My Insurance Strikes Back – Pew Pew –The Story Volume 2 – Part 6

Posted on Updated on

I wish to remind my readers that before I had the insurance I have, I never had to contact my health care company. As the years went by, it felt like I could
not get off the phone with them. If it was not bills, MRI for my brain, MRI for my spine, approvals for medication – it was approval for my procedures. The first few months I did not have a problem with them, but the following years felt like a battle of wills. Stupidity vs Perseverance. I had to defeat the stupidity of my insurance in order to obtain the medical procedures I needed. Up to this point, I won with no
issue, but what came next was that I lost my first battle … well, … well almost lost:

I now had an MRI proving that my back pain was not exaggerated, and there was clear-cut reasoning behind why I felt the pain that I did. To remind you, I had two spinal bones with severe arthritis and two bulging disks, with other anomalies, that we were not concerning ourselves with at this time. The disks were L4 and L5 with surrounding areas. The next day when I got home I called my PCP and left him a message begging for help to get an appointment to see a back specialist ASAP. I knew if he made the phone call for an appointment I may get in a lot faster than if I did.

My PCP did just that. He set up an appointment to meet a specialist in
a few weeks instead of a few months. The following weeks were almost
unbearable. The pain tearing down my back into my legs plus pain shooting upwards from both of my ankles, made for a hurricane of pain through my body. I lay on the floor all day and night. My pain manager prescribed more oxycodone, to help me get through the nights until my
appointment. I did not want to take more medicine, but I had no choice. Other options were illegal and could get me kicked out of the practice.

As the weeks went by the day finally came when my wife and I found ourselves in a new office, waiting for a new doctor, and explaining our whole situation to a new nurse before the doctor came in. Her only
words as she heard our disgust with a new problem and exhaustion of another doctor visit were that she was sorry, and she hoped they could do something for me to help relieve all the pain.

She left the room.  Amanda and I did not talk at all. Amanda sat on the chair to my right slumped down into the seat with her phone, half paying  attention to it. I sat on the table that at this point I figured only
one company made and sold to every doctor I had ever seen. As I waited I filled my time with kicking the step stool around, making more noise then I should, until Amanda stated to be quiet when she
heard voices outside of the door.

I flipped the stool right side up with my feet, disregarding the pain that was rolling up and down my body, as soon as the door handle was pushed open, and my new doctor entered the room.  He introduced himself, read the computer screen the nurse was looking over and turned my way with a model of a spine in his hands. He first apologized for everything I had been through.  His bedside manner was very professional, endearing, and comforting. Using the model, he explained what was wrong with my spine (which I described earlier in this blog entry).  He also stated that the reason he believed I was having pain almost all over my body was because I had a disease called Complex Regional Pain Syndrome. A disease that usually starts in a thirty-year-old patient brought on by a trauma that never has healed. He stated that the fractures the surgeons had made in my ankle over the last eight and half years never healed correctly.  He knew year after year I was being fractured again for another surgery. He stated with this and the pain in my spine my brain had gotten so used to pain that
any type of sensation was being interpreted as pain. I then immediately asked him if this was the reason that wind on a spring day or a fan on low blowing across my legs caused so much pain I had to cover them with a blanket.

He paused and looked at me and stated that was one of the key symptoms of this disease. Amanda and I  sat there stunned for what seemed to be ten minutes as he typed in his computer. The next words out of my mouth were, “Thank you!  I have been dealing with this for years and no one had given me a diagnosis”. My pain manager and Dr. Treaster stated I might have it, but they were not experts in it. He was. I could not believe it. I had a diagnosis. I made him write it down on a pad and I laminated it when I got home. It is displayed on the fridge to this day.

However, before I had the satisfaction of putting up a diagnosis of my pain on the refrigerator like a child bringing home a good test grade from school, I had to cope with his informing me that I was going
to need shots in my back. The shots would be administered at an outpatient facility close to my house and they would make the appointment very soon for me. He stated that the shots should help my
legs and back as they numb the area and help the inflammation between
the joints.

For the first time in long time, I was hopeful. I thanked him profusely and apologized to the nurse for my unenthusiastic attitude before the doctor came in. Amanda and I were thrilled. I was going to get shots, and they made the appointment two weeks on a Wednesday from now.

Can you imagine how happy I was? There I was lying on the floor in pain the next two weeks with a smile on my face. For the first time I had a diagnosis, and an appointment that was going to help not only my back, but my legs, leaving worry just about my ankles and the tumors in my head. I was delighted. I told everyone of my incurable-disease diagnosis, incurable yes, but treatable. I just couldn’t wait. It was like waiting for Christmas, almost better. Two quick shots and then the pain should subside.

I remained jubilant, I was happier than ever, until . . . I think you guessed it, in the mail so very unexpectedly, was a letter from my insurance stating that the procedure was not medically necessary.  A procedure that had been recommended by the hospital they own, a procedure that was recommended by a specialist who only deals with spines. Two doctors had stated that I NEED these shots to help me. However, the Wizard behind the curtain, called the medical managers, said I
did not.

Now I knew for a fact from the last time, that they did not look at the paperwork, so once again a phone call was placed to my appeals coordinator .  When she picked up the phone, I think I heard her sigh.  She heard, “This is Doug Donnangelo again, and I swear you guys do not know your ass from your elbow.”

What’s going on?”, she asked.

