If you’ve been following our journey through insurance claims associated with the boys, most of them have been handled quite fairly.  But there was one (and now a second one that I’ll cover separately) that was handled quite unfairly.  This was for Samuel’s helicopter transfer from John Muir Walnut Creek to Lucile Packard Children’s Hospital in April, 2017.

Today I received a phone call that said there was “new information” related to the appeal, and it’s been re-evaluated and approved.  This was for more than $34,000!

History

(Insert magic harp music with water-drop dissolve to go back in time)

Samuel was transferred from John Muir to Lucile Packard on April 5, 2016 after his respiratory activity was rapidly deteriorating.  The doctors at John Muir couldn’t figure out what was going on, and the respiratory specialists that were needed just weren’t on-staff.  The closest hospital that had these people was in Palo Alto – a 50-mile drive from our house.  So after conferring with doctors and nurses at John Muir, who conferred with their colleagues at Lucile Packard, the decision was made to transfer Samuel quickly.

The doctors at Lucile Packard thought the situation was dire enough that they sent their air ambulance to get him, and he made the ~20-minute flight across the Bay.  He was immediately intubated upon arrival, sedated and quarantined.  It was later determined he was very sick.

IMG_8154
He looks all puffed up from the IV. He has the ventilator down his throat, and many of the other tubes and wires are into his PICC line, or a central line used for drawing blood, giving medicine and feeding him.

When the medical claim was filed, Anthem, on behalf of my prior company, determined that the transfer was for a genetics evaluation and not anything urgent, and therefore they denied the claim.  We went through three levels of appeal, providing more than 30-pages of medical information, notes from NICU Medical Directors at both hospitals, and other materials, only to have all the appeals rejected.  All found the same thing:  his transfer was for a genetics evaluation.

Doctors at John Muir said in their statement that they never would have asked to transfer Samuel for a genetics evaluation, and the doctors at Lucile Packard also stated they never would have approved the transfer.  Doctors just don’t transfer patients for genetics evaluations.  Yes, he needed a genetics evaluation, but it was never a factor in his transfer, and was the furthest thing from our mind.

After all the appeals, it went to an “independent third party reviewer” – selected by Anthem, of course.  Surprise, they found in favor of Anthem for the exact same reason!

A few weeks ago I sent a note to the benefits leader at my former company, asking him to personally review the case and the notes.  My claim is that Anthem and the third party failed to consider all the facts, and never did proper due diligence.  They never called the doctors involved, despite my insistence they do so, and never took steps to clarify things.

I got a note back saying that Anthem’s work was done properly and they weren’t further reviewing this.  I made one more reply to them asking them to take action, or my next stop was the CEO.  I have a draft note already completed.  I’ve also been working behind the scenes with a TV station in the Bay Area about this, and they’ve been drilling Anthem on this as well.

(Insert magic harp music with water-drop dissolve to come back to present day)

This morning, Anthem called and said they received new information, and now the claim was re-evaluated and the rejection was overturned.  I’m to get a new Explanation of Benefits (EOB) and we should see this be paid in full by Anthem.

I’ve asked what the new information was, but they’re going to need to research this and get back to me.  Perhaps I should let this go, but I’m really curious what made the difference.  I don’t think there was any new information.  I think they finally looked at everything that was submitted after the benefits department at AECOM forced them to.  I hope this is what happened, and I can say “thank you” to them.

I won’t count my chickens on this until I receive paperwork showing it’s paid and behind us.  And then we can focus on the last appeal – for another ambulance ride for Sammy to return to Walnut Creek from Oakland following his surgery last February on the day Charlie died.  The insurance company paid 50% of the $18,036 bill.  So now we’ll work to get the final part of this paid and behind us.

In closing, if you have an insurance claim that’s legit, don’t let the insurance companies get away with screwing you over.  I knew our claim was legitimate, and persistence in trying to do the right thing seems to have paid off.

 

 

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2 thoughts on “Anthem Helicopter Appeal – Update

  1. Ugh, dealing with insurance companies SUCKS!!!

    We have been fighting a claim for short term disability benefits – for Rachel’s diastasis. They keep denying it because as far as they are concerned she doesn’t have a hernia, so in their mind she can return to work now. It seems like the insurance companies deny, deny, deny until they are forced to look at the facts and pay out the claim!

    Good job Todd! Due diligence paid off in your case…

    Are we shooting for Monday still? We may need to adjust plans if we get another big storm.

    Please send all our love to your family!

    -Paul

    Like

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