OT: Health Care Hell

[redir]

Yup that's pretty crazy. Is there specific equipment that they have where she does PT or can she at least just do some of it on her own?

[buddybikes]

I got 60 visits with my former insurance (BCBS MA) and now changed insurances so will see how it goes. I need lot manual manipulation due to my back surgeries.

My PT is thinking of going cash only, but says by rule needs to work with insurance now that I have it and she takes it. However once used up can go $$ basis at a negotiated rate.

Certainly how much depends upon how long a visit is. Think I will be offered 65 to 75. If she goes cash only, she has full practice so has the ability to gross over 4K week (no employees) so 1K for expenses wk, take home is doable... Of course need a strong customer base

Good luck with wife, sounds painful.

[Steve in SLO]

Sorry to hear your troubles.
Would suggest that you privately pay for one visit with her existing PT, and ask them for a home regimen to either tide her over or complete her recovery.

[mdeth1313]

PT is standard protocol for frozen shoulder.

We now have 2 visits approved. She is doing stretching/exercises at home but that is not enough as you need to be manipulated to keep/gain range of motion.

My plan has "unlimited" PT visits but that's a load of crap - they'll move to declare it no progress so not worth it at some point.

It seems they have the circular plan going on - BC Cust service blames the doctors for not getting approval properly, then they tell them to do one thing but the 3rd party approval company says they don't do that.

At this point there's no expedited appeals process because it's 7 days after they denied the claims - of course no one was EVER notified they denied the claims when they did, but no one seems to care about that.

We are appealing all the previous stuff and that takes time and now the therapist is working on getting more PT approved.

It has taken a week just to sort out the BS we've been fed from customer service and the 3rd party approval group, now we seem to be able to start moving forward.

In addition to getting the address of the BC/BS ceo and writing a letter, we are also filing a complaint w/ the state attorney general, I'll also be contacting my state legislators.

BTW, I'm totally in favor of eliminating private, for-profit health insurance. Never, ever should have been allowed to go for-profit in the first place.

[buddybikes]

Can your PT teach you how to do some basic things to keep from going backward?

[GScot]

Originally Posted by mdeth1313

PT is standard protocol for frozen shoulder.


In addition to getting the address of the BC/BS ceo and writing a letter, we are also filing a complaint w/ the state attorney general, I'll also be contacting my state legislators.

BTW, I'm totally in favor of eliminating private, for-profit health insurance. Never, ever should have been allowed to go for-profit in the first place.

Good luck. I know every state regulator has a different approach. We lived in TX for the longest time and a complaint there would yield nothing. Was in MO for my disaster and complained/appealed to anyone and everyone relevant and got several thank you for pointing this out letters. That was it though. Now we are in AZ and anecdotally it seems the regulators here have a better reputation for encouraging or forcing insurers to cough up the money.

[MikeD]

Deleted.

[Ozz]

Originally Posted by mdeth1313

...In addition to getting the address of the BC/BS ceo and writing a letter, we are also filing a complaint w/ the state attorney general, I'll also be contacting my state legislators.....

Do you have a state insurance commissioner? They should be on your list as well....

[HenryA]

Originally Posted by eddief

those americans who could benefit from Medicare for all

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

Nope, Medicare is just as f'd. I get enough paperwork from a simple doc visit that may cost as much as the benefit provided. But I do think that the health care insurance industry is a huge scam.

[Jaybee]

Originally Posted by HenryA

Nope, Medicare is just as f'd. I get enough paperwork from a simple doc visit that may cost as much as the benefit provided. But I do think that the health care insurance industry is a huge scam.

Are you prevented from receiving adequate care just because you can't afford it though? Whatever the single payer system is won't be perfect, but it's hard to find people who are gung ho about their existing private plans. I know mine is basically for catastrophes only.

[sailorboy]

Originally Posted by mdeth1313

PT is standard protocol for frozen shoulder.

.

This might not be as cut and dried as you think...yes, 'unlimited' sounds good on paper but insurance co. can always deny reimbursement based on the notes that are written and supposed lack of progress as you mentioned. That's why I suggest you stretch your coverage out by just getting periodic visits to check up but do most of the grunt work of ROM and ther ex on your own. Full disclosure; I'm a PT but I stopped practicing once I left the military which is essentially a single-payer system. It would take a lot to convince me to do what I do in the private sector. It would either be in the VA system or DoD as a GS employee. I would love to be a consultant on how we could replicate our military healthcare system for the rest of the country. It's a no-brainer.

[thwart]

Originally Posted by sailorboy

This might not be as cut and dried as you think...yes, 'unlimited' sounds good on paper but insurance co. can always deny reimbursement based on the notes that are written and supposed lack of progress as you mentioned. That's why I suggest you stretch your coverage out by just getting periodic visits to check up but do most of the grunt work of ROM and ther ex on your own. Full disclosure; I'm a PT but I stopped practicing once I left the military which is essentially a single-payer system. It would take a lot to convince me to do what I do in the private sector. It would either be in the VA system or DoD as a GS employee. I would love to be a consultant on how we could replicate our military healthcare system for the rest of the country. It's a no-brainer.

That says a lot right there... of course the military likely doesn't have the cost constraints that any single payer plan (a la Medicare) would have to include to avoid blowing up the national budget. But still... there's gotta be a better way.

I'd second what's been mentioned above by those wiser than I... see if you can carry on a good part of the therapy on your own.

[parris]

Mdeath my county is going through the exact same issues with Empire. I've heard of multiple problems from people that have been denied due to the 3rd party not knowing what the deal is. It's started to get sorted out but there's several hundred PI$$ED off people due to this crap.

I hope it works out for your wife and your sake.

[djg21]

In New York, you may be able to go to court to seek damages for breach of the insurance policy and, in effect, for breach of the implied covenant of good faith and fair dealing. You probably don’t want to do this for any number of reasons, but if you have exhausted other options, maybe a letter from your attorney using the term “bad faith” might shake the insurer lose. It might also help to have an attestation from your wife’s MD indicating that further PT is medically necessary, that the failure to cover PT could result in lasting injury, and that time is of the essence. Again, talk to a lawyer familiar with these issues.

[Mr. Pink]

So, wait. What exactly is the PT providing that can't be duplicated elsewhere, like, at home or in a gym? I've been to a PT three or four times after incidents, and my attitude the last time was, please, just show me what to do after a few paid for sessions, and I'll take care of it at home and in the gym. Are there certain treatments that require another human to manipulate you? Then why don't you go in there and learn it. It can't be that complicated. I mean, sure, I had a new agey PT that tried to create the aura that she was actually treating me, but, in the end, it was just a lot of stretching and minimal strength work, when you stripped away the BS.

Maybe your wife doesn't belong to a gym? Time to sign up. Then transfer all the exercises there.

Sorry, but so many are so addicted to treatment in this country.