Insurance denies out of network care to Joslin

I need support and help. Our 13 year old daughter has had type 1 diabetes for 29 months. We started her care at Maine Medical Center when we got the call she has diabetes. The care there was triage at best and we were all drowning. After many issues we switched to Joslin Diabetes Center in Boston. Anthem approved the out of network care for this time. We cherish the comprehensive care services and the team approach at Joslin that have helped us navigate life with a diabetes. Our daughter also has ADHD, Graves Disease and vitiligo so the team support especially from the social worker is key to her success at this balancing game.
So we are very upset that Anthem insurance has now made the decision that she is doing well enough to return to Maine Medical Center for care- because it is “in network”.
Anyone with advice- suggestions and thoughts are most welcome. I am the mom and the advocate for this beautiful girl and I want her to have a long healthy and joyful life. thanks.

I am sure it is very hard to deal with this. Anthem is stepping in to make medical decisions and the way to deal with this is to get the medical expertise on your team to fight back. A first line of defense is contesting this decision is to get one or more doctors to attest to the medical necessity of continuing care at Joslin. As you have become painfully aware, Joslin provides a level of care you will not find elsewhere. Your daughter at the age of 13 is most likely struggling with all this and having a variety of medical issues is likely to be very ill served by the change. Your best bet is to get your Joslin doctors to attest that given her various medical conditions all overlapping that only Joslin can provide the care that she needs through their team approach. You can yell till you are blue in the face, and Anthem won’t give a hoot, but they will listen to medical professionals.

There are a lot of reasons why your request may have been denied. You should push for answers with Anthem. If you get health coverage through you or your spouse’s work talk with the person in charge of benefits at your work. If you can you should change to a PPO (preferred provider option) plan so you have the option of going to out of network providers, but the down side is that it will cost you more out of pocket. Unfortunately, HMO’s are a cheaper option because the insurance company has more control. Or you could always move to MA and get a MA health insurance plan (Joslin has been fine for me for both Harvard Pilgrim and BCBSMA) but I doubt that is the option you are looking for :slight_smile:

Thank you. Your thoughts and insight are very helpful. I wrote to her Joslin team and her PCP after reading this and asked them to fax Anthem with all the thoughts you stated and more. It felt great to throw this out and receive support back. I really appreciate it.

Thank you. For now this is it. I am a teacher in Maine and this is the insurance I have for our girl and we aren’t moving anytime soon. <:

I completely agree with this. The insurance companies will sometimes listen to the medical team. And who better to fight for her health than the people who make the immediate decisions on it?

Joslin is a beautiful facility filled with wonderful doctors and staff. I’ve been there a few times and wish that I could afford to go there all the time! They have the first access to new studies and research there too. They are simply amazing so I completely understand why you would want to bring your daughter there.

keep fighting and keep us posted!

ugh! i can’t help too much, but wanted to let you know you’re not alone in feeling this way. after my uncle had several heart attacks in quick succession, my mother fought with his drs to get him transfered from maine medical to a hospital with a much larger cardiac program. both the drs there and his insurance company said there was absolutely no reason he should be transfered, and she started printing out studies (and i mean reams and reams of paper) from online showing the higher survival rates based on certain types of treatment, etc. it took her a few weeks of phone calls (and she is also not afraid to get angry to get someone’s attention), but they did finally agree that his care couldn’t be adequately managed there and he was moved.
have you talked with her social worker at joslin? maybe she could point you towards the proper channels to appeal; surely your daughter is, unfortunately, not the first patient to have this happen.

(where abouts in maine are you?)

We are in Southern Maine – so it is almost as easy to go to Boston as Portland! The social worker at Joslin is an angel and she is helping. They have submitted an appeal to Anthem on our behalf as has the PCP. So much like your uncle we know the care in Maine does not compare to Boston…esp Joslin–which is world class. So I will fight for my girl to have that comprehensive team care as she has overlapping conditions and we are entering the teen years…not the easiest time to have a complicated medical profile. Thanks for sharing…

thanks-- it means a lot to have a cheering section.

Im sorry to hear that your having problems with medical insurance. I too am having difficulties trying to get health insurance back. I’m 21 and have had type 1 for 14.5 years. I also have two types of auto-immune arthritis’s, Fibromyalgia, and Hypothyroidism… I am no longer covered on my parents health insurance due to health problems which led my father to having to retire early from his job which provided excellent health benefits through Atena. I wish I could provide more helpful information, but I’m in the same boat with you in not knowing what to do. Best wishes to you and Joslin I hope a solution is near for your family. God Bless.


Dear Kaila-- so sorry to hear this. Heartbreaking. I hope you contact Joslin Diabetes Center as they do have funds for folks without insurance to receive care. Another thought–Does your state have an insurance program you might qualify for? take good care. grace