Dealing with Insurance

Being a military family isn't always the easiest, but it does occasionally have it's perks. We get to see all different parts of the country, and we do get pretty darn good insurance coverage, as long as you don't need specialty care. Lynk needs specialty care.

Normally, when you are sick or need to be seen, you can easily go to the local military hospital and be seen by your Primary Care Manager (PCM), who is your main doctor. You never see a bill from them, don't have to worry about co-pays, and if they write you a prescription, you just trot on down to the hospital pharmacy, wait about an hour or so in line, and voila, you have your prescription filled, also at no charge.

However, when you need care that the hospital can't take care of, things get tricky. We have been dealing with insurance's red tape for weeks now. Normally, in order to be seen by a specialist, your PCM puts in a referral, which then goes to a regional contractor who fine tunes the referral, and then sends it to insurance, who is supposed to approve the referral, and give you a magical authorization number. The magical authorization number means you don't need to pay for the specialty care out of pocket. This entire process takes approximately 10 business days, or two weeks.

Lynk is special. He has a very special condition which means he needs special doctors. The doctors he needs to see are located at the Emory Eye Center in Atlanta. Unfortunately for us, the Emory Eye Center is not an in-network facility. The first time we requested a referral for Emory, insurance sent us a referral to a place called the Kirklin Clinic in Birmingham, Alabama. A facility that has neither an ophthalmology department or a low vision clinic, both of which Lynk needs.

After several lengthy conversations with insurance, and our referrals being kicked back again, I finally was able to discover exactly what our referrals needed to say. Our referrals needed to specify that we needed two separate doctors. Lynk needs to see an ophthalmologist who specializes in inherited retinal diseases because he has Stargardt's, and an optometrist who specializes in low vision because my 6 year old is legally blind. I let Lynk's PCM (Dr. Brown, Lynk's pediatrician) know exactly what the referrals needed to say. Then it's a waiting game for the referrals to get through the local contractor, then onto insurance.

Today, I checked the insurance website and found - they got kicked back again. Incomplete Information is the official term insurance used to say they weren't going to approve the referrals. I just concluded a rather lengthy chat with someone from Humana, our insurance company. It turns out that their system won't allow any approval for the same specialty at two different locations. According to their system, they had already approved an ophthalmologist at Kirklin, so they couldn't approve Emory.

The funny thing about this is that Kirklin Clinic doesn't even have an ophthalmology or low vision department. They gave us an approval to a place we didn't request, and didn't have the specialists we needed, and then used that approval as an excuse as to why they wouldn't approve the specialists Lynk needs to see.

So now, we have to submit a request to switch the referral from Kirklin to Emory since we will not be using the Kirklin referral. This request will take 3-5 business days to process, but it will probably be longer than that since Columbus day is coming up. And, I now have to call Emory in the morning and verify exactly what name, address, and phone number they bill insurance claims under. For some reason, the referral to Emory was submitted under the name Emory Clinic, not Emory Eye Center.

If we had gone to Emory and they billed insurance under the name Emory Eye Center and not Emory
Clinic, then we would have to foot the bill out-of-pocket. If they bill under specific doctor's names and the referral was for Emory Eye Center, we'd have to foot the bill. So now I get the lovely task of making sure all our ducks are in a row, and that these referrals have their t's crossed and i's dotted.

Dr. Jain at Emory

If we do have to update the referrals to reflect the correct information for insurance billing purposes, then it will be an additional 3-5 wait for processing. So now we are looking at 6-10 business days to process these referrals. I'm hoping this is the last time, and that insurance will finally approve us to be seen by the amazing doctors at Emory. Seriously. Like Dr. Jain, an ophthalmologist who specializes in diseases like Stargardt's. Click his picture over on the left to check out his information. He seems like he'd be the perfect person for Lynk to see for his Stargardt's.

Oh by the way, I completely forgot that people may not know what the difference is between an ophthalmologist and an optometrist. An optometrist is basically someone who deals with vision. They're the ones who prescribe glasses and contacts, check to see how well your eyeballs can see, and can deal with minor eye infections. Ophthalmologists are the doctors who deal with eye diseases, like Stargardt's, Glaucoma, Cataracts, and I'm pretty sure they're all eye surgeons as well, since they have to do cataract surgery a lot.