woman I spoke with says he is capable of transporting himself to doctors etc. Our primary physician disagrees and well as myself. He is unable to walk more than 2 ft without assistance, he sleeps in a recliner chair and uses a bedside comode and is transported to chemo in a wheel chair. I would like some advise from you as to how I can obtain a social worker. I heard that they can assist with ins companies and provide direction for assistance. We currently live in the high desert of California and there is no assistance avail from the american cancer society or any senior centers. Can you advise anything at all for us? God Bless Michelle Quote Link to comment Share on other sites More sharing options...
Larry's Wife Posted July 7, 2009 Share Posted July 7, 2009 Michelle, does your oncology clinic or your hospital have a Patient Advocate? If so, perhaps they can assist you to get your HMO to approve the services you need. Lynn Quote Link to comment Share on other sites More sharing options...
Patti B Posted July 7, 2009 Share Posted July 7, 2009 Michelle- I agree with Lynn - I am actually assigned a social worker through the cancer center I receive chemo at. If not, I would think your docs office would have some idea of who you can contact. Good luck and keep us posted. Hugs - Patti B. Quote Link to comment Share on other sites More sharing options...
michellep Posted July 7, 2009 Author Share Posted July 7, 2009 It was the doc's office that placed the requests initally to the insurance company requesting the social work and home health. They have denied all requests. Odd since they seem to think they know my husband so well and yet they have never seen him. The doctor himself said that we need the assistance and they denied it. I guess my next step is to final an appeal although I need a photocopy of the denial and I wonder if they'll even send it. Thanks for your advice everyone. I told them that I was coming to their office tomorrow and they said I would be denied access. I'm just at the end of my rope here folks. ;-( Quote Link to comment Share on other sites More sharing options...
Larry's Wife Posted July 7, 2009 Share Posted July 7, 2009 Michelle, I'm grasping at straws over this. It seems logical to me that your onc doc must have a copy of the denial. Otherwise, how would they know you were denied? Also, the HMO should have sent you a copy of the denial. If they did not, then I don't see how they could refuse to send you a copy if you asked. Another thing that comes to mind -- if your insurance comes through an employer, might they help you to navigate through the appeal process? One last thing -- California seems to be quite progressive. Perhaps there is a state agency or ombudsman that could advocate for you with the HMO. I told them that I was coming to their office tomorrow and they said I would be denied access. Who told you this and why do you want to go to their office? I'm asking because this is a harsh statement. Quote Link to comment Share on other sites More sharing options...
Patti B Posted July 7, 2009 Share Posted July 7, 2009 Michelle- You know, drastic times call for drastic measures. We have a TV channel here that has what's called "call for action". You tell that a problem and they will attempt to fix it. And some many places want to fix things once they know that the media is involved. This totally sucks for you and I am so sorry. Do they not realize that cancer patients and their families have enough on their plates without this kind of crap??? Good luck!!!! Hugs - Patti B. Quote Link to comment Share on other sites More sharing options...
recce101 Posted July 7, 2009 Share Posted July 7, 2009 Larry's Wife said: California seems to be quite progressive. Perhaps there is a state agency or ombudsman that could advocate for you with the HMO. I poked around Google for a few minutes using a search for "california health insurance complaints" and found several state government agencies that should be able to help, depending on the specific type of insurance or HMO. Here's one: Department of Managed Health Care, Help Center, 1-888-466-2219, http://www.hmohelp.ca.gov/ If that's not the correct agency, they should at least be able to refer you to the correct one. Please let us know what you find out. Aloha, Ned Quote Link to comment Share on other sites More sharing options...
RandyW Posted July 7, 2009 Share Posted July 7, 2009 I wonder if this might help you out!! http://www.patientadvocate.org/help.php?p=186 Quote Link to comment Share on other sites More sharing options...
jaminkw Posted July 7, 2009 Share Posted July 7, 2009 I'm so sorry you are having to go through this. I agreed with Patti about the Patient Advocate. That's who helped me at MDACC. Does your husband go to a hospital or a Cancer Center of any size? I understand that most all hospitals have one. I'm thinking, though, if I went to our small Cancer Center in Key West, I would have probably had a hard time getting help. Hope that one of the suggestions (like the media or Randy's or Ned's links) will help you out. Judy in Key West Quote Link to comment Share on other sites More sharing options...
RandyW Posted July 7, 2009 Share Posted July 7, 2009 To The top !!! Quote Link to comment Share on other sites More sharing options...
jaminkw Posted July 7, 2009 Share Posted July 7, 2009 Randy, what "to the top?" I went back and reread Michelle's original post and still don't see what I missed. The post doesn't say to where he is transported for chemo. I read it and all the others before. Am I missing something else? Judy in Key West Quote Link to comment Share on other sites More sharing options...
cat127 Posted July 7, 2009 Share Posted July 7, 2009 Randy was just bumping this thread up, in hopes of finding some help for the original poster. I guess the one thing I would mention is maybe trying www.livestrong.org, see if they have any input or advice. I would toss the net as far and wide as I can to any and all outreach programs. It seems terribly unacceptable that you are dealing with this as well as the cancer itself. Quote Link to comment Share on other sites More sharing options...
