Latest fun development: my doctor called on Friday morning to say the insurance has denied my request for an operation - seems like they have a list of things you have to try before having the operation and one of them is physical therapy - even though I’m 99.5% sure PT will do nothing.
In addition, I got a another call Friday at noon from the doctor telling me that one of my insurance policies telling me that my medicare advantage plan says I was enrolled once but I have since been terminated. I called them directly and they said “no, you are covered and the coverage is active and you are not terminated.” But for some reason my doctor’s office was told the exact opposite.
So even though I’m covered by not one, not two, but three different insurance policies (COBRA from my employment, Medicare, and Medicare Advantage) this operation may not take place. The doctor said they’d give me a final go/no go status on Monday morning. Until then I’m acting like it will happen (as in doing the prep work like scrubbing and taking tylenol) but expecting it to be postponed.
I don’t think you have posted there, but you should see the nonsense in Jpinard’s Blue Cross thread if you haven’t.
I’m not looking at your imaging, obviously, and it sounds like there must be some structural damage, but as a general rule, trying PT first isn’t an unreasonable policy. Hopefully they can get an exception for you.
I did see what’s going on there. Sheesh. Fortunately, I don’t require expensive medicines (though my wife does and we’re going to find out the joy of that in a month, when her medicaid & supplement plans kick in).
The crazy thing about my hip is that my doctor said it was bone-on-bone, so I don’t get why they believe PT would help. Unless - and stop me if this sounds crazy - they are simply working down a bureaucratic checklist of things we have to do before qualifying for surgery.
One thing to keep in mind is what I mentioned in the Blue Cross thread: insurance companies often have procedural requirements of various sorts that the staff literally CANNOT work around. For example, I have heard of computerized treatment authorization systems where the adjuster HAS to check certain boxes for the computer to transmit the authorization to the medical provider. I can imagine that the adjuster might need to check a box regarding PT before a surgical authorization will issue. There can literally be situations where an adjuster pushes the button to authorize something (or pay something) and the computer goes “BZZZT!” and doesn’t issue the payment/authorization.
The simplest path is to jump through the hoops if they can be accommodated without too much harm or disruption. Or if the hoops are just too much, then you may have a basis to escalate things to a level where the authorization will issue.
Also, sometimes there’s more than one way to “check a box” that the insurance company requires. For example, sometimes a provider can issue a “medical finding” that a certain requirement (like PT) doesn’t apply.
People imagine they are dealing with humans making decisions at these big insurance companies but from my POV representing them for decades, they are more akin to very large industrial machine processes crushin’ that ore, if you know what I mean.
First of all, find out what “boxes need to be checked” with the insurance company if you can. It may well be worth a phone call to the adjuster to find out what the protocol is. If those boxes are easily checked, then bow down before the corporate masters and check the boxes.
Second, there may be ways to obtain waivers or medical overrides to some of the box checking, if the box checking is too hard/slow. Again, try to gather what info you can on what the insurance company actually wants/needs and try to follow along with that to the best of your ability.
Third, if those two steps aren’t working, then look at the BCBS thread for lots of input from folks on the many ways to escalate things. However, if possible, work within the system first. Sometimes that can be easy and sometimes that can be hard.
It’s entirely possible you will need to do a course of physical therapy with no lasting relief and then have the doctor declare “Yep, it’s a surgical case all right, conservative measures have failed” and then they will authorize you (that would be an example of the “box checking” I’m referring to.)
Yes think of this as of you are talking to a tech support call center with “Bob”, who, after describing in detail every step you have taken, goes to their script and starts with, “have you tried turning it off?”
I don’t have anything to add to this, but I really wanted to say thanks for posting your accumulated knowledge of how to work the insurance system. This is really valuable stuff!
Point of order: I consider this “working within” the insurance system rather than “working” the system. “Working” the system as in gaming/exploiting or manipulating it, is something I detest and fight against. It’s actually a big reason why I am OK with wearing the “black hat” in my job. There’s a lot of folks who want to defraud and exploit these systems and preventing fraud and exploitation is a valuable role, IMO.
Yes, It’s a fine line, but that’s how I see it.
And of course, if “working within” doesn’t work, that’s when you escalate, with lawyers, politicians, the media and so forth. But working within is the right starting point, IMO.
Nothing to offer except to say that I love that we finally have a hip replacement thread and mostly that I hope @Charlatan can get the help he needs. I know how frustrating it can be.
But I also want to say it’s been an honor to grow old alongside all y’all. :)
I did have a conversation with the nurse who was trying to get the approval. There were maybe four or five conditions that had to be fulfilled, stuff like
normal movement causes pain
restricted range of motion
(a few more like that)
physical therapy has been unsuccessful
The way she described it, all of the conditions had been met except the PT portion, and they were unwilling to waive that portion, even though the doctor had indicated that PT would be ineffective due to the condition of the joint.
I suspect that’s where I will be going. I’ll find out on Friday.
Why? The system works consumers. I’m not advocating any fraud or illegal activity, but since the insurance bureaucracy is a system expressly designed to limit payouts by denying claims (for valid or invalid reasons) I see no injustice at all in people who understand the system getting an advantage.
Revisiting this topic to say I got a cortisone shot that carried me through my cruise and a few months, but the operation is back on and scheduled for tomorrow morning - full steam ahead!
So tomorrow I will be at least 5% bionic. Or maybe 5% terminator. Something like that.
