When Health Insurance gets it right

The first time The Arlington Group put through the claim for my back surgery it was denied, yesterday I received the results of their appeal.  Surprise, surprise, this time the claim was approved.  However, I'm getting a second opinion because of A) the initial denial, and B) things have so drastically improved since my initial visit to Dr. Kutz.  How drastically have things improved?  On my first visit I had no strength in my right leg and it was nearly impossible to lift my foot more than an inch off of the floor.  This morning I carried the walker I'd been using during the first month out to the car.  That's right, I carried it down three steps and across the lawn.  What makes this so totally ironic is that in the appeal, Dr. Kutz emphasized that I could not walk without the aid of a walker.

That's not true anymore.  What's even more important is that even though I'm not 100% back to where I was before I started falling down, I'd say that I'm at least 80% there.  Do I have arthritis in my lumbar region?  Most definitely.  Is it so bad I need to have 4 of my lumbar vertebrae fused together?  I suspect probably not.  Will I be back to work in a month?  I'd say most assuredly so.  

Now I know everybody complains about health insurance, how expensive it is and how it covers so little, but this time?  I think they got it right.  The fact that my Orthopedic Specialist  needed to enhance information on the appeal to my initial claim is not so good.  Is his diagnosis wrong?  I don't think so.  I do believe that when it came to treating my arthritis The Arlington Group tried to sell me a Gold Plated Cadillac when a simple Ford Focus would have done the trick.

My MRI & Me

Yesterday I drove over to the Arlington Group to pick up a copies of both my MRI and the X-rays of my lower back.  First of all, I have to say I was surprised by how busy they were - patients everywhere which truly didn't surprise me.  As I'd said early, they have a very good reputation.  Anyway, I had to sit and wait because they couldn't find the CD with my MRI and the X-rays.  After about 10 minutes the girl waved from the counter.  "Here, I've found them."  I toddled over and she handed them to me with a cheery "you have a good day."  I smiled and wished her the same.
It wasn't until I got home that I discovered she'd given me something extra:  the authorization for the release of my medical information.  This form is to be kept on file by them... and, of course, they don't have it.  You can see it there, lurking beneath the disk.

Anyway, this shouldn't have surprised me.  I suspect something went awry after my initial diagnosis and for reasons known to only them, they prescribed one of the most invasive, expensive treatments possible.  They had 33 days to pre-authorize the claim and didn't...  maybe they're just not used to having claims denied.  I don't know about you, but I'm fairly certain this is their send off present, that my doctor / patient relationship with the Arlington Group has now been severed.  This is life.

PT over surgery?

I finally heard from the Arlington Group on Friday regarding the copies of my MRI and my back X-rays.  Elaine told me she had just gotten my voice mails (left Tuesday and Wednesday) because their phone system was working improperly.  Right.  Even thought she was very pleasant, I could tell they were writing me off as a patient,  She said things like "if your insurance company approves the claim you have 6 months in which to have the surgery," and that my insurance company "is so difficult to work with."
My neighbor Karen, who is a claims processor for another insurance company, asked me what surgery the Arlington Group had planned.  After I told her she looked at me for quite a bit and then said "they're doing a 4 level fusion without getting a pre-auth?  Some thing's not right there."  I suspect she's correct, that someone dropped the ball at Arlington, or just did very shoddy work.
On 6/5 I go for my second opinion.  What I suspect this Orthopedic Specialist is going to say is that 5 weeks ago I traumatized the hell out of my lower back, the result of falling down so many times.  five weeks ago I couldn't lift my right foot more then 1 inch off the ground, that problem has completely gone away.  I couldn't go up or down stairs, now there's no problem as long as there is a banister.  I could only get around using a walker - today I only use a cane when I'm out in public.  I think my traumatized back is healing.

What do I think this new specialist will prescribe?  I suspect Physical Therapy and perhaps a steroid injection.  I am sure he's going to take a much more conservative approach to my lower back issues.  Hopefully I will be back at work in a month or so because sitting around is boring as hell.  And I don't mind exercising at all.  Jees, I have almost a full gym at my house, I would really like to start using the equipment again.

Avengers is good & the back fusion is bad

I received a call from Elaine at the Arlington Group this AM.  She told me it took her 4 days to get my voice mails because their phone system doesn't work...???  According to her my appeal is before the review board at Anthem Blue Cross and that, if it's approved, will be good for 6 months (which left me with ???).  Anyway, Anthem emailed me the criteria and (surprise, surprise) I don't meet it - no conservative treatment for 3 months prior to surgery.  When I told Elaine I no longer use the walker and only use a cane when I'm outside the house, she said "oh, really."  And when I told her I went to the movies last evening she said "oh, that's nice."

And I did go to the movies.  This is movie season, you know, and actually my biggest lament so far has been that I'm not going to get to see all of these really neat action movies on the big screen.  So, taking a cane with me just in case, I went with friends to see the new Avengers movie last night.

And I thoroughly enjoyed it.  I go to these movies to have fun, to be 12 years old again for a short time.  There are people out there who feel they need to analyze movies of this genre - I don't.  And I know there are people out there who are so caught up in the lore they find flaws - I'm not one of those, either.  I'm a buttered popcorn and soda man and the action on the screen doesn't jolt to a screeching halt I'm happy.  And I thought "The Age of Ultron" was a really, really good movie. 

