In the Healthplans that are Blind the One-Eyed Patient is King
There are only one of three explanations of the behavior of health insurance companies in America:
Based on recent evidence in the national journals (sort of the kind that have Elvis marrying aliens) it appears that choice 3 is the front runner. I refuse to believe that there are any intelligent life forms in insurance companies. Oh, sure there are financially savvy life forms there. Intelligent life forms - no way.
My son Jacob is 10 years old. He was playing baseball (the way the Mets have been playing he may be the starting third baseman next year). He developed pain and numbness down his arm on every throw. Diagnosis: shoulder instability and rotator cuff impingement. Treatment: Physical Therapy and anterior capsular strengthening. This was prescribed. Here is what happened:
We have Oxford insurance. Oxford just got bought out by United Healthcare. Sort of like the Corleone Family buying out the Salazzos. A third company, OrthoNet does an unknown function for Oxford. Unknown only to patients. They "review" claims and "manage" Orthopaedic care. Essentially they make David Spade in the "NO" commercials look like a yes man. Their only job is to deny claims. They do this so that they personally make more money. United/Oxford gives them more money if OrthoNet pays less claims. Based on the blind Orthopaedic consultants who bumble in the dark for OrthoNet, my son received approval for 4 physical therapy sessions. The first was an evaluation. Now there are three. The only thing I know that can happen in three days is securing Baghdad (oh, if it were so easy...)
Clearly, OrthoNet is blind to medical facts. They are blind to patient disease. They probably are illegal in what they are doing in that they receive incentives (kickback) on the money they save for Oxford/United. They are doing this using fraudulent means. They claim they reviewed my son's case but as I am his doctor, I never received a request for records. In America this is kickback and fraud.
When it comes to caring about the health of you and your family, the insurance companies will be blind. If there is a penny on the floor they will land on it and suck it up faster than a Dirt Devil.
It is remarkable that when I actually opened the letter and saw the number "4" next to approved visits it was then that I realized that you actually have to LOOK at what the insurance companies are doing. Amazing concept. If you watch your insurance company rip you off, even in the corner of your eye, one eye, you may actually see what is going on and may be able to do something about it.
We may even make you king. You can't be The King, though. That is for Elvis only.
Dr. K.
Related Topics: Checking Up on Managed Care, Top Healthcare Priorities Targeted
- They are controlled by a small number of incredibly smart people who hire an massive number of incredibly stupid people so that an unknown but ever growing number of stockholders can make gobs of money.
- They are controlled by a small number of mildly intelligent characters who, due to the fact that the current regulatory environment favors health plans over sanity, are luckily getting wealthy
- They are controlled by five blind men, an elephant, and Soylent Green.
Based on recent evidence in the national journals (sort of the kind that have Elvis marrying aliens) it appears that choice 3 is the front runner. I refuse to believe that there are any intelligent life forms in insurance companies. Oh, sure there are financially savvy life forms there. Intelligent life forms - no way.
My son Jacob is 10 years old. He was playing baseball (the way the Mets have been playing he may be the starting third baseman next year). He developed pain and numbness down his arm on every throw. Diagnosis: shoulder instability and rotator cuff impingement. Treatment: Physical Therapy and anterior capsular strengthening. This was prescribed. Here is what happened:
We have Oxford insurance. Oxford just got bought out by United Healthcare. Sort of like the Corleone Family buying out the Salazzos. A third company, OrthoNet does an unknown function for Oxford. Unknown only to patients. They "review" claims and "manage" Orthopaedic care. Essentially they make David Spade in the "NO" commercials look like a yes man. Their only job is to deny claims. They do this so that they personally make more money. United/Oxford gives them more money if OrthoNet pays less claims. Based on the blind Orthopaedic consultants who bumble in the dark for OrthoNet, my son received approval for 4 physical therapy sessions. The first was an evaluation. Now there are three. The only thing I know that can happen in three days is securing Baghdad (oh, if it were so easy...)
