My doctor prescribed 30 more days of Physical Therapy . . . but

[boobooday]

my Insurance Company gets to decide whether or not I really get 30 more days, or whether I am cut off at 60, after major surgery on my shoulder.

Death panel?

Just saying . . .

Who is that bureaucrat between me and my doctor????

[Critters2]

1. The insurance industry likes to argue that they're not saying you can't have

30 more days of PT. They're just saying they won't pay for it.

Bastids.

[boobooday]

2. The co-pays are already a hardship

But yes, of course. Pay for it yourself, you irresponsible person!

[Romulox]

4. And the government is saying that we have to pay for *insurance* regardless

if we have enough left over to pay for *care*. :wtf:

[timeforpeace]

28. Says one thing and he's ready to be President. Ever wonder why we get such crappy presidents? That's

why.

[Romulox]

3. I was told to call my insurance company before scheduling an MRI

It feels like a violation of my privacy to even have to discuss my medical condition with an insurance adjuster. :shrug:

[KansDem]

7. Something similar happened to me...

My doctor ran some tests and found I needed a certain medicine. He wrote me a prescription. I took it to the pharmacy and was told I couldn't fill it because the insurance company wanted me to take another round of tests. I surmised they were second-guessing my doctor. Anyway, I underwent a second round of tests (taking time off work to do so) and was okay-ed by the insurance company for the medicine originally prescribed by my doctor.

It is an invasion of privacy to have an insurance adjuster second-guess your doctor.

As a sign read at a recent pro-heath care reform rally: "Prohibit Health Insurance CEOs from Practicing Medicine" ...because that's exactly what they're doing...

[boobooday]

21. Wow, that's really crazy

Now the insurance company is prescribing what tests you need?

:wtf:

[KansDem]

33. Yeah, I thought it crazy...

Insurance companies shouldn't be second-guessing doctors. I put my faith in my doctor to do what's right for me, not the insurance company.

For what it's worth: I suffered a heart attack in 2003 and was diagnosed with diabetes at the same time, so I'm very much in tune with what my doctor recommends.

[Mika]

8. Imo, it is.

That's why I don't do insurance at my practice. Its the patient's insurance. Let them deal with it themselves so they can see what they are paying for (of course my staff and I will help them with needed medical details).

It certainly has opened the eyes of many patients, and my office staff isn't getting the angry calls from patients who's insurance company had denied payment.

I am more than willing to help patients with payment plans and it ends up being cheaper overall than insurance premiums, deductables and copays. Additionally, a higher percentage of their money is then spent on actual treatments, not corporate profits. An insurance rep isn't going to come into the office to deal with an emergency on a Sunday evening, as I do. Once they see the light, despite the expense, they're happy.

[Hannah Bell]

10. "Let them deal with it themselves" - that seems like a good idea; that

way people would better understand how bollixed & labyrinthine the system is. Do many docs/hospitals/clinics do this, to your knowledge?

[Mika]

12. More were. But now the downturn has many groveling for business.

Dentistry is in a state of emergency. Needs triage.

With home equity so low people can't use their ponzi scheme/house/bank for credit lines to pay for expensive dentistry. It is crushing the field right now.

The dental insurance programs out there force dentists to use Chinese outsourcing dental labs to keep costs down, resulting in yet another innovative American manufacturing sector to be decimated and destroyed ... all of their jobs taken over by cheap Chinese sweatshops with little if any professional regulation that US labs have to adhere to.

US dentistry is crashing and burning right now. Quality care is all but destroyed by our Corporate Masters.

[enid602]

15. outsource

¨Chinese outsourcing dental labs¨ --- radioactive crowns, perhaps?

[Mika]

18. There are already several lead & cadmium poisoning reports.

US dental labs have to comply with materials certification and supply material safety data, annually re-certify infection control procedures, face professional regulation inspections, OSHA inspections, etc., while Chinese labs don't. Nice huh?