RandyW Posted July 7, 2009 Share Posted July 7, 2009 Yes To The top just puts the post at top of page for more attention and responses ! I hope Michelle gets her help in here !! Quote Link to comment Share on other sites More sharing options...
michellep Posted July 7, 2009 Author Share Posted July 7, 2009 "Larry's Wife"]Michelle, does your oncology clinic or your hospital have a Patient Advocate? If so, perhaps they can assist you to get your HMO to approve the services you need.Lynn Went for chemo today and asked about the advocate. Sorry to say that they don't have one. Quote Link to comment Share on other sites More sharing options...
michellep Posted July 7, 2009 Author Share Posted July 7, 2009 "Larry's Wife"]Michelle, I'm grasping at straws over this. It seems logical to me that your onc doc must have a copy of the denial. Otherwise, how would they know you were denied? Also, the HMO should have sent you a copy of the denial. If they did not, then I don't see how they could refuse to send you a copy if you asked. Another thing that comes to mind -- if your insurance comes through an employer, might they help you to navigate through the appeal process? One last thing -- California seems to be quite progressive. Perhaps there is a state agency or ombudsman that could advocate for you with the HMO. I told them that I was coming to their office tomorrow and they said I would be denied access. Who told you this and why do you want to go to their office? I'm asking because this is a harsh statement. The doc does not have a copy because the ins company says it hasn't been generated yet. My husband is retired from Nasa and I have placed calls to them for assistance. And the reason I wanted to go to their office is because in order to file and appeal I must have a copy of the denial form and so far no luck getting it. Quote Link to comment Share on other sites More sharing options...
michellep Posted July 7, 2009 Author Share Posted July 7, 2009 Thanks for all the suggestions etc. So far no luck with this problem but I will continue to research and see what I can do. I spoke with someone from the medical group today and for some unknown reason (which she refused to explain) she says my husband's physical condition is "fine". I told her that he is unable to walk more than 2 ft at a time without assistance etc....She just said to me....Well, Mrs XXXX "You are mistaken". I then let her know that I have begun tape recording all conversations. HA HA Anyway, I have made up my mind about something. I absolutely refuse to beg anyone for anything anymore. From now on I shall be formally known as the "steam roller". I will process appeals....call newspapers....tv stations...what ever it takes so that my husband will get the care he needs. I figure that with Obama's plans for universal health care the news media might be interested. Quote Link to comment Share on other sites More sharing options...
Patti B Posted July 7, 2009 Share Posted July 7, 2009 Good for you, Michelle - give them hell!!! What about calling your state senators office or state representative. Maybe they can get something moving!!! Good luck !! Hugs - Patti B. Quote Link to comment Share on other sites More sharing options...
jaminkw Posted July 8, 2009 Share Posted July 8, 2009 You go get them Michelle. I believe in diplomacy in the beginning but you are definitely getting the run around. I'm all for steam rolling at this point. Judy in Key West Quote Link to comment Share on other sites More sharing options...
michellep Posted July 8, 2009 Author Share Posted July 8, 2009 Judy I see your a retired mental health counselor......HELP! ha ha Quote Link to comment Share on other sites More sharing options...
Larry's Wife Posted July 8, 2009 Share Posted July 8, 2009 Wow, Michelle. I'm blown away by your dilemma. The answer is no, but you can't appeal it because the paperwork hasn't been generated yet? That's just not right!! Yes, you now must be a barracuda and rip them up!! Quote Link to comment Share on other sites More sharing options...
recce101 Posted July 8, 2009 Share Posted July 8, 2009 You know, this reminds me of the plot of Matt Damon's movie "The Rainmaker" — seriously! Damon plays the role of a young law school graduate who, as his first big case, takes on an established health insurance company whose modus operandi is ripping off their clients. With the help of a gutsy associate (Danny DeVito) and a sympathetic judge, he ripped that company a new one! I picked up the DVD in the $5 bin of our local Walmart, and have watched it 3 times. Go get em, Michelle! This is ridiculous. Ned Quote Link to comment Share on other sites More sharing options...
jstdzy Posted July 8, 2009 Share Posted July 8, 2009 Michelle, I know you probably already did this, but there were a couple of responses to your question at cancergrace.org Dana Quote Link to comment Share on other sites More sharing options...
Katy66 Posted July 8, 2009 Share Posted July 8, 2009 Michelle, I have no advice that hasn't already been given but I just wanted to say how sorry I am that you are going through this at a time when your focus and attention should be on your husband, not worrying about his insurance. How dare they say based on what they are reading in some book what your husband's condition is? Someone suggested going to your congressman/woman and I would sure give that a try. I've said from the beginning that I have been lucky with Gene's insurance and hearing your story makes me realize how unbelievably lucky we are! I will keep you both in my thoughts and prayers...this has to work out for you! Quote Link to comment Share on other sites More sharing options...
michellep Posted July 8, 2009 Author Share Posted July 8, 2009 A bit of an update I guess.....I filed an emergency appeal with the insurance company this morning on the phone ( expedited with 3 day response) and I also contacted the Dept of Managed Health Care for the State of California. The DMHC says I need a copy of the denial in order to proceed.....so guess what? I'm getting into my car and driving over the the same medical group that said they would call security on me if I show up. If you don't hear back soon, perhaps it will be because I'm in handcuffs? ha ha As soon as someone comes to stay with my husband....I'm on my way! Quote Link to comment Share on other sites More sharing options...
Patti B Posted July 8, 2009 Share Posted July 8, 2009 YOU GO, GIRLFRIEND!!!!! If they threaten to call the cops on you, tell them your one call will be to the news media!!!! NOONE deserves the treatment you have been given!!!! I am beginning to not like the state of California at all!!!! Good luck!!!! Hugs - Patti B. Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You can post now and register later. If you have an account, sign in now to post with your account.