How insurance companies manipulate doctor's second opinions to agree with their decisions
It started out with an innocuous call from our insurance company to our family doctor stating that they had a pain specialist that they would like to arrange to give a second opinion concerning my wife's acute onset of severe pain requiring her to have a wheelchair. Although we had called for pre-approval for expensive injections with a pain specialist and had not received a denial of coverage, any correspondence or payment of thousands of dollars, we thought that now we would get some answers. As we were arranging the appointment, the contacts at the insurance company told me that they would comply with their doctor's findings. The specialist had great credentials, was considered to be excellent in his specialty, so we started the process.
The end result was that he agreed with her current course of treatments, dictated a letter explaining his findings and sent it to the insurance company with a copy to my wife.
After the appointment there was a two week silence from the insurance company, so I called to find out about the payments and coverage. I was told the following: "Yes we received the letter and have been reviewing, but although he dictated his findings and his hesitation in his doing the treatments or physical therapy, it was signed by the office manager and we need to talk to the doctor before we approve it."
Over the next few weeks, it gets really interesting and I received my first education in insurance logic.
The actual appointment with the specialist chosen by our insurance company consisted of a long day of tests, meeting with physical therapists and a lengthy conversation with the doctor, he stated that as she was beginning to slowly improve with the treatments he would suggest continuing that course of action. Since he did not specialize in ligament disorders or these types of injections, he was more comfortable with her continuing with the therapy that she was having done with the previous specialist.
After a few more weeks, we found out that there was a flurry of phone conversations with their specialist and that the insurance company told him that they would accept his findings and have the other specialist do a few injections, but they would only cover the physical therapy at his location. The doctor was a reasonable and good man, but was facing the reality of either complying with their demands or our being forced to pay thousands more for treatment and agreed.
In the early stages of her disability, my wife had gone through extensive PT before she was diagnosed with torn/stretched ligaments and was given passive therapy. After each session she grew steadily worse. After it was determined that her problems were ligament related, it was determined that the stretching of the ligaments during therapy actually contributed to her getting worse. We explained that to the insurance company to no avail.
Since it made no medical sense to have one specialist handle injections and coordinating with PT the areas of concern, we declined their illogical solution.
The justification they gave was that our family doctor agreed to the second opinion, they paid for the second opinion and we should abide by their decision. This was the beginning of the financial difficulties that we had over a period of many years, but today my wife is leading a normal life, although with some painful days and continuing periodical treatments. Had the insurance company listened in the early stages of her disorder, the outcome would have been much better and would caused our financial burden. I have never thought that insurance should cover everything; I have only expected to be told whether or not something is covered.
This is what can happen today with private insurance policies. There is no question that had she been covered by a large group policy that the outcome would have been much different. The companies are set up to handle complaints and questions with the group policies, but don't really have a motive to give that same attention and care to individuals. When I watch the healthcare debates, I am very interested in how this problem will be resolved, if at all.
TVP tvp@dyingforinsurance.com
The end result was that he agreed with her current course of treatments, dictated a letter explaining his findings and sent it to the insurance company with a copy to my wife.
After the appointment there was a two week silence from the insurance company, so I called to find out about the payments and coverage. I was told the following: "Yes we received the letter and have been reviewing, but although he dictated his findings and his hesitation in his doing the treatments or physical therapy, it was signed by the office manager and we need to talk to the doctor before we approve it."
Over the next few weeks, it gets really interesting and I received my first education in insurance logic.
The actual appointment with the specialist chosen by our insurance company consisted of a long day of tests, meeting with physical therapists and a lengthy conversation with the doctor, he stated that as she was beginning to slowly improve with the treatments he would suggest continuing that course of action. Since he did not specialize in ligament disorders or these types of injections, he was more comfortable with her continuing with the therapy that she was having done with the previous specialist.
After a few more weeks, we found out that there was a flurry of phone conversations with their specialist and that the insurance company told him that they would accept his findings and have the other specialist do a few injections, but they would only cover the physical therapy at his location. The doctor was a reasonable and good man, but was facing the reality of either complying with their demands or our being forced to pay thousands more for treatment and agreed.
In the early stages of her disability, my wife had gone through extensive PT before she was diagnosed with torn/stretched ligaments and was given passive therapy. After each session she grew steadily worse. After it was determined that her problems were ligament related, it was determined that the stretching of the ligaments during therapy actually contributed to her getting worse. We explained that to the insurance company to no avail.
Since it made no medical sense to have one specialist handle injections and coordinating with PT the areas of concern, we declined their illogical solution.
The justification they gave was that our family doctor agreed to the second opinion, they paid for the second opinion and we should abide by their decision. This was the beginning of the financial difficulties that we had over a period of many years, but today my wife is leading a normal life, although with some painful days and continuing periodical treatments. Had the insurance company listened in the early stages of her disorder, the outcome would have been much better and would caused our financial burden. I have never thought that insurance should cover everything; I have only expected to be told whether or not something is covered.
This is what can happen today with private insurance policies. There is no question that had she been covered by a large group policy that the outcome would have been much different. The companies are set up to handle complaints and questions with the group policies, but don't really have a motive to give that same attention and care to individuals. When I watch the healthcare debates, I am very interested in how this problem will be resolved, if at all.
TVP tvp@dyingforinsurance.com
Posted by The Virtual Patient at 10/31/2009 6:38 AM 
Categories: Costs, doctors, Insurance, Private Policies, Appeal denial, Pre-approval
Tags: doctors Appeal Private Policies coverage preapproval costs
Categories: Costs, doctors, Insurance, Private Policies, Appeal denial, Pre-approval
Tags: doctors Appeal Private Policies coverage preapproval costs
This page added to Google cache Cached: http://google.com/search?q=cache:http://dyingforinsurance.com/2009/10/31/how-insurance-companies-manipulate-doctors-second-opinions-to-agree-with-their-decisions.aspx?ref=rss&ei=AFQjCNHajN_OX0kgxzx7UGA1yBffree PoRndfWq
Reply to this
This is telling of how much insurance can screw you up at the moment you need it the most. Had you known, you would have prepared for the financial difficulties, but you were left to dry without knowing where to go. I hope the new legislation will force all companies to pay for all illnesses.
Reply to this