Unfortunately, the push by the US mega-labs ownership is to expand Chinese outsourcing, so the ADA, the National Assoc of Dental Labs (NADL), and the National Board for Certification (NBC) are all pushing for some kind of phony "certification" by these formerly august associations to accommodate ownership - and to kill off the jobs of hundreds of thousands of decently paid (not well paid), highly dedicated, well trained and certified US dental laboratory technicians.

Its the utter destruction of yet another entire US manufacturing sector.

[enid602]

20. poison

We might not be around to see the end of this US manufacturing sector, with all the poison they may be putting in our mouths.

[Hannah Bell]

17. thanks for the info.

[boobooday]

22. We really need universal dental care included in health care

It's so strange how these two things are kept separate, even though they both involve your health!

[JerseygirlCT]

13. I wonder if that's a way to structure things

insurance only for major medical catastrophes - the sort of stuff no one could pay cash for, no matter the payment plan - and regular care in cash.

[boobooday]

23. That makes me want to ask, what is catastrophic?

I can't afford the monthly expense of the meds that keep me alive, but as long as I have them, I am productive and healthy.

I could never pay cash, and without my meds, I am literally dead (Insulin pump).

[JerseygirlCT]

26. That's a good question

and bringing the cost of drugs down is another part of this puzzle. I wonder if there's a chart somewhere that compares the cost of drugs as pharma cos. were freed to advertise liberally. I suspect there's some correlation there, myself. I also remember reading somewhere that a good amount of the R&D that pharma claims is really behind skyrocketing costs is actually done by the gov't.

[boobooday]

27. You have to wonder

I used to take insulin that was extracted from cows/pigs. It cost 5 dollars a bottle when I was diagnosed in 1978. Now the synthetic insulin that I put in my pump is like $200. And what are you going to do? There is no generic, no competition, no other manufacturer.

Not a free market.

[JerseygirlCT]

31. And there really ought to be some trade-off for that

monopoly.

[CountAllVotes]

5. Medicare wouldn't pay for it

they only pay for a certain # of visits a year and that is it. If you need more, you pay for all of it. That part Medicare would have paid for would be at 80%. The other 20% is your problem.

Let's hear it for MEDICARE FOR ALL!

[Gormy Cuss]

9. Medicare for all would be a vast improvement if for no other reason than you'd know what it will pay

and what it covers. Right now under many private insurance plans it's like playing the lottery.
And then of course there's the fact that Medicare can't drop your coverage to save costs.

[CountAllVotes]

11. $1840.00 goes quick with PT

>>Medicare is required to limit how much it pays for outpatient therapy services per year. This is called an annual financial limitation, or cap. Your Medicare benefit for outpatient physical therapy and speech-language pathology services (combined) is limited to $1840 per year. There is a separate yearly benefit limit of $1840 for outpatient occupational therapy.

Medicare Part B pays for Occupational, Physical, and Speech therapy as long as it is medically necessary, but only up to the yearly benefit limit of $1840. Before the limits, you pay 20% of the Medicare-approved amount after you have met your yearly deductible. After you have reached the $1840 cap, you will be responsible for 100% of the charge, unless you have other insurance coverage.

http://www.medicare.gov/Coverage/Search/Results.asp?State=CA|California&Coverage=50|Physical%2C+Occupational%2C+and+Speech+Therapy&submitState=View+Results+%3E


*********

If you have a costly supplemental policy, it might cover more visits. However, $1840.00 worth of physical therapy might be as few as 15 visits. The OP needs 30 more visits he/she states, hence Medicare would be pretty useless without a costly supplemental plan to top it off.

:(

[Gormy Cuss]

14. Again, Medicare at least makes it clear what it covers and what it doesn't.

I didn't assert that it's perfect, just that it's better than the vagaries of private insurers who get to choose based on their profitability model.

In a model where everyone was eligible for Medicare there would be a strong political incentive to expand coverage in areas that are currently weak. In this specific example there would also be a strong cost motive to provided better rehabilitative coverage for otherwise able-bodied younger workers because by getting them back into the workforce they are contributing more into the Medicare fund.

[CountAllVotes]

29. well the OP's bill would not be covered

too little too late. :(

[LuckyLib]

6. Even when PT would cost them less, they'd rather protest it -- then have to pay for the really

expensive treatments they can't always deny. Bastids is right.

