Today I am launching a new feature on my blog: Guest Blogger Du Jour. I’m starting off with a bang thanks to my friend Lynn Smith. Lynn is fairly *new* to autism and biomedical treatments; however, you’d never know that by talking to her. This is a woman who has taken the autism bull by the horns and has tackled its ass. Lynn’s not messing around, she’s out to bring her daughter back from the abyss of an ASD. So without further ado, I present you with my first ever guest blogger, Lynn Smith ((and the audience roars)) [if you are interested in a guest blogger spot, please email me at charlieinwonderland@yahoo.com]:
The purpose of this post is to share our story of getting insurance approval for Dr. Arthur Krigsman through our insurance company, which will be referred to as “InsuranceCo” throughout the piece.
On April 28th we had our initial phone consult with Dr. Krigsman to review my daughter Beth’s medical history and lab results. It was determined that the next steps would be having her scoped, pill cam, and biopsy procedure. These were scheduled for June 2nd in Austin, TX.
During the middle of May one of Dr. Krigsman’s employee’s contacted InsuranceCo to get pre-certification for the procedures, at which point the Insurance company quickly said “No”. I then contacted insurance and spoke to numerous representatives. Several transfers and many tears later, I spoke to a lovely insurance lady named Tiffany. She was the most helpful person. She too was struggling with some insurance processes, as she has fertility issues. How we shared this on the phone that day, I really don’t remember. In any event, she helped me do what was needed and open an “In-Network Exceptions request”. This means that the in-network doctors either are not geographically close to our location, or do not do the same procedures. It took me 4 business days to get this squared away with insurance, and our “In Network Exception” was finally open on May 22nd. I then contacted my daughter’s pediatricians office to let them know – insurance will be calling.
Just for the record, our Pediatrician’s office doesn’t really know or understand what I’ve been doing to determine what’s wrong with Beth. I was able to convince them to “sign off” on the lab work Dr. Krigsman requested (so it’d go through insurance) and I was able to get them to examine her for the pre-surgery exam. Outside of that, they were completely out of the loop. So it was going to be hard for them to say, Beth needed to see Dr. Krigsman. And as it turns out, they didn’t.
With only 4 business days until we traveled to Austin, TX to meet Dr. Krigsman I called and faxed the insurance company daily. I faxed the nurse assigned to “our exception” black and white pictures of Beth. I continuously thanked her for her help. I faxed them her growth chart. I faxed them her test results, showing she had a problem. I faxed them her vaccine schedule. I faxed them a letter of necessity from Dr. Krigsman’s office. Finally on 5/28/2009 with one more business day to go - I called Insurance to check on the status – at which point they told me they could not accept any medical records from me. They must come from the pediatrician’s office. So I faxed everything to the pediatrician’s office and asked them to fax it to insurance. Come on, InsuranceCo – why the heck does it matter if I send the results or the doctor does it. I just wanted them to have them. I’m certainly not versed in writing or creating phony test results. InsuranceCo was clearly trying to break me – and I will not be broken by them or Autism.
I called insurance one more time on 5-29-2009 at which point they told me, all of the test result information is good but they can not accept it from me. I now needed an in-network GI doctor to refer me to Dr. Krigsman. At which point, I got off the phone with them and made an appointment to see Dr. Color (not his real name) for June 25th.
On June 1st we met with Dr. Krigsman for our pre-op appointment. I shared with him our insurance struggles and he said he would help. We went forward with the procedures as scheduled. The scope didn’t reveal much other than some inflammation. Now we wait for the biopsy and pill cam results. We spent the rest of the week in Austin and tried to make it a vacation for our other two children.
The trip home was very tiring. We ran out of special meats for Beth and were left with organic hot dogs. Beth had been boycotting hot dogs for the past week, but we tried to serve them to her anyway. We stopped at a Dairy Queen for lunch, presented Beth with water and organic hot dogs – while the rest of us ate blizzards, fries, burgers, and chili dogs. She was so upset with her meal options, that I caved and gave her one French fry to appease her. It worked, she really enjoyed the French fry and we were able to enjoy the rest of our lunch.
June 8th, my son had a baseball game and I decided that Beth and I should go (since it was his last game). Beth had an organic picnic at the ball field. When we arrived home there was a letter in the mail from InsuranceCo. Geez, not another denial letter! Oh my gosh – it was an approval letter dated June 3rd. We were approved for 3 visits from June 1st – September 1st (or whichever came first). I was in shock and actually wasn’t sure the letter “translated” to mean what I thought it meant. So June 9th I called InsuranceCo and verified the meaning. I also wrote down the date time and who I spoke with and confirmed these calls are recorded, right? Just in case I need to reference this call sometime in the future.
Fast forward to June 17th, the pill cam results are in and it looks like Crohn’s. This is not what I wanted to hear, but I did want there to be something. But wait, we still need the biopsy results. June 23rd biopsy results are in and are negative. The pill cam results showed lots of damage Beth has a diagnosis of Autistic Enterocolitis and we began treatment that night.