Clearly, OrthoNet is blind to medical facts. They are blind to patient disease. They probably are illegal in what they are doing in that they receive incentives (kickback) on the money they save for Oxford/United. They are doing this using fraudulent means. They claim they reviewed my son's case but as I am his doctor, I never received a request for records. In America this is kickback and fraud.
When it comes to caring about the health of you and your family, the insurance companies will be blind. If there is a penny on the floor they will land on it and suck it up faster than a Dirt Devil.
It is remarkable that when I actually opened the letter and saw the number "4" next to approved visits it was then that I realized that you actually have to LOOK at what the insurance companies are doing. Amazing concept. If you watch your insurance company rip you off, even in the corner of your eye, one eye, you may actually see what is going on and may be able to do something about it.
We may even make you king. You can't be The King, though. That is for Elvis only.
Dr. K.
Related Topics: Checking Up on Managed Care, Top Healthcare Priorities Targeted
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5 Comments:
I would like to sue my health insurance (the notorious Aetna) for harrassment. It is bad enough when you are having medical problems, but when you have to fight with them to pay every claim it is ridiculous. You think the claim is paid, and then 4 months later you get a collection notice. My daughter is in college. She has diabetes, and every time she uses the insurance they want us to prove she is still a student. Normal insurance companies ask once or twice a year.
Too bad we can't get a few uncorrupted politicians to change things, but they don't exist.
A lot can be done in 4 physical therapy visits; the main role of PT is to teach a person what to do. He then has to do the exercises on his own at home or at a gym. 3 visits was enough for my rotator cuff problems.
I don't think your insurance company was being unreasonable in authorizing 4 PT visits.
Dr. Rack:
Unfortunately you have been led astray in your thinking. There is NO main role in PT. There Are many roles depending upon the circumstance and the disease. Rotator cuff problems often have adhesive capsulitis- stiffness- is 3 visits enough then. You are basing this opinion on exactly what experience? The literature does not suport you 3 visit idea as much as giving the patient a video and sayinf rots of ruck. The point is that the insurance company NEVER asked for documentation of clinical support- they made a knee jerk (of the shoulder) response and never consulted clinical data. THAT is bad medicine. But I guess you knew that, too...
Dr. K.
Dr. K,
I apologize for commenting on your son's case and saying that I agree with the insurance company. I am not a pediatrician or an orthopedist, and did not have the clinical data, and therefore was not qualified to comment. Again I apologise.
I had an accident 12/4 fell in a big hole in the dark, tore my supraspinatus tendon and labrum (my conditions are what Chad Pennington had). I had pt with a fine therapist. I had surgery in May to fix it. My therapist lived an hr.'s drive away, I decided to try another therapist. Now Orthonet tells the therapist I used 58 out of 60 visits, when I only used 27. What's going on? Oxford said oh you have open authorizations and there are probably visits unused on there that are counted against you, they suggested I file with their Appeal division. I did. They told me they don't handle that, it is a claims issue. The therapist put in for 8 visits and got 2 because Orthonet says she did not provide clinical info. a Letter of Medical Necessity and besides I used 58 out of 60 visits. I then find out that therapists can in effect double bill, that is you have 1 visit but if they do 3 modalities, ie. stem (tens) or ultrasound, exercise, and physical manipulation they can bill Oxford for 2 sessions, knocking down your available visits twice as fast without you knowing anything about it. Further, they said that if the therapy is longer than 1/2 hour they can bill that as 2 sessions also, so they let you exercise for 10 minutes, use the tens on you for 15 minutes, massage you a little for 10 minutes and whamo 35 minutes plus the heat pack time is billable as 2 office visits when you have only been there once. What sleaze bags. Those 2 visits that they authorized when 8 were requested they also said they thought I could recover the rest of my mobility at home doing home exercise, my Dr. is taking me back in the operating room because the scar tissue that formed after my surgery prevents me from moving my arm, but Orthonet doesn't understand that. I am going to complain to the Board of Directors at Oxford including their Chief Medical Officer, I am also going to file a complaint with the State Insurance Dept., and whoever else I can complain too. Hey it's an election year, who want's my vote?
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