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Post by Deleted on Feb 12, 2018 14:16:45 GMT -6
The good news about the investigation being in CA is that CA is one of the only states with a State department/agency that has power to cite and fine managed care organizations. They are slow to do so and have been “soft” in previous cases. But authority to actually do something with complaints is key.
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mb3
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Post by mb3 on Feb 12, 2018 14:17:37 GMT -6
Also not really political but did anyone else read the story about Aetna not actually having doctors review patient charts before approving or denying treatment? So far they are only being investigated in CA but I have this...sneaking suspicion that perhaps the reason I couldn’t get approved for less invasive treatments for my knee was something similar. Oh I absolutely believe that the first level of appeal on these things is not completed by M.D.s in most cases. With mine the surgeon told me straight up that I’d get denied the first time and it would be because no one would even look at the file- they’d just see a request for arthritis injections for a 32 year old and deny saying someone my age can’t have severe osteoarthritis. And they were so matter of fact about it, like this is just how it is.
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Post by Deleted on Feb 12, 2018 14:21:12 GMT -6
Oh I absolutely believe that the first level of appeal on these things is not completed by M.D.s in most cases. With mine the surgeon told me straight up that I’d get denied the first time and it would be because no one would even look at the file- they’d just see a request for arthritis injections for a 32 year old and deny saying someone my age can’t have severe osteoarthritis. And they were so matter of fact about it, like this is just how it is. Yup. Unfortunately that is very true. I recently worked on a case where we got the procedure authorized prior to surgery, but the organ removed ended up weight more than the weight estimated (by a few ounces), which meant the medical code for the procedure changed by one digit. The surgery was done by the same approach and procedure. Insurance company refuses to pay us stating we got the wrong code authorized. I don’t think a human even looks at it. Luckily, it’s managed Medicaid so the patient won’t owe, but we did a free surgery.
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byjove
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Post by byjove on Feb 12, 2018 14:24:18 GMT -6
With mine the surgeon told me straight up that I’d get denied the first time and it would be because no one would even look at the file- they’d just see a request for arthritis injections for a 32 year old and deny saying someone my age can’t have severe osteoarthritis. And they were so matter of fact about it, like this is just how it is. Yup. Unfortunately that is very true. I recently worked on a case where we got the procedure authorized prior to surgery, but the organ removed ended up weight more than the weight estimated (by a few ounces), which meant the medical code for the procedure changed by one digit. The surgery was done by the same approach and procedure. Insurance company refuses to pay us stating we got the wrong code authorized. I don’t think a human even looks at it. Luckily, it’s managed Medicaid so the patient won’t owe, but we did a free surgery. This doesn't even make sense to me?! Like, how would you know the exact weight of an organ before it is removed? And that just completely changes the surgery?
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mb3
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Post by mb3 on Feb 12, 2018 14:24:52 GMT -6
With mine the surgeon told me straight up that I’d get denied the first time and it would be because no one would even look at the file- they’d just see a request for arthritis injections for a 32 year old and deny saying someone my age can’t have severe osteoarthritis. And they were so matter of fact about it, like this is just how it is. Yup. Unfortunately that is very true. I recently worked on a case where we got the procedure authorized prior to surgery, but the organ removed ended up weight more than the weight estimated (by a few ounces), which meant the medical code for the procedure changed by one digit. The surgery was done by the same approach and procedure. Insurance company refuses to pay us stating we got the wrong code authorized. I don’t think a human even looks at it. Luckily, it’s managed Medicaid so the patient won’t owe, but we did a free surgery. 😳😳😳 Just humor me here, would there be any recourse if it were private insurance? The exhaustive appeals process only and hoping for the best?
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Post by Deleted on Feb 12, 2018 14:26:47 GMT -6
Yup. Unfortunately that is very true. I recently worked on a case where we got the procedure authorized prior to surgery, but the organ removed ended up weight more than the weight estimated (by a few ounces), which meant the medical code for the procedure changed by one digit. The surgery was done by the same approach and procedure. Insurance company refuses to pay us stating we got the wrong code authorized. I don’t think a human even looks at it. Luckily, it’s managed Medicaid so the patient won’t owe, but we did a free surgery. This doesn't even make sense to me?! Like, how would you know the exact weight of an organ before it is removed? And that just completely changes the surgery? Nope. nothing about the surgery changed. Isn't that crazy??
