24601NoMore
Thinks s/he gets paid by the post
- Joined
- Dec 8, 2015
- Messages
- 1,179
Hey, everyone. Wondering how many of you have had issues getting pre-authorizations for medical tests or procedures approved?
I need a MRI for the (likely) shoulder injury that happened when I got the first COVID shot. The pain is moderate and enough to wake me at night. So, I went to my Orthapedic Dr who did all the tests he can do. Need some imaging to figure out what's going on.
They submit for the MRI pre-authorization. Takes forever (almost 2 weeks) to hear back - DENIED. Here's the kicker..it's denied because I "haven't completed a 6-week trial of doctor prescribed treatment. Supported treatments include (but are not limited to) medications for swelling or pain, physical therapy, and/or oral or injected steroids".
So, the Doctor should just do random injections into my joint (possibly causing further issues), or I should do random PT when the PT therapist would have no idea what the underlying issue is? Or, I should just "suck it up" and take steroids or some other drugs for 6 weeks to see if that helps? Seriously?
There's NOTHING in my healthcare contract (I looked) that says you need to "complete 6 weeks of doctor prescribed treatment" before you can get a MRI. I plan to emphasize the heck out of that point in my appeal.
Turns out the company doing the denial is apparently a third-party, more evil than Satan and all his minions corrupt piece of garbage from the seventh level of hell called Evicore. Do a google search on these demons. People with Stage 4 cancer who need something..DENIED. In a car accident with a bone literally sticking out of my back - need surgery..DENIED - "not medically necessary".
Lots of talk online about a class action lawsuit against Evicore. Turns out many larger insurers (BCBS, Cigna, my own provider [Priority Health] and more) all use them. I even came across a story where a large employer moved all his hundreds employees off BCBS (I think of NH), paid $70K MORE a year for a plan with a different insurer, because of all the problems with Evicore and their denial of services that were obviously medically necessary.
Even more heartbreaking - Evicore is being sued by a lady who got denied for a MRI, then months later when it was finally approved after multiple appeals - they found her back pain was being caused by a tumor that had spread to multiple discs. She's now paralyzed for life and in a wheelchair, when earlier treatment would have prevented that extensive damage from occuring. All to save on approving an MRI for her. I hope she wins tens of millions in damages.
Also heard that Evicore "peer to peer" reviews if you contest their denial happens with Doctors with totally random and rarely applicable skills. Need an Oncology review? The Evicore Doctor talking to your own doctor might be a speech pathologist. Or an OBGYN, instead of an actual Oncologist on their end. Yeah, I actually saw lots of reports online of that reportedly happening.
Has anyone else had this type of issue or run into these evil morons from Evicore? I realize imaging is generally hard to get approvals on. But in this case, I have a $7,000 deductible that I'll never, ever hit unless I get hit by a bus or come down with a horrible disease. So, I'll be paying for the MRI totally out of pocket ANYWAY! The only thing their approval gets me is the "contracted" vs "cash" price. Probably a net difference of $2-250 or so, and what I pay if I have to do "cash" will not apply against my super massive deductible.
While the $2-250 difference on the MRI isn't super major, I do worry..what happens if wife or I ever have a more serious issue that requires surgery, life saving treatment of some sort, etc? This demon spawned company is out there regularly denying approval hoping people give up and go away. So you then have to appeal and fight..and by then, it may be too late and your health has deteriorated further - perhaps permanently..or perhaps to the point of fatality. This is candidly terrifying and doesn't seem to improve any on Medicare who I believe plays the same cost-savings games. Man, I miss the corporate sponsored healthcare. It wasn't perfect, but 10,000X better than the "A"CA.
Appreciate all insight, horror stories, etc. I'm sure there are many.
I need a MRI for the (likely) shoulder injury that happened when I got the first COVID shot. The pain is moderate and enough to wake me at night. So, I went to my Orthapedic Dr who did all the tests he can do. Need some imaging to figure out what's going on.
They submit for the MRI pre-authorization. Takes forever (almost 2 weeks) to hear back - DENIED. Here's the kicker..it's denied because I "haven't completed a 6-week trial of doctor prescribed treatment. Supported treatments include (but are not limited to) medications for swelling or pain, physical therapy, and/or oral or injected steroids".
So, the Doctor should just do random injections into my joint (possibly causing further issues), or I should do random PT when the PT therapist would have no idea what the underlying issue is? Or, I should just "suck it up" and take steroids or some other drugs for 6 weeks to see if that helps? Seriously?
There's NOTHING in my healthcare contract (I looked) that says you need to "complete 6 weeks of doctor prescribed treatment" before you can get a MRI. I plan to emphasize the heck out of that point in my appeal.
Turns out the company doing the denial is apparently a third-party, more evil than Satan and all his minions corrupt piece of garbage from the seventh level of hell called Evicore. Do a google search on these demons. People with Stage 4 cancer who need something..DENIED. In a car accident with a bone literally sticking out of my back - need surgery..DENIED - "not medically necessary".
Lots of talk online about a class action lawsuit against Evicore. Turns out many larger insurers (BCBS, Cigna, my own provider [Priority Health] and more) all use them. I even came across a story where a large employer moved all his hundreds employees off BCBS (I think of NH), paid $70K MORE a year for a plan with a different insurer, because of all the problems with Evicore and their denial of services that were obviously medically necessary.
Even more heartbreaking - Evicore is being sued by a lady who got denied for a MRI, then months later when it was finally approved after multiple appeals - they found her back pain was being caused by a tumor that had spread to multiple discs. She's now paralyzed for life and in a wheelchair, when earlier treatment would have prevented that extensive damage from occuring. All to save on approving an MRI for her. I hope she wins tens of millions in damages.
Also heard that Evicore "peer to peer" reviews if you contest their denial happens with Doctors with totally random and rarely applicable skills. Need an Oncology review? The Evicore Doctor talking to your own doctor might be a speech pathologist. Or an OBGYN, instead of an actual Oncologist on their end. Yeah, I actually saw lots of reports online of that reportedly happening.
Has anyone else had this type of issue or run into these evil morons from Evicore? I realize imaging is generally hard to get approvals on. But in this case, I have a $7,000 deductible that I'll never, ever hit unless I get hit by a bus or come down with a horrible disease. So, I'll be paying for the MRI totally out of pocket ANYWAY! The only thing their approval gets me is the "contracted" vs "cash" price. Probably a net difference of $2-250 or so, and what I pay if I have to do "cash" will not apply against my super massive deductible.
While the $2-250 difference on the MRI isn't super major, I do worry..what happens if wife or I ever have a more serious issue that requires surgery, life saving treatment of some sort, etc? This demon spawned company is out there regularly denying approval hoping people give up and go away. So you then have to appeal and fight..and by then, it may be too late and your health has deteriorated further - perhaps permanently..or perhaps to the point of fatality. This is candidly terrifying and doesn't seem to improve any on Medicare who I believe plays the same cost-savings games. Man, I miss the corporate sponsored healthcare. It wasn't perfect, but 10,000X better than the "A"CA.
Appreciate all insight, horror stories, etc. I'm sure there are many.