Just so you know, having dealt stuff with my mom, Medicare wasn't much different. It's pretty much across the board. Not defending the situation and procedures, just saying BCBS isn't alone.
Our screwed-up heath care system
- Thread starter SEIOWA CLONE
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Look, I am not ******** about BC in particular, but the whole system. Wife hurts knee on Monday, and gets it X-rayed, goes in today, doctor looks a knee and says they need an MRI to know for sure, and calls down, and they are free to do an MRI any time this afternoon, just have to get BC to approve it. But BC refuses to do the MRI without PT first, even though they could have done the MRI this afternoon and by Monday they would know the extent of the injury and the best course of action from there. Instead, she starts PT on Monday, and then we are going to have to see down the road how the knee reacts to the PT, and then have an MRI if its warranted.
The doctor thought we should get an MRI, both my wife and I want to get the MRI, and they can do it this afternoon, but insurance has another plan. Now tell me who is making the decision about treatment here, the doctor, my wife and I or in the insurance company?
We have BC/BS here too, and an employee recently was hit by a car in a parking lot and tore up her knee. The regular doc supposedly can't order the MRI, but only a surgeon can. So she needs a reference to a surgeon to get that. She is working on that with her ob/gyn, since she doesn't have a primary care physician to do the referral. And the urgent care idiots where she went first can't/won't do that referral, for whatever reason.
I would see if getting a referral to a surgeon may help. Good luck.
My guess is that they push PT first because that will fix the problem x% of the time for those without internal damage, and it's way way cheaper than surgery. But for those that end up needing surgery, it just delays the inevitable. I know for back pain, studies have shown that PT is more effective than pills, surgery, and chiro, but also much cheaper (esp compared to surgery). But people want "fixed" they don't want to "work" ie PT.
I would see if getting a referral to a surgeon may help. Good luck.
My guess is that they push PT first because that will fix the problem x% of the time for those without internal damage, and it's way way cheaper than surgery. But for those that end up needing surgery, it just delays the inevitable. I know for back pain, studies have shown that PT is more effective than pills, surgery, and chiro, but also much cheaper (esp compared to surgery). But people want "fixed" they don't want to "work" ie PT.
Woah, I guess I didn't look at the timeline. Why the hell did the doctor wait until today with an X-Ray on Monday. Seriously, my son tore his ACL in a Friday night game, went to the PT on Monday, they said we think ACL, here is a PT schedule, we hit the doctor on tuesday and took the XRay. They said no breakage, so an MRI is next and we will check with BCBS, got a call a couple hours later saying the MRI is a go. We scheduled it for Thursday at a larger hospital nearby and had results friday morning. PT person put a word in for us with the person they recommended and surgery was performed about 2.5 weeks after injury.
Our system has major issues, no doubt and not questioning of that. I will question the process of your medical provider/Dr though. They seem much slower than the ones in the boonies up in the north country here. This is why I say go to a PT IMMEDIATELY with any non breakage. They will assess and get things rolling much quicker than the doctors will.
With knees, the PT will build up your quads and other supporting muscles that will deteriorate while on crutches or immobile. The 1-2 week blitz to build up the rest of the leg will carry it through until you are able to apply weight again or get full PT for most people. That means quicker recovery and less time in PT afterwards. It's actually a win win in these situations.
My wife was diagnosed with Cancer this fall...I'll spare you all the details because frankly I'll just piss myself off explaining them but I'll say this. Its been a fight with the insurance the whole way. My BC people fought with Mayo clinic on care....Mayo freaking clinic. Imagine that? It was insane. Our healthcare system is broken, the only ones not aware are the ones that are fortunate enough to have not seen the belly of the beast.
No clue why the long wait time, like I said, she went to the ER on Monday, they X-rayed the knee then, braced it, got her on crutches and then told her to set up an appointment with her regular doctor later in the week. She called Monday and today was the first time they had an opening.
I guess I am just pissed off that we could have done the MRI this afternoon, and BC said they wanted PT first. When I spoke to a couple of pharmacists that I know on Monday while picking up some meds, they both thought that since it "popped" and at her age, that surgery was the likely outcome, but it would take an MRI to determine that, which we could have done today.
First, I hope and wish for the best to your wife. I should have said that first in my first reply.
Totally understand the frustration and irritation. Seems when things seem obvious, none of us understand the waits and hold ups.
I used to be totally ticked at the insurance companies and still don't care for them, but have lightened up since my niece became a medical Dr. She did rounds/interns (whatever you officially call them) and would talk about the crap that went down in there. There were things that were a PITA when I took care of my mom and I would complain about the insurance companies to her and she would laugh and say, that's not the insurance company creating that problem, that is the doctor. She would go on and explain how the dr and clinic could bill more for doing certain things (that really inconvenienced me/mom as the patient) but they would blame it on the insurance company to the patient. I had heard some of these things while an EMT and one of my sisters was a CFO of a couple hospitals. It made me think, when I would talk to the people I would supervise about raises and other issues, I would always say, that's all that my bosses allow me to do, nothing I can do about that. Basically use them as peeing posts and blame someone that they can hate besides me and make me look better. Kind of the approach with Doctors sometimes it appears.
