In January 2011, after months of appeal, letters, phone calls, a well-documented complaint lodged with the State Insurance Commissioner, repeated and diligent pressure and follow-up, Patient Navigator convinced a major mental health insurer to cover its share of 4 weeks of inpatient treatment for our client. His family received $27,580, the full amount allowable under his insurance plan. He wrote us to say “You are a hero, a champion, a medalist, a gladiator!”
Patient Navigator had been working with the client’s mental health providers to ensure a steady stream of information to the disability insurer when suddenly, the benefits were cut off. The family was frantic. The mental health provider had failed to provide a detailed letter to the insurer. Patient Navigator drafted the letter for the doctor using records available to us. The mental health provider reviewed it, made minor edits and we sent it along to the insurance company. Within 48 hours, the insurer called to tell us the client’s benefits had been retroactively reinstated. The family was ecstatic.“Awesome news!! Thanks so much!!
Melinda’s mother had paid her premiums for many years before she got sick. But when Mom needed help, the long term care insurer used every tool in its arsenal to complicate her access to the payments she was owed. She died before the company ever paid her. However, Patient Navigator worked doggedly to make the insurer paid what was owed and recovered $14,600 for the family after many months of persistent efforts. “You have done it, thank you!”
Theresa’s father had a painful back injury that required surgery, and significant recuperation time. Theresa was concerned that her dad’s company would not provide a short term disability benefit for his recovery time, but could not get a straight answer from the Human Resources department. Patient Navigator contacted the disability carrier and determined that Theresa’s father was not yet eligible for short-term disability, but that he would be in another six weeks. The surgery was delayed until his recovery would be covered, thus avoiding significant financial hardship.“The Patient Navigator team has been an invaluable resource in helping us make informed decisions regarding my husband’s care.”
Melinda’s mother had already spent over 100 days in the nursing home and had exhausted Medicare’s coverage. However, when Patient Navigator reviewed the nursing home’s submission to the secondary insurer requesting additional coverage, we discovered several key documents were missing. Patient Navigator helped the social worker prepare a proper and complete request. Since then, under Patient Navigator’s supervision, Melinda’s mother has been given three extensions totaling over 105 days, covered fully by insurance.
The client’s tests and surgeries had been improperly billed to the insurance company by the hospital. The client was subsequently sent overseas for work, and had no idea the claim had not been paid. It wasn’t until bill collectors started calling him that he realized something was wrong. Patient Navigator got to work and solved the problem. The claim was paid and the bill collectors stopped calling.
When Sharon became very ill, she was late paying her monthly retiree insurance premium to her former employer. After a complicated series of events, the insurance was cancelled even though Sharon needed to begin cancer treatments. Patient Navigator assisted with the family’s appeal and requested an expedited review. The insurance was reinstated, much to the patient’s relief.“Advice that we got in our initial consultation and follow up emails supported a ruling that reinstated our insurance – more than $200,000 value.”
The company providing her disability compensation was reluctant to continue benefits. Patient Navigator gathered clinical information from multiple doctors, submitted and tracked the paperwork, and convinced the insurance company to continue paying Nancy’s disability benefits. And we have made sure those benefits were renewed for the last four years, each time compiling reports with a dozen doctor statements, test results, and medical and financial records.
Patient Navigator was told by the insurance company that the therapy services were not covered because pre-authorization was required and not been obtained beforehand. The Navigator escalated to a supervisor who finally confirmed that retroactive pre-authorization was possible, but rarely approved. Patient Navigator re-submitted the claims on Matthew’s behalf and after weeks of follow-up phone calls, the retroactive pre-authorization was unexpectedly granted. Since Matthew had paid out-of-pocket, the Navigator worked with the office manager to redirect the insurance payment back to Matthew. Ten days later, Matthew received a reimbursement check from the physical therapist for the $556 covered by insurance.
Patient Navigator researched the best options to reinstate her coverage. We also researched and analyzed the Medicare Part D Prescription Coverage options available in her area. Irene regained coverage during the open enrollment period.
She called Patient Navigator to ask whether she should file for disability because she was running out of sick days at work. Elizabeth’s personnel office hadn’t told her about the Government’s leave donation program, which allows colleagues to donate leave to a sick employee. When Patient Navigator launched a leave donation drive among Elizabeth’s colleagues in Washington, D.C., she received over 700 hours of donated leave, thus allowing her to keep her job and avoid going on disability.
Although a Vietnam veteran, Steve was having trouble getting assistance from the Veterans Administration (VA), lost his insurance and was deeply depressed. His sister Ginny planned to visit him in Kansas City. Patient Navigator arranged a meeting with local Congressional staff to enlist their support for intervention with the VA. Ginney was armed with briefing materials, talking points and a schedule of appointments to advocate for her brother. Later, Patient Navigator negotiated a follow-up operation to repair the colostomy. Steve’s insurance benefits were restored.
Because the boy had a rare genetic condition, the insurance billing codes did not easily correspond to the services he needed. We helped Stacy build a strong, well-documented case of medical necessity to appeal the denied claims, and the insurer ultimately paid them in full.
His records had been lost in a 1973 fire at the Defense Department. Patient Navigator tracked down his discharge papers through employment, state and county records. We helped Phyllis enroll her dad so that he received the benefits to which he was entitled.
Since the doctors involved in her care were difficult to reach, Patient Navigator enlisted the help of nurses and staff. In one case, we drafted the Letter of Medical Necessity that the doctor ultimately signed and took care of all communications with the patient’s insurer.
We resolved this. When her mother passed away, Sharon asked us to help her father find a new insurance plan because the couple’s small group plan was now unaffordable. Patient Navigator presented several options so that Sharon and her father could make an informed and cost-effective choice about new insurance and helped them procure documentation proving creditable coverage.
Due to a degenerative vision disorder, Victor felt he could no longer do the information technology work he loved, and reluctantly planned to apply for long term disability. While helping him with the disability forms and necessary medical statements, Patient Navigator also listened to Victor’s real concerns about wanting to be productive. We encouraged him to explore alternatives with his employer, potentially using assistive technology. Ultimately Victor’s company provided the assistive technology, and Victor happily and thankfully returned to his job.
Newsletter Archive
From Our Blog:©2012 My Patient Navigator, LLC - Entries (RSS) Comments (RSS)
Privacy Policy - Terms of Use - Accessibility Statement - Administration
Thank you for printing this article. Please don't forget to come back to mypatientnavigator.com for the latest articles and the best information on taking control of your healthcare.
My Patient Navigator™
