I’ve been dealing with an issue this past couple weeks here in Florida that might just give a small taste of the frustration an injured worker feels when an important medical procedure is denied by the insurance carrier responsible for their claim. The irritation is centered around two distinct areas; a denial with which they do not agree or understand, and the inability to speak with the person or persons who made that particular decision.

My family is pretty funny when it comes to doctors. All of us will insist our loved ones go to the doctor at the first sign of any trouble, yet when the issue belongs to us, we procrastinate endlessly. I am not one to run (or in this case, hobble) off to the doctor unless and until it becomes an unavoidable issue. Such has been the case with my right knee.

For probably over a year (I really haven’t kept track, and the timeline I give may be slightly inaccurate) I have been having problems with my right knee. It started with a loud and uncomfortable “popping” that occasionally occurred when walking. While it was not really painful, it could be heard across a quiet room, and was a very annoying phenomenon. It felt like someone was pulling my kneecap down and then letting it snap back in place with each step. Pain gradually entered the equation, and I visited my doctor, who ordered an x-ray of the knee. That x-ray showed no arthritis and did not offer up any clues as to what might be happening. Suspecting a muscular issue, I turned to massage to try and alleviate the intermittent yet growing discomfort I was feeling. 

That didn’t really do the trick for me. The knee now stiffens during sedentary periods and I must take a moment when standing to straighten it. At times it causes noticeable limping, and inhibits my ability (or desire) to walk longer distances. Pain when the leg is straightened or moving is now fairly constant.

Finally, two weeks ago, during an annual physical (which I faithfully have every 5 years or so), I discussed the knee with my doctor. He examined it again and determined we would need an MRI to have a better idea of what might be going on in there. According to my health insurance plan, that MRI would require my doctor to obtain a pre-authorization. 

A week went by and I heard nothing. When I checked back with the doctor’s office, I was surprised to learn that my health insurance company denied the authorization for the MRI.

I won’t specifically identify this carrier, except to say that “Florida” features prominently in their name. The other word in their name rhymes with “screw” or “you”. If my persistent subtlety has not allowed me to convey the notion that I am a pissed off customer of this particular company, I apologize.

At least I am a pissed off customer with a fairly well-read blog.

This experience is starting to feel like my health is being managed by a Soviet era planning committee. I was told that my doctor would need to schedule a peer-to-peer review with my insurance company, so they could either reverse their decision or somehow determine a better treatment protocol for my knee. I called the carrier directly, and while I was not permitted to speak to the actual people who determine these things, I was allowed to wait on hold for 10 minutes while the person helping me “went to speak to them”. When she returned she actually told me “I am going to read this to you just as it was given to me”; she proceeded to prattle on about standards requiring a certain length of treatment prior to an MRI, the need for x-rays to be provided, and a question if attempts to try various treatments such as physical therapy and so on were already employed.

Now, my pea sized non-medical brain thinks of an MRI as a diagnostic tool. It is something used to help determine what a problem actually is prior to deciding on a course of treatment for the particular malady. I’m not sure why physical therapy, which I think of more as a treatment method, should be employed without actually knowing what we are supposed to be treating.

But what do I know? I am not a doctor, and apparently neither is my doctor. This is a decision for the medical politburo. Considering our health insurance premiums are almost $13,000 a year, it is a frustrating situation that can certainly give one a case of the blues. Even further, consider their negotiated discounts and the fact that I have a $300 co-pay for MRI’s, and you will realize their actual exposure here is minimal – likely less than a few hundred dollars. 

Thinking about it makes me blue in the face. 

I understand that at times procedures and treatments must be questioned. It happens in workers’ comp all the time. However, there are often fundamental differences between general health and workers’ comp. In workers’ comp, there are different players and profit incentives, and some of the actors are unknown to the people paying the bills. In my situation my physician is an approved participant in our HMO. He is a known element, and for workers’ comp that offers a greater lesson in managed care for those states that allow employer directed care.

Put good doctors in your network, and let them do the damn job they are paid to do. Let the doctor be the doctor. If we can find and reward good physicians while eliminating the politburo mentality we will get better outcomes, at ultimately lower costs overall.

I’m particularly frustrated, as my travel schedule is fairly intense the next few weeks, and even if we can get a quick resolution to this imbecilic problem I am going to be further delayed in resolution. So, if you see me hobbling along at the Nebraska Workers’ Compensation Symposium, the NWCDN in Chicago, the IAIABC in Portland, ME or CWC Risk Conference in Dana Point, CA, you will know the back story as to why that is the case. The comrades of the central planning committee have deemed it appropriate. 

Sorry if I sound a bit whiny. After all, this is a bit depressing, and September is a hot month here. I can honestly say it sucks having the Florida blues.  

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