I told her about what happened and that treatment that I needed that was covered under my insurance had once again been denied by a medical manager who had never seen me; treatment that had been recommended by two of their own doctors who had examined me, knew what was wrong with me and knew the treatment I required.

She quickly began typing. As she typed, my jubilation ended and all I saw was red and I let loose, “How the hell can you guys say something is not medically necessary when your own doctors said it is? We know from our last conversation they did not look at my chart, we know they denied it hoping that they would not have to pay for it. We also know, I am going to win this, no matter what it takes, a lawyer or me rolling over their stupid asses, one way or the other.”

Once again she took the comments in stride.  She must have a technique to block out this type of aggravation over the phone or she heard it so much she got used to it. All I knew was that working for a company that declined coverage for the legitimate medical needs of their customers, and taking calls from them while they dumped their anger on me did not seem like the kind of job I wanted.

She placed me on hold for what seemed like an hour, as my blood pressure skyrocketed and I experienced an adrenaline rush triggered by my anger that would have enabled me to split a car in half with my bare hands.  She got back on the phone and by her tone, it seemed to her she had an answer that would satisfy me.

“Mr. Donnangelo I know you are upset, but we want the best medical solution for you, our medical manager believes that you need to try physical therapy first.” She waited with baited breath for my answer.

After a minute of unsuccessfully trying to calm down, I replied, “Are you guys assholes? Are you hoping senior citizens just accept your answer so your company saves money? How can he suggest that? How does he know more than my doctors? Does he know I have been lying on the floor in pain for weeks and I finally have a diagnosis and he thinks physical therapy will help me!!!!.”

“Yes, understand, we reviewed your file. . . . ”

Before she could finish, I continued my tirade, “Does your doctor know I already have had 8 years of physical therapy on my body? Oh wait he doesn’t because he didn’t do his due diligence!!!! Get my shots approved now!”

“You had physical therapy? Let me see…oh yes here it is…yes it shows you had a lot of physical therapy, I will get your records and present them to him.”

“You have to be kidding me! Okay… Okay…. Look my appointment is Wednesday next week. Today is Thursday.  Get it done before my appointment, because if I have to delay, I will be lying on my back once again, for weeks, until they can fit me in. Tell that asshole he better approve it, before I have a lawyer and myself run over his ass so fast, he will not know what hit him.”

I found myself once again, wanting a phone I could bang down, wanting to make a loud noise, but instead it was a press of a disconnect button. I was out on my deck fuming. Amanda could see I was about to flip over a table or burn a shed down.   Before I could contemplate how to release my anger, my phone rang. It was my spine doctor.

“Hi Mr. Donnangelo. I am sorry to say your shots were denied, and the doctor, who usually never makes phone calls, called the medical manager to let them know you need those shots, but it did no good. They upheld the denial.”
I told her, “Don’t worry I just got off the phone with them.  Tell the doctor I am truly appreciative of his making the phone call, but you leave those fucking assholes to me. Once I run their asses over the phone it will be approved, trust me.”

“Oh! You already know. I am so sorry, Insurances can be so difficult sometimes. I truly am sorry, but the doctor really did try”, she replied.

I commented back “Don’t worry about it, let me handle it, just let him know once again I appreciated it. I will have it approved or they will regret it.”

“Okay, just keep us posted and good luck. We were shocked too when it was denied, you really need these shots.”  I thanked her and told her once again, not to worry about it.

A few days passed and it was Monday, two days before the appointment.  I called the appeals coordinator and left a message. I tried two more times that day and could not get through. How I stopped myself from punching a hole through the wall is beyond me.  I was able to control my frustration with pure will power.

Tuesday morning came. The phone rang around 9 a.m. and on the other end was the appeals coordinator. “I have good news Mr. Donnangelo. I received your physical therapy notes and I know there is enough here for you to win your appeal to get your shots.”

“Great….. My appointment is tomorrow.  Get it done immediately, please.”
“That is the problem, the only medical manager here is the one who denied it. It is hospital policy that the medical manager who denied it cannot see the appeal to overturn it so it won’t be until Thursday.”

“Are you telling me right now, I am going to have to lie down on the floor another two weeks until the doctors can fit me in, because the jack ass who did not spend three minutes looking up my record and denied my shots was proven wrong?  Proven wrong by my  medical records. But it is your company policy that when medical managers make a decision that is overturned they can’t change it themselves! You cannot possibly be telling me this. I was a manager for a bank.  If I made an error my company let me be a big boy and fix the error or override it.”
“I know Mr. Donnangelo and I am truly sorry but your shots will be approved, just not until a few days.”

“Oh my god, do you know that your company is the dumbest company I have ever worked with? I truly appreciate your help getting this approved, but how do you work with such incompetence? I mean from claims, to approvals, and to appeals. I have nothing but issues. I did not have to contact Highmark one time. What the hell is wrong with you guys? Look, it is time for me to have a sit down with your CEO. Thank you, but I have to go.”

I hung up right away, rescheduled my shots for two weeks later. I spent the time during those two weeks, refining my letter to the CEO, and to my surprise within a day I had a meeting set to meet the vice president. My dad and I could not wait….

Afterword

This is a little more condensed than what I went through. It took longer and it was a little worse, but everything written is true. I could not believe Mr. Medical Manager, who knew what was best for me and felt a denial was best, could not overturn his decision once proven documentation was handed in. If you have not read all of my entries, you will want to read the next one.

denial-clipart-canstock16421140
An all to familiar word when dealing with my insurance.  However, I did not let it stop me.

 

 

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s