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#519084 - 10/06/18 08:52 PM Health insurance delaying medical services
mutagen Offline

Registered: 04/14/14
Posts: 14
I’m in a lot of pain and have multiple health problems, and I’m on short term disability. I have health problems that affect a lower percentage of Ankylosing Spondylitis patients. I’m on Remicade and multiple painkillers and muscle relaxants, and I still have unbearable pain. My rheumatologist is seriously against prescribing pain killers aside from NSAIDs, but has prescribed them. I’m constantly waiting for the health insurance company to approve medical services to receive treatment.

My health insurance company continues to lengthen the treatment process by intentionally prolonging the prior authorization process. Many of the medical services, i.e. MRIs, medical treatments require a prior authorization for my current health insurance plan. The health insurance carrier is the only carrier provided by my employer and I selected the plan with the highest level of coverage. My prior authorizations on average take 3 to 4 weeks for approval.

The doctor submits the prior authorization and it rarely comes back with an approval within a reasonable amount of time. The insurance company consistently asks for more information on why the medical service is necessary. Once the insurance company receives the medical necessity response from the doctor, the insurance company responds stating the medical service is medically unnecessary and provides recommendations for specific medical treatments prior to approving the medical service. This still occurs even though the doctor already tried those recommendations. After multiple peer reviews, where my doctor presents their case why I need the medical service to a doctor working for the insurance company, the insurance company finally decides to approve the medical service. This arduous prior authorization process is not just with one single doctor, but multiple doctors/specialists.

The MRI results that were deemed medically unnecessary all showed abnormalities. I’ve repeatedly rescheduled medical services due to consistent denials of medical care. I’ve had Aetna, and Blue Cross Blue Shield in the past and did not encounter these problems. When a doctor at Johns Hopkins ordered an imaging test, immediately after the appointment I was able to go next door to get my MRI or CT scan.

I’ve contacted the State Insurance Administration to address the issue with the health insurance company. They were not able to do much, because self-funded Health insurance plans are not within their jurisdiction. I was told to contact my employers Health insurance Administrator and The Department of Labor (DOL) Employee Benefits Security Administration. I contacted my employer’s health insurance administrator and they were not able to provide much assistance. I contacted the DOL and they said that they couldn’t directly contact the health insurance company, but would send a letter to my employer.

I believe the health insurance company is abusing the prior authorization process by intentionally prolonging the process to discourage treatment. Has anybody else dealt with these problems and how did you get faster treatment? What recourse do I have?

Edited by mutagen (10/06/18 09:00 PM)

#519085 - 10/07/18 04:40 AM Re: Health insurance delaying medical services [Re: mutagen]
Frederick Online   content

Registered: 03/28/06
Posts: 292
Sorry I can't be of any help mutagen but as I live in the U.K. the health system here is very different. Your posting makes me realise even more just how lucky I am. Have I got it right in thinking that Trump put a stop to Obama's Medicare system. Would Obama's Medicare have been any better for people like you and me who suffer from chronic conditions like A.S.? The British N.H.S. is far from perfect but seems to me to be better than what you have in the U.S.

#519086 - 10/07/18 07:31 AM Re: Health insurance delaying medical services [Re: mutagen]
Smed Offline

Registered: 09/05/01
Posts: 946
Obama care is the problem-

#519088 - 10/08/18 05:12 AM Re: Health insurance delaying medical services [Re: Smed]
Frederick Online   content

Registered: 03/28/06
Posts: 292
Originally Posted By Smed
Obama care is the problem-

Well there's one lesson I've learned today then


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