BTW, my niece went into ER care since she said it's less red-tape since you are doing critical stuff and less jumping through hoops with profit margins and issues with patients. Nobody really fights the doctor and puts up barriers when it's to save a life in the ER.
TL/DR: Our medical field has many issues, with the insurance companies being one, but far from the only one.
Not enough competition, thus allowing insurance companies to leverage corporate policies. Competition is directly proportional to the effort the government puts into promoting it. But, sadly, monopoly laws are only enforced when it politically benefits a politician. Also, the legal system (which BTW never has losers) has become so entrenched it severely mitigates small startups. The whole system has slid downhill during my lifetime. My father who started 5 companies in his lifetime told me shortly before he died that sadly we (ie his children) won't have those same opportunities ever again. I'm solutions oriented, but unfortunately short of Armageddon, can not see a solution. We're beyond the tipping point. As the CEO for Sony back in the 90's said, the U.S. is no longer in the business of making money by making products. It's in the business of making money by manipulating money.
We got a notice from DMOS in Des Moines about paying our account. I called them up and asked them “what account?” The proceed to tell me there are three charges one was our portion of an MRI (which was $900), a wrist brace, and X-Ray for our son after breaking his wrist playing football. Our provider was United Health Care. They took X-Rays and waited a couple weeks. During that time they told him he was OK to practice, no PT. It continued to hurt and then Dr. called for an MRI. We waited 3 days and I ended up calling UHC and asked what was going on, they told me it had just been approved. WTF??
Meanwhile, our “account” with DMOS of which we had never seen a bill for was going to go to a collection agency. I was f’n pissed!!
Turns out they were not happy with the company they were using to send out statements and our account “fell through the cracks” as they were changing companies.
We got the old apology song and dance. They were not going to send a collection agency. After we started paying on it, we come to find out there are two more charges that never got addressed. I came unglued!! Health Care in general sucks!!
BTW- I switched over to BCBS way cheaper than what I had. My BP meds are free of charge now.
Meanwhile, our “account” with DMOS of which we had never seen a bill for was going to go to a collection agency. I was f’n pissed!!
Turns out they were not happy with the company they were using to send out statements and our account “fell through the cracks” as they were changing companies.
We got the old apology song and dance. They were not going to send a collection agency. After we started paying on it, we come to find out there are two more charges that never got addressed. I came unglued!! Health Care in general sucks!!
BTW- I switched over to BCBS way cheaper than what I had. My BP meds are free of charge now.
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BC/BS is not one monolithic company with one set of rules. You might have Wellmark BC/BS or Anthem BC/BS or Highmark BC/BS or BC/BS of Pennsylvania or Texas, or Alabama. All with different rules and regulations.
My wife has some minor surgery done a few years ago. This was through Mercy. One bill from the first clinic, another from the doctors clinic, then one from the surgical center associated with the hospital/doctor (inside the hospital even), one from the performing doctor, and then an anesthesiologist bill showed up at the end. We met right before she went in for surgery and I told them to just put it on this credit card (cheap me is going to get my 1-2% cash kick back), so I was confused what the bills were about. Once the insurance cleared, we owed towards everything but the surgery center because they were the last to submit and last to hit the deductible and out of pocket. So the one who collected the money owed us basically what I had paid them. I had to pay the others and fight to get our money back out of the first.
Meant the OP since he replied to a reply I had to the OP.
Also, I see Trinity health has bought out Mercy.
Start the PT but at the same time be a royal pain in the ass with the insurance company. Also get the hospital's insurance specialist working for you on it. My son has constant medical issues so we are always fighting the insurance company. Luckily (for us, not for him) my boss's son has had even more medical issues so he often will give me advice on where to go or where to turn. He has had to fight the insurance company close to a dozen times. It sometimes takes time but they have never lost a fight with the insurance company.
The insurance company is counting on you being a lamb and taking it. If you are enough of a lion and it is costing them money to deal with you - especially on an issue like this where they likely eventually will be paying for exactly what you are asking for anyway - they are more likely to relent.
We just got them to rollover on genetic testing by being a pain in the ass. We get it, it is really expensive, but I paid you for insurance for years when I was a young, healthy single person and never used my coverage. Now that I need it and pay for damned good coverage you are damn well going to hold up your end of the bargain!
/End rant
The insurance company is counting on you being a lamb and taking it. If you are enough of a lion and it is costing them money to deal with you - especially on an issue like this where they likely eventually will be paying for exactly what you are asking for anyway - they are more likely to relent.
We just got them to rollover on genetic testing by being a pain in the ass. We get it, it is really expensive, but I paid you for insurance for years when I was a young, healthy single person and never used my coverage. Now that I need it and pay for damned good coverage you are damn well going to hold up your end of the bargain!
/End rant