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Post by Deleted on Feb 12, 2018 14:28:59 GMT -6
Yup. Unfortunately that is very true. I recently worked on a case where we got the procedure authorized prior to surgery, but the organ removed ended up weight more than the weight estimated (by a few ounces), which meant the medical code for the procedure changed by one digit. The surgery was done by the same approach and procedure. Insurance company refuses to pay us stating we got the wrong code authorized. I don’t think a human even looks at it. Luckily, it’s managed Medicaid so the patient won’t owe, but we did a free surgery. 😳😳😳 Just humor me here, would there be any recourse if it were private insurance? The exhaustive appeals process only and hoping for the best? It's pretty much the same. We have appealed the payor several times, but they keep denying it. If it was an HMO, we could file a complaint to the state insurance department, but it's probably not worth it. We also could technically bill the patient for some of it if it was private insurance, but we likely wouldn't beyond co-pay, etc because they thought it was authorized before the surgery (as we did)
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dc2london
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Post by dc2london on Feb 12, 2018 14:30:09 GMT -6
I've been kind of checked out except for here the last couple of days. What's going on? This is where I've been as well. But there were bombs, drone planes (?) that are utilizing US technology from Iran and Al Bagdaddy (sp) was wounded over the weekend? I only caught a tail end of something There was good coverage in yesterday's Post
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Post by Deleted on Feb 12, 2018 14:31:34 GMT -6
Sorry, sort of non-related job rant.
I'm supremely disgusted by the Medicaid lifetime limits. Medicaid serves some of the sickest populations of patients, so it's just incredibly devastating.
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byjove
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Post by byjove on Feb 12, 2018 14:33:08 GMT -6
Even with a doctor's note for food allergies and intolerances, with programs like WIC, they just don't have the stock and will give parents whatever they have on hand, which 99% would make the child sick- like not having hypoallergenic formula and giving them the step down which has casein protein. And the programs just shrug and say they did their best. Same for baby food pouches etc. Your child is allergic to squash, but we only have squash containing pouches? Oh well. I'm confused. WIC you purchase at regular grocery stores, right? Is that not the case in every state? I don't know all of the details, but my understanding is no. At least some states require you to go to a WIC office. ETA this is based off reading stories over and over from moms with WIC on the allergy boards
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mb3
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Post by mb3 on Feb 12, 2018 14:34:07 GMT -6
😳😳😳 Just humor me here, would there be any recourse if it were private insurance? The exhaustive appeals process only and hoping for the best? It's pretty much the same. We have appealed the payor several times, but they keep denying it. If it was an HMO, we could file a complaint to the state insurance department, but it's probably not worth it. We also could technically bill the patient for some of it if it was private insurance, but we likely wouldn't beyond co-pay, etc because they thought it was authorized before the surgery (as we did) Ugggggh. Sorry, I know I’m making this all about me. But my insurance still has not paid the claim for my knee and that makes me super nervous, even though we had a preauthorization and I know what was submitted matched that. The $63k bill has me terrified.
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dc2london
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Post by dc2london on Feb 12, 2018 14:34:18 GMT -6
I have so many feelings/questions about this. On the one hand, I think of all the people living in food deserts who might benefit from having fresh, healthy food delivered to their door. On the other hand, I have about a gazillion questions about how this would be practically applied (do people get to choose the time of their deliveries? what happens if a delivery is mis-delivered? stolen? not refrigerated properly? etc.) Do people get to choose their own foods? Are food allergies & special diets taken into consideration? How will vendors be selected? Will it end up w/ some prison-system vendors, where goods are insanely overpriced and there's no alternatives due to lack of competition? And so on and so forth. I could see ways this could be super useful & helpful. I could also easily see this turning into a paternalistic, overpriced means of policing what poor people eat and people ending up with a crap ton of expensive food they can't/won't eat & losing the funds to buy food they actually can/will eat. I really do not trust Republicans to get this right, either. Yeah I anticipate this being rife with corruption
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byjove
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Post by byjove on Feb 12, 2018 14:34:46 GMT -6
This doesn't even make sense to me?! Like, how would you know the exact weight of an organ before it is removed? And that just completely changes the surgery? Nope. nothing about the surgery changed. Isn't that crazy??
