do you have a negative opinion on

[Tacori E-ring]

i don't think insurance is a scam, I think it is flawed. There is a difference.

I understand your point, Tacori. And i know you're coming from a different perspective. I respect that, and of course I respect you; we go way back.

I've seen and heard agents and underwriters downright refuse to pay out claims that had every right to be paid out. Very sad situations, people thought they were prepared and were left with absolutely nothing after paying into policies for years and years.

I do think it's a scam in that people pay money every month into a policy that will likely never repay THEM like they anticipated.

it's been going on since the Middle Ages. I learned that when I had to study for my test to become an agent.

Having been on both sides, I still believe and always will believe that insurance is a scam. Paint it in any light you want, but don't tell me it's all on the up-and-up and in the best interest of the general population.

Straight Medicaid seems like a sweet deal to me. They even pay for transportation.

I totally understand your point of view. I think some insurance companies are more difficult to work with, Optum comes to mind. I am sure there re lots of things that happen behind he scenes that would be upsetting! I think they are out for profits. But fear keeps me paying my premiums.

 

[Tacori E-ring]

One of my job duties is to call insurance companies for precerification and concurrent reviews (mental health and substance abuse benefits). They are horrible and they are denying more and more often. Even if someone is actively suicidal or psychotic,after x number of days they want them out. They also are trying to become more and more involved in patients care which is ridiculous seeing how they have no interaction or contact with the patient.

I have to laugh because the insurance company had a general GP on their staff who never evaluated me or even spoke with me "look" at my case and the PT's notes and turn me down for further coverage based on that. He is not even an orthopedist and he is evaluating something well beyond his knowledge without all of the necessary info. I have a suspicion that as incentive for these doctors there is a bonus system for turning down as many people as possible. Though I am sure we will never get the real answer on that one.

I can only speak doe behavioral health. What happens is when they can't approve more days there is a "peer to peer" review. One of our doctors speaks to the doctor that works for the insurance company. 75% of the time they give the patient additional day. When they don't we then appeal. Sometimes it work, sometimes it doesn't but know you can appeal the decision.

Thanks Tacori. My PT did the peer to peer review last week and they denied us again (general practitioner who has no experience in orthopedics at Orthonet spoke with my physical therapist and didn't even listen to what he had to say and just denied denied denied) and now I am just waiting for the letter of medical necessity from my surgeon and my therapist will file an appeal.
Unfortunately based on what my therapist told me there is a 90% chance of losing the appeal.

I am disillusioned about the (and disappointed in) insurance companies and mine in particular. Cigna and Orthonet have failed me as far as I am concerned. I never really needed them till this year and then they drop me like a hot potato before I am ready. Pathetic. And finally the woman at Orthonet called me back last night after 3 plus business days (during dinner I mean calling at 6:30PM really? after I called her friday at 1PM and left a message asking to be called back as soon as she could and that's when she calls me back-wed night) and she offered the company line and that was it.

Pathetic and IMO Orthonet sucks.

I am sorry Missy. Hope you win your appeal and get the treatment you need.

 

[missy]

Thank you Tacori. I am not holding out hope about winning the appeal. The system is weighted against us but my surgeon sent a letter of medical necessity to my PT place today and they are sending the appeal in now. It takes about 2 weeks I think and that's expedited or something like that so again not expecting to win but it would be nice if I did.

In any case I appreciate your good wishes and I plan on paying for PT once a week out of pocket and I will be doing all my PT exercises at home so hopefully will not be losing ground. It's just that progress is excruciatingly slow with my type of injury and the insurance just doesn't want to recognize that because then they would have to continue to pay part of my therapy costs.