Dave-El Vs. the Health Insurance Industry

Often in this blog, I run off at the mouth about some damn thing or another. Frequently these posts are political as I rant and rage against the dying of the light of reason at the latest dumbass thing done or said by Donald Trump or one of this supporters. I pisses me off that some my mental and emotional energy is consumed by these morons. But the passions inflamed by the reckless and dangerous actions of Donald Trump and those who support him do serve sometimes to distract from more personal concerns.

 

In other words, what’s up with Dave-El?

 

Part of what’s up with me is I’m still fighting the battles of the past, particularly of 2017.

 

To summarize:

I had a fall in January 2017. The cause of the fall was attributed to a stroke. The result of the fall was a shattered elbow of my left arm.

 

I had surgery in January to fix the immediate damage and a subsequent follow up surgery in August to address some issues with some bone growth inhibiting motion in my left arm. 

 

From February through December of 2017,  I received physical therapy. The first few sessions were painful and stressful but I made significant progress in regaining use of my left arm.  With the second surgery in August 2017 and the physical therapy, I have regained almost full motion and use of my left arm. I still have some small issues with stiffness in my left arm but for the most part, I’m OK.

 

The problem that persists into September 2018 is with my insurance company. They have refused to pay the claims on my physical therapy. 

 

Some background: after my August 2017 surgery, my physical therapist Andy suggested I may want to contact my insurance company to confirm my physical therapy benefits. So I gave them a call and was assured I was still covered for physical therapy through the rest of the calendar year.

 

Well, that sounded great but I figured Andy wouldn’t have wanted me to call unless there was a catch.

 

OK, there was one. The provider (the physical therapist) would need to provide a report to the insurer to confirm that my injuries still required continued therapy after my 30^th visit.

 

So I advised Andy and we moved on.

 

Then I started getting notices from the insurer rejecting claims for services by the physical therapist starting in September 2017.

 

Every time I called the insurance company, I was told the same thing:

1. “Yes, Mr. Long, you still covered for physical therapy through the rest of the calendar year.” 
2. “All we need is that report from the provider to confirm that your injuries still require continued therapy after your 30^th visit.”
3. “If we can get this information, this is all settled.”
4. ““Yes, Mr. Long, you still covered.”  

 

Every time, I spoke with the office administrator at the physical therapist:

1. “Yes, Mr. Long, we are submitting that information as required by your insurer.”
2.  “I’ve confirmed with the insurance company you are still covered for physical therapy through the rest of the calendar year.”   
3. “We’ve run into this sort of thing before. It’ll be sorted out, I’m sure.”

 

Eventually I reached a point in my physical therapy where my left arm had a very good range of motion and an acceptable level of strength. It was not like I was in such great shape before the accident.  So my therapy came to an end in December. I hated to see it end. They were nice people there and they had done good work to get my left arm working again.

 

There was one more notice from the insurance company rejecting claims. One more call to the insurer. 

1. “Yes, Mr. Long, you were covered for physical therapy through the calendar year.” 
2. “All we need is that report from the provider to confirm that your injuries still require continued therapy after your 30^th visit.”
3. “If we can get this information, this is all settled.”
4. ““Yes, Mr. Long, you are covered.”  

 

One more call with the office administrator at the physical therapist:

1. “Yes, Mr. Long, have submitted everything the insurer has asked for,” 
2.  “I’ve confirmed with the insurance company you were covered for physical therapy.”   

 

And then….I forgot about it.

 

Yes, that was stupid but damn it, I tend to do stupid stuff like that. I don’t know if it’s some kind of lack of object permanence or what but I do have a bad habit that if something is not in front of me, I tend to forget about it. I can’t tell you how many problems in my life would not be problems if I didn’t do that.

 

Then this problem wound up in front of me again.

 

I got a call from the office administrator at the physical therapist in April of this year.

 

Their last appeal with the insurer was rejected. The claims from September to December would not be paid.

 

I wondered why but the office administrator didn’t know. So I called the insurance company and I’m just going to cut ‘n’ paste this bit.

 

1. “Yes, Mr. Long, you were covered for physical therapy through the calendar year.” 
2. “All we need is that report from the provider to confirm that your injuries still require continued therapy after your 30^th visit.”
3. “If we can get this information, this is all settled.”
4. ““Yes, Mr. Long, you are covered.”  

 

OK, what the hell? What wasn’t clear to me was this:

1. Was the insurer not getting any info from the provider?
2. Was the insurer not getting the right info form the provider?

 

I requested (nay, demanded!) a conference call with myself, a representative from the insurer and the office administrator at the physical therapist to sort this out once and for all.

 

Which I damn well know I should’ve done when this mess first started in the fall of 2017. 

 

In this conference call that took place in June 2018, a word was used that had not been used in any prior call I made to the insurer: pre-certification.

 

In short, the insurer was saying there was no prior approval given before I received physical therapy for the 31^st visit and onward.

 

At no point was this ever stated to me. In fact, every time I was assured by the insurer ““If we can get this information, this is all settled” was apparently not a true statement. If the problem all along was that the requested information was being received after the fact, there was no way getting this information was going to ever settle anything. 

 

While the provider had exhausted their appeals, I had my own options to appeal so I did. Then I heard nothing. But this time, out of sight was not out of mind. I followed up and by late July, I got someone on the phone who told me my appeal had been denied due to the lack of precertification for the claims made from September to December 2017.

 

OK, that was bullshit. Yes, that’s why the insurer was rejecting the claims based on lack of precertification. My whole appeal was based on the premise that a requirement for precertification was never communicated to me. Then I was advised I had one more option to appeal. I would receive a phone call from an appeals committee who would interview me. 

 

That took place today, September 11, 2018.  The committee consisted of a doctor and two reps with the insurer. I made my case.

1) I did due diligence to call the insurer to confirm my benefits and any requirements to receive those benefits.

2) At no time was I told that I needed prior authorization to continue to receive medical treatment I was already receiving.

3)  There was a pronounced lack of clarity as to the nature of the problem regarding whatever they needed from the provider.

I also added this all started from a fall I had in January 2017 while I was waiting for my mother to die.

 

The call ended graciously. I was advised that a decision would be reached today and a letter informing me of that decision will be mailed by the 13^th. 

 

I hope I made my case for the insurer to reconsider and pay these claims but I have absolutely no hope of that. 

 

Tapping into a line of credit with my bank, I’ve paid the medical bill. If the answer from the insurer is no as I expect it will be, I want this to be done. I don’t want this hanging over me anymore. 

 

2017 was a rough year. I went through a lot of physical and emotional hurt which quite frankly weights me down like an anchor.

 

I still have moments where back I’m lying in that parking lot, staring into the night sky, broken and bleeding.

 

I find myself back staring into the white glare of florescent lights in the ER while nurses are yelling something about me having a stroke. 

 

Sometimes I’m back where I’m staggering around my dimly lit hospital room hooked to an IV when I get the text at 3 AM, telling me my mom had passed away.

 

All these memories and more replay on a loop, not just as film images flickering on a wall for me to review with bemusement but as actual events that I relive as if I’m back there.

 

For good or ill, this mess with the insurance company needs to end. I hope it ends well but mostly, it just needs to end.

 

And that, dear reader, is what’s up with Dave-El.

 

I think I might be looking forward to the next “what stupid shit is Trump up to” post.