doctors didn't send in ESI appeal

[Maria]

I'm feeling very upset right now because I initiated a process to get an ESI back in Sept. and it was denied because my OSS took an xray and found facet degeneration on L4 now so he just commented on that so ESI was denied on basis not helpful for facet degen.

I was given until Oct.10th to have appeal in with WC re ESI so I called PM and that very day I called they were going to send in an appeal as well as I made an appt. with my PTP (primary treating physician) and he also said he would send in an appeal (tho he said "don't hold your breath" and was in and out of the room in a minute I think).

I get transforaminal ESI at L4 bilateral approach and it has been greatly helpful and it helps me to be able to travel to see my father in Fla. and help him out but I've not had one for a number of months and while my spine is OK I'm waking up with pain and dragging a bit as far as doing housework and such. Walking is fine and sitting could be greatly enhanced with an ESI and my father sits around quite a bit now at 88 (it's about all he can do as walking is very difficult for him).

Anyway~ no appeal was sent by either doctor!!! I've been going to these guys now for some time. The OSS since 1998 and the PM since 2004 and they both know my circumstances and my requests.

It aggravates me to no end that I do my part but they didn't do theirs re the appeal.

What I didn't do was check several days before the appeal to make sure papers were actually sent in because I got all caught up in my GI issues and endoscopy/colonscopy procedural garbage...

I just talked with the WC Risk Manager and this person also knows my circumstances and asked again "and when are you going to have your surgery?".... I know she enjoys this part where a "lifer" (on future medical) gets denials and the doctors don't do their appeals in a timely fashion as she has the power to authorize the ESI and not even waste the $$ and time sending it thru to UR.

This isn't going to stop me from pursuing what I want but it rather makes my visit with my father more difficult for me and less helpful.

Ok sorry for the rant tho I'm sure any of you with WC know the stupid BS games but I'm really disappointed in my doctors since I've been going to them for some time now.

[Katie]

Maria, I'm so sorry. I've been on the wrong end of some doctors and their lack of help too. They often do more harm than good, don't they.

If only they understood how a small statement, or lack of one, has such a devastating affect on our lives....it only takes a few minutes out of their day, but it makes or breaks us, sometimes for weeks, sometimes forever.

Good for you with going ahead with your appeal, and not letting them get you down. I'm very impressed with your drive. Go girl!

[dshobbies]

Sorry Maria for stepping on your thread but-

Picture this scenario with a government bureaucracy running things

[Katie]

I'm sorry this turned political, Maria, but I want to assure those who think that government involvement can make things worse are mistaken. This case of yours is about as bad as it gets, without anyone else's help.

I live in the land of the government funded health service, and frankly, I don't see anything being any better on the US side of the line. People are getting refused treatment on everyday things down there, not just on out of the ordinary things like spine surgery. I would rather do battle on just my spine, just once in my life, instead of with every other treatment I've needed over the past fifty years. One speed bump in half a century with NO extra charges along the way for anything else sure beats fighting insurance companies each and every time I walk into a doctor's office.

OK, strongly worded explanation over. Back to Maria's very legitimate issue

[Maria]

I understand your point Dale but with WC it is an entity unto itself.

Now if one wants to utilize the services of an attorney to fight a denial if the person/patient wants to utlize the services of an attorney to fight the appeal and the the appeal is lost in court then the costs all fall on the person/patient.

I don't know about other states with WC as they all vary I believe but CA has really turned sour for patients thanks to the Govenator. I used to like the guy as an actor but not as the Gov.

My case is very old and I have been fortunate enough to retain my benefits this long but I am viewed as a "lifer" re WC and they don't like that. They feel that the insurance company shouldn't be still paying for an injury dated "all the way back in 1982" as they have stated it in the denial.

I view it differently. I view it as the benefits were stipulated back in '82 to cover my low back with future medical and no time line was denoted. It used to be called "lifetime future medical" which I've been told by the insurance company is definately not correct.

Oh well.. it's a battle but I am a good little warrior when it comes to being tenacious.

Or I would have others that say "you like to fight"~ it does come in handy with WC!