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Post by Deleted on Feb 12, 2018 14:37:30 GMT -6
It's pretty much the same. We have appealed the payor several times, but they keep denying it. If it was an HMO, we could file a complaint to the state insurance department, but it's probably not worth it. We also could technically bill the patient for some of it if it was private insurance, but we likely wouldn't beyond co-pay, etc because they thought it was authorized before the surgery (as we did) Ugggggh. Sorry, I know I’m making this all about me. But my insurance still has not paid the claim for my knee and that makes me super nervous, even though we had a preauthorization and I know what was submitted matched that. The $63k bill has me terrified. I think you will be fine. If you are concerned, go ahead and call the provider's financial counseling department to ease your concerns. The most we would bill the patient is the amount the insurance would have paid, so definitely less than the total billed charges, but I really don't think we would do that for any case where the claim was pre-authorized.
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Post by Deleted on Feb 12, 2018 14:39:49 GMT -6
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Post by oreobitsy on Feb 12, 2018 14:39:59 GMT -6
I saw this over the weekend and was so mad. I hope the coverage of this helps them so that he can stay. Not that it is ever ok to rip a family apart but when a child is facing cancer treatments, it is so cold-hearted.
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jkjacq
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Post by jkjacq on Feb 12, 2018 14:41:25 GMT -6
Even with a doctor's note for food allergies and intolerances, with programs like WIC, they just don't have the stock and will give parents whatever they have on hand, which 99% would make the child sick- like not having hypoallergenic formula and giving them the step down which has casein protein. And the programs just shrug and say they did their best. Same for baby food pouches etc. Your child is allergic to squash, but we only have squash containing pouches? Oh well. I'm confused. WIC you purchase at regular grocery stores, right? Is that not the case in every state? I think some WIC programs are part food bank especially with formula. I cant speak from experience but I've heard of they 'gave' me X instead of them having to purchase.
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cakewench
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Post by cakewench on Feb 12, 2018 14:48:50 GMT -6
Junior’s wife rushed to hospital after opening envelope with white powder: qklnk.co/R3D6qOIt turned out to be cornstarch. The Trump family is deplorable, but this was not even remotely appropriate.
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dc2london
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Post by dc2london on Feb 12, 2018 14:51:00 GMT -6
Um whoa
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dc2london
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Post by dc2london on Feb 12, 2018 14:51:16 GMT -6
Sarah is back and is super jazzed to be here
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jkjacq
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Post by jkjacq on Feb 12, 2018 14:52:29 GMT -6
her ruffles are distracting
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dc2london
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Post by dc2london on Feb 12, 2018 14:53:47 GMT -6
she won't say whether *anyone* at the WH was notified by the FBI about Porter. But that's bupkis bc we know McGahn was told.
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jkjacq
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Post by jkjacq on Feb 12, 2018 14:54:16 GMT -6
When was anyone aware
SHS talks about victims which is something no one else has.
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jkjacq
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Post by jkjacq on Feb 12, 2018 14:54:59 GMT -6
Why hasn't POTUS said that?
Its my job to speak for the pres and those are his words.
SURE
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dc2london
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Post by dc2london on Feb 12, 2018 14:55:19 GMT -6
CV: Does POTUS believe Rob Porter's accusers?
SHS: We take DV very seriously and believe all allegations should be investigated.
CV: Why won't POTUS say that himself?
SHS: It's my job to speak for him.
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dc2london
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Post by dc2london on Feb 12, 2018 14:55:43 GMT -6
oh. Beating your wife is "having issues in the past."
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Post by hawkeye2015 on Feb 12, 2018 14:55:44 GMT -6
I can't imagine why SHS didn't share this letter with us.
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dc2london
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Post by dc2london on Feb 12, 2018 14:56:25 GMT -6
JA: thefuq with the Tweets though?
SHS: I TOLD you he wants everyone to have due process GAWD
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jkjacq
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Post by jkjacq on Feb 12, 2018 14:56:42 GMT -6
does he sitll wish Porter well
He wanta the best for ALL americans
What about his tweet? Why does it look like hes defending Porter?
Look, the pres and entire admin take allegations seriously he supports victims above all else and is simply saying there should be due process.
Jim- its tone deaf sarah. LOL for days
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dc2london
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Post by dc2london on Feb 12, 2018 14:57:21 GMT -6
she's still referring to this all as "mere allegations." This is bullshit.
Jim Acosta asks if they're being tone deaf but she doesn't bite
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