Insurance: A convenience and an annoyance

In one day I went from being indifferent about our insurance company to being really annoyed by it.

We have an HMO which requires that I get a referral to have special procures done which, although new for me since switching from a PPO, is not a big deal. For Maddy, I quickly learned that there is more required with newborns. In addition to the referrals that I need to get for her GI specialist visits, I also have to have Prior Authorization for any medication that is not standard for babies (i.e. Prevacid, Zantac, etc). I’m assuming this is a standard practice of insurance companies when covering meds for the little ones. Unfortunately, I only learned of this when I went to pick up her medication and 1) their system had her as not being covered and 2) after I called the company to make sure she was, they told me that she needed the prior authorization. Good to know!

Now back to the referrals. This, I don’t understand and will need to make my 3rd call to the company to get smoothed over. My pediatrician’s office has 2 locations: Princeton and West Windsor. It’s the same office, same doctors, same everything. The only things that are different are the last 2 numbers on the end of the code that they bill with to the company. We had Maddy signed up with the WW office and had no problem with copays. All of a sudden, her copay at the Princeton office was $40 instead of the regular $20. When I made the call about it, I was told that the Princeton office registered as an out-of-network doctor since it was a different number from WW. What I was told is that I have to get a referral if I wanted to go to the same doctor but at a different location. RE—DIC-U-LOUS! The billing dept NEVER heard of this issue with my insurance company and thinks I’m getting the run around. I’ve spoken with 2 different customer service people who tell me, sorry I have to get a referral. I decided to give it a rest for a week before I call back again to speak with a manager or supervisor.

Back to prior authorization. The GI specialists told me that the Neocate formula, which Maddy has to feed with, is most definitely covered by insurance as is her special compound medications. I’ve submitted my receipts to them to submit to my insurance. We’ll see if it gets approved. One positive out of all of this is that it’s helping me to be more organized with paperwork, etc.