Wednesday, August 5, 2009

Catch-22, HMO Style

Reading the faxes from overnight.

Idiotic HMO, Inc., sent over a note saying that they were refusing to pay for a patient's MRI because "This does not meet our criteria for lumbar spine MRI's. The patient must undergo a minimum of 8 weeks of physical therapy, without benefit, before an MRI will be authorized."

Farther down on the same page, under guidelines for physical therapy, it says "Idiotic HMO, Inc., will not cover more then 6 weeks of physical therapy per calender year."

12 comments:

Theresa said...

That sounds about right. Hear about it everyday, in one form or another,from the parents (my mom is on dialysis).

Crazy Mama said...

My HMO refused to pay for my son's EEG that his pediatrician set up. The reason? Incorrect diagnostic code was used when the EEG was REQUESTED. Now, the pediatrician had his suspicions, but couldn't exactly put the cart before the horse and name a diagnosis without having the test run. Fast forward six months and countless phone calls, I ended up paying for it out of pocket after the Children's Hospital (who did the EEG) and pediatrician pointed fingers at each other. UGH. I will say this, though, it will only be worse if we rely on our government to determine "medical necessity".

Anonymous said...

This is a sad state of affairs and I
wish this surprised me. Lets do an
MRI AFTER PT, cuz we really want the
therapist worry about more damage:
severe herniated disc or a tumor that
needs action ASAP! Or you for the same
reason. I have a feeling you would
want a looky loo before treatment!

It/ sounds like the souless HMO yes/no
(sorry) does not take his oath seriously. Maybe their oath it to the
money god. Wow minimum 8wks before
MRI but will only pay for 6 wks! Are the extra 2 wks a weed out program for
the seekers? haha *scream*. I am a
layperson, so if my thoughts are off
base sorry. BTW I love your blog!!

Beloved Parrot said...

I do not see how government-provided medical insurance could possibly be any worse than what we all struggle with today. Please note that I said "government-provided medical INSURANCE," not health care.

Anonymous said...

Beloved Parrot:

Agree 100%. Private insurance is MUCH worse than either Medicare or Medicaid for capricious, unreasonable denial of coverage for needed care.

Robert

Anonymous said...

Count me in on Gov't Provided Health Insurance. The profit motive of some providers today is downright criminal.

Call me Bob said...

Grumble, these kind of sinuous complications in medical bureacracy are quite saddening (and perhaps complications is a bit too euphemistic). This instance in particular, as Dr. Grumpy describes it, is prime suspect of all the bureacracy in action. Yet, the frustration that the ineptness of the system brings up is accompanied with an awkward feeling of uneasiness-namely, it is blatantly clear the private health insurance is the bane of healthcare and something needs to be done, but will public government insurance be better in the long run? Rather, I should say, while we can assume government insurance would obviate the unecessary qualms with doctors when it pertains to an incentive for the insurance to make profit (since it's the government, profit isn't an issue), we can't really be sure of what all of the negative outcomes of government insurance would be (aside from extra debt-though that in itself is contentious). Haha, it always comes down to "hope for the best" and proceed, no?

hannah said...

Mental health coverage is always fun. If it's an emergency admit, you have to re-authorize every two days but you can be denied for either being "too well" or not doing "well enough" in the program. During my long-term stay, they pre-authorized six weeks but after 3.5 weeks said "no, we only authorized four weeks."

Of course, at least I HAVE mental health coverage. I'm not sure how the parity law that was passed last year has done anything...I still know of people with insurance that doesn't cover any form of mental health treatment, or only covers five outpatient visits a year, or with ridiculously low life-time caps on costs....

peedee said...

ummm, I have a major health plan thru work. I rolled my ankle off a curb and fell hitting my knee June 1st while moving. The ankle was casted has healed and we've moved onto the knee that was banged up in the fall.

My doc did a simple physical test on my knee called the Lachmans Test to see if the ACL was stable. It wasnt stable, I was sent for an MRI, which was approved within 2 days and dontcha know....the MRI showed the ACL is blown out. Surgery for ACL reconstruction is scheduled and been approved already.

I must be a lucky one. I never have a problem with my insurance benefits. And I'm crazy and clumsy. I USE my benefits believe me.

Anonymous said...

So basically the patient just needs to make sure that they only need PT starting in December of each year. No other time of the year will do.

Funnyrunner said...

HMOs bite. I would not be caught dead using one.

Frantic Pharmacist said...

Now wait a minute, I thought the reason we didn't want government sponsored health care is because there will be bureaucrats standing between us and our doctors. I take that to mean we can get ANYTHING we want right now under the current system, whenever we want it. Are you trying to tell me that's not true?? Oy.

 
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