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Insurance Victories

Pulmonary Rehab, PH & Insurance: Don’t Take No for an Answer

Fall 2011

By: Doug Taylor, PH Patient

Doug Taylor

Doug Taylor

Insurance issues can be really frustrating for pulmonary hypertension patients, but as I have learned, when it comes to getting the answers you need, don’t accept no for an answer from someone who doesn’t have the authority to say yes.

Four years ago I started on pulmonary rehabilitation for pulmonary hypertension, and I have been going ever since. It is important that the rehab was specifically for PH. At the time, I was on COBRA and my insurance covered the initial rehab. I don’t recall the standard number of “Phase II” visits that were allowed, but at the end of the initial period, I was told by the rehab staff that insurance did not cover Phase III. I requested they submit the claim as a courtesy and they did. My insurance covered it with no questions asked.

Then there was a change in the COBRA carrier. With the new insurance, I again requested they submit the claim, and pulmonary rehab Phase III was again covered with no questions asked. When I became covered by Medicare through a Medicare Advantage plan, I was told by everybody — rehab staff, customer service, billing and insurance departments with the provider — that Medicare plans do not cover Phase III pulmonary rehab. I had to fight to get them even to submit the claims. Eventually they did. The claims were denied because of lack of required codes. Instead of supplying the codes, the provider chose to bill me in violation of their agreement with the insurance carrier. Eventually, they did supply the codes, and my carrier covered Phase III pulmonary rehab.

Since then, I have had a change in my Medicare Advantage Plan. I had to go through the whole process and arguments again, but eventually the provider submitted the claims. And again, the claims lacked the proper codes. After many calls on my part, all the required information was submitted, and again, the carrier covered Phase III pulmonary rehab.

Next, to my dismay, the provider instituted a policy of changing account numbers every four to six months, and it looked like I was going to have to go through the whole process two to three times a year. For 2011, I started trying to get claims submitted properly in March. Finally, in January 2012, I wrote to the president of the hospital and told him very clearly the issues I was facing and asked if he felt it was appropriate that they had not been resolved in 10 months.

The president forwarded my letter to the director of patient financial services, who told his personal assistant to take care of the problem. She called me, verified that she understood the issues, and I provided her with some additional information in the form of EOBs (Explanation of Benefits). She took care of the billing problems for me. She also told me that it is true that Medicare plans do not cover Phase III pulmonary rehab for conditions such as COPD. However, she said that many of them do cover Phase III pulmonary rehab for pulmonary hypertension. Pulmonary hypertension is so rare that most rehab programs don’t see even one patient.

With my previous coverage, I did not have to pay anything out of pocket for pulmonary rehab. It wasn’t until the first couple of months this year that I had to pay co-insurance until my maximum out-of-pocket expenses were met.

Bills from providers are one of my pet peeves because I think they are intentionally misleading and vague. The providers are betting on people getting their bills and thinking the amount must be right without verifying what they are paying for. My bills for pulmonary rehab provide the first date of service and no others, even though they cover three to six months of service.

One deputy director told me my claims were denied on a particular date (based on entries in their database). I asked him to send me a copy, which he promised to do. He called back to apologize because on the date in question, they had not even submitted a claim.

I figure I’m not so special. If this has happened to me, then it has happened to others too. How many PH patients are missing out on the proven benefits of pulmonary rehab because their providers tell them it isn’t covered by insurance and they have to pay $60 – 70 a month?

If you have to fight for insurance rights, don’t give up. Sometimes it is hard. Representatives from the provider told me several times that my insurance denied payment, but I kept fighting, and I kept calling, and I finally got the situation worked out.

By: Doug Taylor, PH Patient

This article was first published in Pathlight Summer 2012