I think Government issued health care for those that have nothing or would choose to use it would be far better than nothing. I've worked with patients that had nothing or very little because even tho they were indigent or just above poverty level they did not qualify for mediCal or any type of health care assistance.

And this is a sad state. The truth is that if the sick are taken care of especially with contagious/contact diseases then there would far less liklihood of spread of contagious disease and less $$ spent on pandemic spread.

Sometimes spending more initially means spending less overall. Keep the family unit healthy as sick parents can not take care of healthy kids but they can spread their germs to their kids and vice versa.

No one stays home from school or work when slightly ill and viral fomites are everywhere. Viruses are what we really have to worry about spreading as bacterial infections do not spread like viruses but one usually is much sicker by the time the infection has become a bacterial infection and therefore the over all cost of treatment is elevated as well as potential time for hospitalization and care.

Unlike many people I do not care what someone's immigrant status is where medical treatment is concerned. If the person is here and they are sick they are here~ and not treating the individual only means there will be more spread of germs/disease/contagions/contaminants.

These are just my uneducated opionions so I'm sure there are many that could beat my thoughts down with a stick but I just want healthcare for all~ yesterday and not so dang much struggle with what is supposed to be already stipulated for those of us with WC.

WC needs to stop wasting money by running the simplest decision thru Utilization Review~ this is really a wasteful process unless it's a major decision that needs further medically warrented input. Unlike a routine ESI for someone who has been getting them since 2001 and always states the ESI improves the level of pain by nearly 100%.

I guess being clear as glass isn't something that WC can comprehend. It would rather waste money muddling things up and then have the Govenator talk about having "cleaned up WC in the state of CA." ~ so not true.

[dshobbies]

I hear you Maria but there are two sides to the wc coin. And this is very definitely a hot topic.

As an employer from '76-'96, our wc premiums had skyrocketed and were out of control. Claims were paid regardless of their legitimacy. Reform was urgently needed which came about after we sold our business. I'm told by the new owners the system is far from perfect but much more reasonable and affordable and fraudulent claims are finally being denied...as are legitimate ones. Two different friends had to get an attorney involved before wc would pay for their injuries. You too are also dealing with instituted by our system of government.

Kind of like the definition of a living wage is dependent on if you're paying it out or receiving it!

Katie; our health care system is very definitely broken and is dire need of reform. However, the history of a government run or mandating anything, especially in this country usually goes from broken to an outright fiasco. Time will tell.

Then again, if you've read too many of my previous posts, I sure do love those soap boxes

My best to all, Dale

[Maria]

Dale,
Of course. It's just that my case is very not fraudulent and very stable with good results from same treatment requested, ordered, and given (transforaminal ESIs).

I've been on the same meds for years/same dose and one of the meds (pain) costs $8/mo. Gabapentin is more but WC doesn't want to pay for Lyrica which is even more costly and G works for me so we leave it at that. Then there is my Miralax.

WC wastes $$ with denials for people like me with old cases that are very stable.

Go chase what appears to be obviously fraudulent is what I think vs. giving someone like me more hassle.

Of course I can understand where WC would like to dump me as that would be one less person to cover costs on so prolonging or denying care seems appropriate from the insurance company's standpoint.

[dshobbies]

Sorry Maria,

I didn't mean to suggest your claim was not in every way legitimate. We all know of your daily suffering. I just wanted to demonstrate that reform was necessary but in fixing one part of wc, and not all that great either, they completely screwed up the other part and guess who got screwed?

There's an online petition going around, though I've read online petitions carry little weight since they cannot be verified, that endorses an amendment put forth by Congressman John Flemming requiring congress to accept the same health care system they would impose on us. Under the current bill they would be exempt.
Congressman John Fleming : Home

OK, not another word!
D

[Maria]

Dale,
didn't mean to even suggest you thought my claim wasn't legit just am too biased when it comes to the legitmacy of my case and was babbling on to this end.

You've always been one to support me as well as others here and I realize what you were trying to say previously.

thanks to all who read/replied/listened. That helped.