Who gives care to people who are alone?

Dio

Ever since DH started having what seemed to be psychotic episodes and was hospitalized 7 months ago, I've been experiencing loads of road blocks from our insurance company, claiming (pardon the pun) that our claims were either missing info or that the service codes--basic psych evaluation, individual therapy, and medication management--are not included in our benefits...are you kidding me?!

While I was cursing and cussing, DH asked "how do people without spouses (or partners) manage this? Who takes care of them?" Wow! I was floored by his comments. Indeed, how do they get the care they need and deal with insurance, assuming they have insurance, and the like?

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Kibbee

Sounds like your provider's office is coding incorrectly, or the coding is correct but the insurance company is (1) denying because the service provided falls outside the parameters of your coverage plan, or (2) yanking you around in the hopes they can avoid paying on your claim.

It may be helpful to start with the Billing & Coding manager at your providers office.  Before you contact him/ her get all your documentation together, including the codes & the insurance company's stated reasons for denial.  The Billing &Coding manager should work with you to determine if the original coding was done correctly.  If it was not, it's incumbent on the Billing & Coding manager to have their staff make the coding corrections and re-submit the claims.  (And frankly, do a better job on staff training, and on quality control around outcomes!)  

If the coding was done correctly, then the problem is the insurance company.  The question to be determined with them is whether the services provided were within the scope of your insurance plan.  If so, and if coded appropriately, they need to pay the claim.

Every insurance plan is different.  For instance, my plan will cover an annual physical and labs, (preventive care / well visit) at 100%.  If I want to bring up a new issue, I ask my physician whether doing so will change her coding for the visit from an annual physical, to an acute visit.  I've learned the hard way that if the visit gets coded anything other than an annual physical, I won't get that 100% coverage.  Bottom line is we have to be as informed as possible about our insurance plans scope of coverage, and be ready to self-advocate to assure we get the benefit we are paying for.

Stuck in the middle

Dio wrote:

Indeed, how do they get the care they need and deal with insurance, assuming they have insurance, and the like?

They don't.  75% of the unhoused people have severe mental illnesses.  One of my disabled son's former RCF roommates became homeless and was stabbed to death by another homeless person.  

If you did not care for your LO, he would quite likely be sleeping outdoors and eating from dumpsters.  And not getting medical care of any kind.  Bless you.

Gig Harbor

I have a friend whose husband has a terminal cancer. He has lived longer than was expected and is doing well but he attributes it to his wife. She has navigated the VA and has been his supporter working tirelessly to get him great care. Without her he never would have been able to do that.