[Obamanaut]

16. Miz O was allowed a limited number of PT visits, so every visit

we got them to show us at least one thing we could do at home to augment her visits. It's not the perfect solution, but it worked for us.

She was relearning to walk and regain the use of one hand following a motorscooter accident involving brain trauma.

edited to add: One of the things we did a lot of was walk around the yard picking up pine cones. I held onto that little web belt they use while she worked on maintaining balance while walking/bending, and holding on to pine cones without gripping them too hard. Not perfect, but it worked.

And good luck to you.

[boobooday]

24. Thanks

Pretty much all I get is instruction on a series of exercises I do at home to stretch and get the strength back in my shoulder. I get 1/2 hour per week.

I'm willing to do the work myself, cause I know that's how it has to get done. But it's good to have the regular meetings with the therapist, cause she tells me when I'm doing it wrong!

[madrchsod]

19. since you are in intensive therapy

be sure to do your home exercises they will give you. i did`t follow the "rules" and it lengthen my recovery. one important thing..when you are "healed" do not think you can do what you did before with the arm/shoulder. i think i`m paying the price for not following that rule.

having trouble putting on clothes? what i did was cut my t-shirts and shirts up the side and velcro`d. my shoulder surgery was a breeze-three holes and out that afternoon but the 6 months of therapy sucked.

get well!

[boobooday]

25. Man, I had a hell of a time dressing myself for a while!

I'm really just getting instruction from the PT (1/2 hour per week), and I'm trying like hell to do everything they tell me. I'm finally at the point where I can wash my hair with both hands! haha

Did you have a slap tear? That was my issue. I wish I'd have thought to make a couple of t-shirts with the velcro! That would have helped a lot, although my sling had so much velcro I often felt like some kind of bondage velcro girl!

[gkhouston]

32. My favorite was deodorant. I realized there was a towel rack in the bathroom

at just the right height for me to prop the elbow of my "bad" arm on it using my good arm. My roommate laughed her ass off when she saw me doing it.

[boobooday]

37. I couldn't even do that much

I referred to it as the "pit of despair" for about a month.

[Bonobo]

30. I would need to reach a family deductible of $4,000...

to get my fucked up knee even looked at. I mean I can't even have it looked at. They pay almost nothing until my deductible is reached...

[silverlib]

34. Physical therapy gets it from both sides...

My daughter is a physical therapist. She gets it from one side with the insurance companies refusing therapy prescribed by doctors and the she gets a quota (so many patients per hour) from her employer. She still keeps her license, but stays home with her children. Hopefully she'll be able to open her own clinic someday.

I hope you get what you need (from both sides).

[deaniac21]

35. Or the doctor trying to get all he can get....

[ThomCat]

36. My last Phystical Therapist had to argue daily with Orthonet

the company all insurance companies use to approve or deny Physical Therapy claims.

to get me more of the visits my doctor proscribed. Orthonet only approved payment for the first 6 visits. Then for 4 more. Then 4 more. Then 2 more. I never knew day to day if I should/could schedule my next appointments or not. Then they just cut me off.

My doctor wanted me in physical therapy to slow down my loss of function, to maintain the use I still had in my hands and in my legs to prevent things from getting worse. In other words, we were not expecting improvements. When you are spiraling downward, stopping the spiral IS an improvement.

But Orthonet and the Insurance company decided that a maintenance program is not a valid use of physical therapy. They don't care that it would help me. Their rule is that physical Therapy Must show measurable improvement within a few weeks or it is not worth "THEIR" money. So they cut me off.

They are terrified that Physical Therapy might become a real part of people's long term care, and they certainly can't have that. Part of their business plan is to make sure they never have to pay for long term Physical Therapy. So they only allow it for quick fixes.

Can you imagine if they could get away with putting restrictions like this on medications? "You can't get those medications for your MS unless it will cure you within 4 weeks. Oh, there is no cure for MS? Then I guess you don't need those medications, do you? Denied!"