OT: Health Care Hell

[mdeth1313]

My wife had surgery for a frozen shoulder. It was so bad they had to go in and clean it out before they could manipulate it (zero external rotation). This was after months of PT.

Protocol for after surgery is intense PT. Surgery was Dec 26th, she actually had PT that day and then continued daily. After a week or two she was doing so well they cut it back to 3 days a week. Last Friday Empire BC/BS sends a letter that all PT from Nov on was denied and all current and future PT is denied.

Surgeon and Physical Therapist have sent letters - it's been a week - we were told a review could take 30-45 days and her mobility has gone from 150 degrees to 110 degrees during the week w/out PT.

BC told her PT to fax all letters and info to BC when it should have gone to their 3rd party claims processor.

Anyone have any advice for getting them to move their asses on this before she needs surgery again? Maybe it's time to get a lawyer?

Apparently they switched to a new 3rd party claims processor over the summer so they just approved everything without reviewing it. When their software came online in Nov they started denying everything, but didn't notify us until January. Opening a new case (to expedite getting PT now) would mean they won't cover the past stuff they denied.

I'm ready to vote for anyone who wants to get rid of for-profit health insurance.

[AngryScientist]

That's bizarre and very unfortunate.

No advice other than, if you can float it, she may want to pay out of pocket for the PT until you can get the insurance situation settled.

[schwa86]

If you have an insurance plan regulated by the state (ERISA plans that are self insured are not) it is likely that your state (usually via the insurance department) has a consumer protection function. While your situation may not technically be appealable to them yet, because you haven’t exhausted the insurers internal process, state folks frequently have means to make informal calls to get things moving. I take it Empire is NYS. If so, on cursory glance, this looks like approximately the right place. https://www.health.ny.gov/health_car...re/complaints/

[mdeth1313]

Thanks - we're getting our ducks in a row. It is NY and the issue seems to be Blue Cross switched to a new 3rd party provider that approves claims - when they came online they denied everything and anything that was in the past they closed out.

BC says the doctors need to do a peer to peer to get them covered and the 3rd party says they won't do peer to peer on past claims. This is where we'll need someone to facilitate.

[benb]

We've been paying for PT out of pocket for a while, preferably out of HSA/FSA.

Some PTs don't even deal with insurance. I was told it's because PT is cheap enough that the cost of dealing with the insurance can be equal to/more than the cost to run the PT business. E.x. the business has to double the # of employees because 1 PT working 40 hours a week generates 40 hours of work fighting with the insurance.

"You can pay me $50/hr for your PT. Or you can pay me $100 an hour through insurance and you'll get a $50 co-pay", etc...

I can believe it based on how annoying my insurance (UHC) is and how much time I waste on it.

[Mikej]

That is unfortunate. The several times I went to PT it was in the $300 a session range with insurance. Our state requires a Doctorate now (but it is not an MD), so I don't see getting a pt session for $50 out of pocket around here.

[vqdriver]

insurance - can't offer any sage advice other than to say that if their 3rd party is like most industries, they justify their services by telling bc that they'll save them money. they do this by denying claims en masse. if anything becomes a huge deal (bad press) then they can apologize publicly and say "oh, it's not us. it was this outside company"

wife - pay out of pocket if you can swing it. her health and well being would take priority over the costs because i can imagine this type of condition could deteriorate and cause other expenses (and loss of income if she works) that would exceed costs of the pt. of course you can claim all the out of pocket expenses after insurance has done their nonsense claims review

[zap]

Originally Posted by benb

Some PTs don't even deal with insurance.

The PT I used when we lived in metro D.C. only accepted cash or cc. Fifty bucks a visit. Same (cash or cc only) for one of our doctors.

Hope it works out for mdeth wife....pt is a critical part of the healing process.

[sailorboy]

This is sad and I feel for the OP. I second those who have suggested out of pocket therapy. You can often submit your own PT bills to your insurance co. for reimbursement after the fact. Since they are cutting out the billing arm of the process, the PT can charge less. Everybody wins. I would also suggest you research a bit more into the effectiveness of PT for her condition. At least for the non-operative route, more recent research has reported less gains from 'intensive' PT for frozen shoulder, and in some cases it actually makes the patient worse. Just get them to teach you/her how to self-treat and have periodic follow-ups to measure, make modifications and maybe manipulate the thoracic spine or possibly use dry needling to augment what you are doing at home. It is a long slog and often the issue resolves on it's own over (a long) time. Now that surgery is in the mix (rarely necessary) that may change things a bit.

[benb]

My $50 example was not current.

It's been 7 years since I had to go.

I don't recall what my wife paid, she went last year. Same story though.

I *hate* this whole FSA/HSA type program. Premiums keep going up, higher deductible, higher out of pocket max. They sold it as a big scam that patients would "shop around" and force medical costs down. Yah right.

That said for 2020 my company actually did not get a rate hike. But we have 15k employees and deep pockets. The actual plan costs a lot more than 3 years ago when I worked for a 500 person private company. (We got swallowed at the end of 2017... somehow the bigger company can't get as good insurance...)

I paid around $10k total for insurance + deductible + out of pocket last year. Family of 3, I'm the oldest at 42. No one had a surgery or cancer or anything expensive. My kid is 7 and there were a couple ER visits but still... And again, I work for a multi-billion dollar company with > 10k employees. Our HQ is in CA and it sounds like the CA employees do much better on Kaiser.

I have had tendonitis in my arm for ages and I have to admit I should be going for PT and have been putting it off cause I hate all this BS.

[ftf]

Welcome to for profit healthcare..... they aren’t here to provide service, they are here to pad the bottom line with your money.

[semdoug]

You probably will not like this, I don't like it either, but I find it astounding your wife has had as much PC as you have mentioned. I have never had more than 10 PT visits approved by several past and current insurance companies, as well as the military and VA systems.

With that said, I hope you are able to get this worked out in your wife's favor.

[GScot]

Insurance is in the business of collecting premiums, paying claims is to be avoided at all times.

Similar when I went through the elbow replacement in 2015. They covered 3 PT sessions. After four additional surgeries for a drug resistant infection that were as invasive as the first they would not cover any PT. In spite of doing everything in network including showing up at a company emergency room they managed to leave me on the hook for roughly 3X what my max out of pocket expense was supposed to be.

Even if it has limitations I look forward to the day that single payer healthcare is implemented and every last urchin and leach feasting off the for profit system is out on their ass. Of course it won't matter much as they've already looted the country quite effectively.

[el cheapo]

Let's face it...we are all just economic units to be used to generate a profit from birth to death.

[eddief]

are too afraid of change and won't act in their own self interest.