Thoughts

I sent an appeal letter to the ACN about a month ago. I have received a letter from them.

It states:”This patient has been receiving ongoing passive treatment (continuation of care from January, 2005 to present with 25 visits in past 6 months) for the same or similar complaints without resolution or measures or clinically relevant subjective or objective functional improvement. Continuation of care that is failing to produce a sustainable, measurable change in the clinical status of a patient and/or is designed to maintain health and wellbeing (such as preventive and/or maintenance care) is not a covered benefit per the exclusions section of the patient’s certificate of coverage.”

It seems comical to me that they do not cover preventive or maintenance but nothing we have says that. Our certificate of coverage does not mention this. This also came 2 weeks after talking with Cathy (Kathy) at the ACN and she stated several times that they were not allowed to take appeals or rule on them. YET this letter was signed by Maureen S. Appeals Coordinator. Also if the insurance does not cover preventive or maintenance care then why do they pay for pain medicines, high blood pressure medicines, and all the mental health medicines? I think the ACN is trying to pull the wool over our eyes when it is 90% cotton. In other words I feel there is a scam going on.

It is rather disheartening that OCLC does not advertise their benefits honestly. They do not mention that some items that are suppose to be covered may not be due to the association of United Healthcare and the ACN. The restrictions are put on Pysical Therapy and Chiropractic Care

http://www.oclc.org/americalatina/en/careers/workingat/benefits.htm

OCLC provides a rich package of benefits designed to foster the well-being of our employees and their families. Some of these benefits include:

Medical plan options

Comprehensive, competitively priced medical plans are available on the first day of employment to all full-time employees and their families. Prescription drug benefits are included in the medical plan options.

Two plan options are currently available for medical coverage:

1. Preferred Provider Organization (PPO). This plan provides benefits for both in-network and out-of-network care. Each time care is received you decide whether to see an in-network or out-of-network provider, however, to receive a higher level of coverage (90% after deductible), a network provider should be utilized.
2. Exclusive Provider Organization (EPO). This plan provides benefits for in-network care only; no benefits are paid if you utilize a non-network provider (except in the case of an emergency). Many services are either paid at 100% or have a modest copay.

You may read more of the ongoing denial here

http://rhiannon.blogs.pagannation.com/2008/03/20/united-healthcare-acn-and-oclc-insurance-mess/

and about the ACN

http://rhiannon.blogs.pagannation.com/2008/03/31/what-does-the-acn-do-deny-help-and-does-not-follow-their-mission-statements/