Now that I have all this knowledge under my belt and the approval from InsuranceCo, I decided to continue on with the in-network GI doctor appointment. I’d ask for his referral to Dr. Krigsman (we’ve already used up the 3 appointment approval within the first 30days). June 25th after waiting for 45 minutes Dr. Color enters the room. I explain to him why the visit, and that I just want the referral. His response, “she’s at 25% on the growth chart.” OMG! I then pull out my stack of test results, growth chart information (showing only 2 lbs gained in 1 year) and went into exhaustive details about what we’ve tried. I showed him the approval letter from InsuranceCo. Dr. Color agreed to writing the referral letter. He wanted copies of all of the test results. He quizzed me on what the results were:
Did she get scoped upper and lower? Yes, it revealed some inflammation and white specs.
Did she have a biopsy? Yes, it was negative.
We also did the pill cam – it showed lots of damage, blisters, ulcers, etc…and he stated that he would never give a diagnosis based on the pill cam. He diagnosis based on the biopsy.
So, if I would have taken Beth to him in the beginning – he would have dismissed my concerns and said she was okay. Did you get that just now?
Dr. Color then proceeded to warn me that there are GI Doctors out there making claims that aren’t true. Parents are being taken advantage of…I asked what are the claims? Silence. I asked, that the autism will be cured? He said, Yes. Well, I assured him Dr. Krigsman is only promising to treat her GI issues. He has not promised to heal her autism.
I then asked point blank “Is there something you know about Dr. Krigsman that you are concerned about or that I should be concerned about.” The answer, No.
I told Dr. Color, I didn’t want to play games with him or insurance. I just want to have his referral to Dr. Krigsman, as insurance had once told me I would need. He agreed to write the letter, as long as he could have copies of all of the test results so he could review and use the information in the referral letter. With that I turned over my precious stack of papers – I wanted to guard them. Dr. Color left the room, and I packed up Beth and headed to the nurses station, where I waited for my papers. Before leaving, I asked for a contact for follow-up, so I could ensure getting the referral letter.
I left the doctors office energized. We had a treatment plan in place for Beth, we had started the medication, and the sleepless nights had begun as well. The medicine is working! I should also add, Dr. Color never made any recommendations nor did he tell me what he would do if Beth were under his care. Very interesting, don’t you think??
My journey with in-network doctors and InsuranceCo processes is probably not over. I have submitted the bills to insurance for reimbursement and look forward to their response.
If you are a mother or father reading this, I hope that this story has encouraged you to continue pushing for Insurance coverage, treatment and care of your child. It’s hard, it’s tiring, but when it goes the way you need it to go, it’s very energizing.
Lynn Smith
One Determined Mother from Munford, TN
The purpose of this post is to share our story of getting insurance approval for Dr. Arthur Krigsman through our insurance company, which will be referred to as “InsuranceCo” throughout the piece.
On April 28th we had our initial phone consult with Dr. Krigsman to review my daughter Beth’s medical history and lab results. It was determined that the next steps would be having her scoped, pill cam, and biopsy procedure. These were scheduled for June 2nd in Austin, TX.
During the middle of May one of Dr. Krigsman’s employee’s contacted InsuranceCo to get pre-certification for the procedures, at which point the Insurance company quickly said “No”. I then contacted insurance and spoke to numerous representatives. Several transfers and many tears later, I spoke to a lovely insurance lady named Tiffany. She was the most helpful person. She too was struggling with some insurance processes, as she has fertility issues. How we shared this on the phone that day, I really don’t remember. In any event, she helped me do what was needed and open an “In-Network Exceptions request”. This means that the in-network doctors either are not geographically close to our location, or do not do the same procedures. It took me 4 business days to get this squared away with insurance, and our “In Network Exception” was finally open on May 22nd. I then contacted my daughter’s pediatricians office to let them know – insurance will be calling.
Just for the record, our Pediatrician’s office doesn’t really know or understand what I’ve been doing to determine what’s wrong with Beth. I was able to convince them to “sign off” on the lab work Dr. Krigsman requested (so it’d go through insurance) and I was able to get them to examine her for the pre-surgery exam. Outside of that, they were completely out of the loop. So it was going to be hard for them to say, Beth needed to see Dr. Krigsman. And as it turns out, they didn’t.
With only 4 business days until we traveled to Austin, TX to meet Dr. Krigsman I called and faxed the insurance company daily. I faxed the nurse assigned to “our exception” black and white pictures of Beth. I continuously thanked her for her help. I faxed them her growth chart. I faxed them her test results, showing she had a problem. I faxed them her vaccine schedule. I faxed them a letter of necessity from Dr. Krigsman’s office. Finally on 5/28/2009 with one more business day to go - I called Insurance to check on the status – at which point they told me they could not accept any medical records from me. They must come from the pediatrician’s office. So I faxed everything to the pediatrician’s office and asked them to fax it to insurance. Come on, InsuranceCo – why the heck does it matter if I send the results or the doctor does it. I just wanted them to have them. I’m certainly not versed in writing or creating phony test results. InsuranceCo was clearly trying to break me – and I will not be broken by them or Autism.