The new Mad Max movie has just started.  I'm planning on going to see it next week. 

Somewhere between a Cadillac and a Chevy Malibu

There I was berating both my insurance company and The Arlington Group, and then last evening I received the actual denial in the mail.  This morning I called OIP (Orthopedic Institute of Pennsylvania) and made an appointment to get a second opinion.  Why? Because the denial was very specific about one thing - the spinal fusion.  They pretty much rebutted every  point my orthopedist had used to justify the surgery in the first place.  So I did what I should have done 33 days ago, decided to get a 2nd opinion.  I also called the Arlington Group and told them I was going to need copies of my MRI as well as my X-rays.  I have not heard back from them.

Things have changed in the past 33 days.  Back then I was falling down a lot - I don't fall any more.  Back the only way I could go up or down a staircase was on my butt - today I, as long as there are banisters, I can walk up and down.  Back then, the only way I could drive a car was by pulling up on my pants leg to move my foot from the gas pedal to the brake pedal.  Today I have absolutely no problem driving.  I drove over to see my 81 year old mother on Mother's Day.  Thursday evening I'm going to see the Avengers.  So do I really need to have extensive back surgery, where they fuse the L2, L3, L4 and L5 vertebrae together?  I suspect this 2nd opinion is going to say 'not necessary.'

So, did the insurance company do right?  Probably.  Did the Arlington Group do me wrong?  Nah, I don't think so, not really.  They were most likely trying to sell me a fully loaded Cadillac when what I really needed Chevy Malibu.

Claim Denied

For those wondering how my surgery went?  Well, it didn't.  I received a call on evening of May 5, 10 hours and 40 minutes before my scheduled surgery telling me my insurance denied my claim.  The excuse given was that my insurance company had recently changed their criteria.  Now I do know, for a fact, that insurance companies do change criteria, sometimes quite often.  What has me more then a little concerned was that I agreed to the surgery back on April 2.  What I'm hearing from a lot of people is it should not have taken 33 days and some 13 odd hours for my surgical team to find out about this denial.  There is a last ditch effort in which there was a Peer to Peer doctor review to get a quick approval on an appeal.

So here I sit waiting while my FMLA slowly runs out.

Oh, and they know I'm not very happy.

And I keep think back to Tiara, and how she had such a difficult time getting my FMLA (leave of absence) form processed correctly.  Why?  Because on one of the times that I called I was told that she was in charge of forms.  Would someone whose responsibility it was to fill out all forms be the one person to file an insurance claim?  I'm thinking it probably is.  Which leads me to believe that she did just a shitty job filling out my insurance claim.

The Tarnished Tiara

I was contacted by corporate yesterday regarding my Leave of Absence.  First of all, it isn't a full LOA, it's actually FMLA - you know the Family Medical Leave Act.  What that does is guarantee that my position and rate of pay will be guaranteed for 12 weeks.  I can go on full Leave of Absence for 12 months, but after the first 3 months my position and rate of pay are no longer guaranteed.  The HR rep I spoke to said store usually don't demote you.  Anyway, this is important because Tiara, the associate at Arlington Orthopedic Specialists totally ignored everything I said when I gave her my paperwork.  I had told her my LOA needed to begin on 3/30 and run until 6/20 which was not what was written on the form.

She listed my starting date as 5/6 (the date of my surgery) and running until 7/29 and then beginning again on 7/30 and running until 11/6.  So I called Arlington and the first person I talked to was  really surprised by the November date.  And, of course, I had to wait on the line for almost 15 minutes before Tiara finally picked up her extension.  When I explained the situation to her she said "but that's your surgery date and we automatically extend it for 6 months."  So, I explained the situation again repeating how my surgeon said it was "realistic" for me to go back to work on 6/20 with restrictions.  And Tiara said, "well, you can go back to work any time."  And I wondered if someone had hit her with a stupid brick, or was she normally this inept.

Anyway, she agreed to changed the dates on the form and fax it a 2nd time back to corporate.  I will call corporate later this morning to make sure Tiara did the right thing.  I've already talked to the store and they know when I return I'll have restrictions.  I wasn't that impressed with Tiara to begin with, but now I know she truly is tarnished.

Laminectomies and me

I received the Pre-Op Medical clearance paperwork in the mail yesterday from the Arlington Group (no connection to Arlington, VA) and for the first time got to see exactly what my surgery was going to entail: bilateral laminectomies.  Sounds fun, doesn't it?  I went online to see educate myself, as usual, and realized this was going to be a little more extensive then I'd originally thought.  Ah well, that's life.  It's either have it done or slowly lose the use of first my right leg, and then the left, to arthritis.  If possible, I'd like to save the wheelchair days until I'm in my 80' or 90's.

I also looked at a couple of forums to see what people were actually saying about the procedure and there really weren't that many comments.  And of those few that had been posted about 2/3 were negative.  What surprised me was not that there were negative comments, but that there were so few - one of the forums only had 16 comments since 2012.  That's not a lot.  In fact that's an incredibly small number when you consider the procedures have been performed about 1.5 million times since then.

Anyway, all I'm doing is waiting.  Oh, and playing video games.