A little update

Whitney · #1 03-11-2004, 12:22 AM

Well

It seems as if one chapter ends for another to only begin!! So, the nursing agency has finally submitted the claims to the correct insurance policy, etc. They are "charging" my insurance company $3000 per day for 12 hours. My insurance is paying 70% of their total charge. They are an out-of-network agency and we are waiting to see if my policy (secondary) will pay for the remaining 30%. Originally, UHC approved 100% coverage on my policy despite the fact my policy does not cover out-of-network services. They called it an EPO exclusion. I am not sure if that exclusion continued into the new year and I am absolutely certain the agency again did NOT work w/ UHC on submitting the claims to the 2nd policy.

So, they ARE screwing my insurance company by charging RIDICULOUS prices. At this rate, Alex will cap out quickly on the primary policy.

GOOD NEWS
We did get the Medicaid Waiver and we WILL BE expedited to the top of the waiting list.

BUT

Medicaid is cancelling their contract w/ our nursing agency in 3 weeks. So, we absolutely have to change agencies regardless.

Colorado is cancelling our agency's contract due to their inability to comply w/ federal regulations.

So, I will be scrambling to find a new agency that can staff accordingly. The only reason we went with this agency in the first place is that they were the only ones that could staff. So, we may be in trouble soon.

Anyway, Alex is doing very well and he will have a bronch in a few weeks. We will keep everyone updated. We are hoping they will decrease his CPAP to 12 and eliminate his Lasix.

Regards

Whitney

Jacob's Mom · #2 03-11-2004, 06:29 AM

Whitney, I have been following your posts about this and I have to say that I am really sorry you have to go through all of this. Isn't it enough that we have to deal with these medically fragile children!? It is always something! The same is true for us and our insurance.

We have had to go out of our network for nursing and they can charge our insurance outrageous rates. And, it is so funny, because we only get 2-3 days a week covered (at my request), but the director of the agency is ALWAYS saying to me, "Please, don't hesitate to call me if you ever want to increase your hours." Frankly, the only thing she has on her mind is more $$$$ from our insurance company.

I hope it gets better for you - quickly!

Amanda

hcs_mom · #3 03-11-2004, 07:28 AM

Whitney,

I'm glad the waiver got approved, but so sorry that you have to find another nursing agency. Don't know if you've done this or if applicable in Colorado, but here goes...

We have independent medicaid providers here. The case worker assisting you with waiver may have a list or contact your nearest children's hospital nicu and ask if they have any nurses that do private duty nursing. (We had quite a few nurses in our NICU that did private duty part time.) The downside to this is that you have to do all the legwork, including interviewing. Also, if they call off, you'd be hard pressed to find a back up. Our nursing agency has an on-call staff, which makes it a little better. The other option, if one agency can't staff all your hours, see if they will split with another agency. They don't like to do this, but some of them will.

I wish you luck in your search for nursing. Take care. Good luck with the bronch.

Jennie

cariaad · #4 03-11-2004, 07:45 AM

Just cusrious, isnt there some kind of regulation about not inflating charges just because they are going to an insurance company? $250 /hour for nursing is ridiculous. I'd look into it...Deb

Jacob's Mom · #5 03-11-2004, 08:22 AM

Deb, You would certainly think that is true. However, I found out that our last DME company was charging our insurance company $17 for a box of q-tips

. It is so ridiculous. I wish I had more time to research the regulations.

Stefan & Jennifer · #6 03-11-2004, 09:28 AM

$250/hour for nursing---holy

!! We pay our skilled and trained and family member baby sitter $275/week and she works 10 hours days!!! Of course our health plan doesn't have a nursing benefit and this is all out of pocket, but still....

Our health plan finally put their foot down with our DME---they will no longer be covering sterile Q-tips at $21/box. So the DME kindly offered to let us pay $21/box of 200. I laughed and told them I'd go to the pharmacy down the street and buy them myself for $5/box.