Retired from Illinois. Technically, I was an employee of the State of
Illinois; my retirement fund was from the state. In the buyout plan which
they offered, there was a PPO (Preferred Provider Organization).
However, I moved to Indiana which is outside the boundaries of this
particular PPO. Hence, I can go to any doctor, medical service, or
facility and the PPO pays according to a fee schedule.
I broke my back. Really broke my bones, not some muscle strain or
back pain due to a bruise. The pain was terrific. I couldn't sit up or get
up or roll over. The lower half of my body went into severe spasms.
The ambulance took me to the ER. Two damaged vertebrae confirmed.
Put into a bed and hooked up to IV for !) intense pain, 2) convulsions, and
3) muscle relaxants.
Next day the doctor called the company that handles the paperwork
for this insurance company.
After three days the insurance company called to inform me that I
could no longer be in the hospital since no surgery was being done at
that time. Services that I was receiving could be done at some other
facility--home, nursing center, outpatient, etc.
Wife explained that I could not move myself at all (the rolling over,
sitting up, lifting hips, moving body by pulling with arms), was in very
severe pain, was not fully rational because of the potent medications,
and still having painful uncontrollable jerking of legs.
The clerk was unwavering. I had to leave the hospital right away.
Another quirk in the PPO was that---you would have to listen to a
lawyer for thirty minutes to understand the rationale behind this clause--
I could not stay in the hospital even if I paid for it myself!
The clerk on the phone in Chicago was not a nurse and did not
have any specific diagnostic training. She did not have my x-rays or
reports of examinations by several medical doctors, including an M.D.
with special training and experience in trauma and another M.D. who
is a highly regarded and experienced neurosurgeon.
All this woman knew was that since I wasn't receiving some high
level of therapy or some surgical procedure right now, I had to leave the
hospital.
***As several people have noted, in order to cope with weird decisions
by insurance companies, you need a doctor who can say the correct
things and process the paperwork correctly.***
My doctor called the "paperwork processing center" in Chicago and
calmly, methodically, and professionally dictated the exact phrases and
sentences that required the PPO to allow me to stay right where I was.
I'm telling you, my wife and I almost fell over in a faint when the woman
in Chicago told us, in no uncertain terms, that I absolutely had to leave the
hospital right away!
A few days later, after some sophisticated testing and after some of
the swelling around the spinal cord had gone down, I had surgery in two
places on the bones. Then I still had to stay on the machine that metered
the pain killers, muscle relaxants, and anti-spasmatic drugs into my arm.
I still couldn't sit up or straighten my self in the bed.
For two weeks I hardly knew where I was because of the medications.
Then the pain and convulsions stopped and in another five days I could
get up and sit in a chair with one person helping me.
Then I went home and with some in-home help and some trips to a
rehap clinic, I got to where I could get around again.
The point of telling about my experience is that a person must
insist on proper care. Don't accept the decisions of a voice on a phone
from the neighboring state. I found out later that these clerks attend
training sessions on how to be assertive (read that as "how to be
pushy" or "how to be a bully" or "how to override a patient's common
sense") in order to hold down costs for the insurance companies.
Often the doctor himself has to get on the phone and handle the
situation or has to fax a report to some paper-shuffler halfway across
the country.
With insurance companies "The big print gives it to you, and the
small print takes it away."
Well, I'm going to mow my lawn now and then spade up a little
patch of my garden. Love you, Pat