I called insurance one more time on 5-29-2009 at which point they told me, all of the test result information is good but they can not accept it from me. I now needed an in-network GI doctor to refer me to Dr. Krigsman. At which point, I got off the phone with them and made an appointment to see Dr. Color (not his real name) for June 25th.
On June 1st we met with Dr. Krigsman for our pre-op appointment. I shared with him our insurance struggles and he said he would help. We went forward with the procedures as scheduled. The scope didn’t reveal much other than some inflammation. Now we wait for the biopsy and pill cam results. We spent the rest of the week in Austin and tried to make it a vacation for our other two children.
The trip home was very tiring. We ran out of special meats for Beth and were left with organic hot dogs. Beth had been boycotting hot dogs for the past week, but we tried to serve them to her anyway. We stopped at a Dairy Queen for lunch, presented Beth with water and organic hot dogs – while the rest of us ate blizzards, fries, burgers, and chili dogs. She was so upset with her meal options, that I caved and gave her one French fry to appease her. It worked, she really enjoyed the French fry and we were able to enjoy the rest of our lunch.
June 8th, my son had a baseball game and I decided that Beth and I should go (since it was his last game). Beth had an organic picnic at the ball field. When we arrived home there was a letter in the mail from InsuranceCo. Geez, not another denial letter! Oh my gosh – it was an approval letter dated June 3rd. We were approved for 3 visits from June 1st – September 1st (or whichever came first). I was in shock and actually wasn’t sure the letter “translated” to mean what I thought it meant. So June 9th I called InsuranceCo and verified the meaning. I also wrote down the date time and who I spoke with and confirmed these calls are recorded, right? Just in case I need to reference this call sometime in the future.
Fast forward to June 17th, the pill cam results are in and it looks like Crohn’s. This is not what I wanted to hear, but I did want there to be something. But wait, we still need the biopsy results. June 23rd biopsy results are in and are negative. The pill cam results showed lots of damage Beth has a diagnosis of Autistic Enterocolitis and we began treatment that night.
Now that I have all this knowledge under my belt and the approval from InsuranceCo, I decided to continue on with the in-network GI doctor appointment. I’d ask for his referral to Dr. Krigsman (we’ve already used up the 3 appointment approval within the first 30days). June 25th after waiting for 45 minutes Dr. Color enters the room. I explain to him why the visit, and that I just want the referral. His response, “she’s at 25% on the growth chart.” OMG! I then pull out my stack of test results, growth chart information (showing only 2 lbs gained in 1 year) and went into exhaustive details about what we’ve tried. I showed him the approval letter from InsuranceCo. Dr. Color agreed to writing the referral letter. He wanted copies of all of the test results. He quizzed me on what the results were:
Did she get scoped upper and lower? Yes, it revealed some inflammation and white specs.
Did she have a biopsy? Yes, it was negative.
We also did the pill cam – it showed lots of damage, blisters, ulcers, etc…and he stated that he would never give a diagnosis based on the pill cam. He diagnosis based on the biopsy.
So, if I would have taken Beth to him in the beginning – he would have dismissed my concerns and said she was okay. Did you get that just now?
Dr. Color then proceeded to warn me that there are GI Doctors out there making claims that aren’t true. Parents are being taken advantage of…I asked what are the claims? Silence. I asked, that the autism will be cured? He said, Yes. Well, I assured him Dr. Krigsman is only promising to treat her GI issues. He has not promised to heal her autism.
I then asked point blank “Is there something you know about Dr. Krigsman that you are concerned about or that I should be concerned about.” The answer, No.
I told Dr. Color, I didn’t want to play games with him or insurance. I just want to have his referral to Dr. Krigsman, as insurance had once told me I would need. He agreed to write the letter, as long as he could have copies of all of the test results so he could review and use the information in the referral letter. With that I turned over my precious stack of papers – I wanted to guard them. Dr. Color left the room, and I packed up Beth and headed to the nurses station, where I waited for my papers. Before leaving, I asked for a contact for follow-up, so I could ensure getting the referral letter.
I left the doctors office energized. We had a treatment plan in place for Beth, we had started the medication, and the sleepless nights had begun as well. The medicine is working! I should also add, Dr. Color never made any recommendations nor did he tell me what he would do if Beth were under his care. Very interesting, don’t you think??
My journey with in-network doctors and InsuranceCo processes is probably not over. I have submitted the bills to insurance for reimbursement and look forward to their response.
If you are a mother or father reading this, I hope that this story has encouraged you to continue pushing for Insurance coverage, treatment and care of your child. It’s hard, it’s tiring, but when it goes the way you need it to go, it’s very energizing.
Lynn Smith
One Determined Mother from Munford, TN