Coventry Georgia Rate Alert!

[AndreaSti]

Update!

Coventry denied the doctors appeal, stated he has to do therapy for 4 weeks. The therapy consists of strengthening exercises 2 hrs a day 3 days a week.

The doctor said if his suspicions are correct and it is a torn meniscus the exercises will be painful and of no help, he communicated this to Coventry and they said at the end of therapy if no better we will approve the MRI.

I am at a loss, the client just called and said he can't miss this much time from work and if they did the mri when he first went and if he needed surgery he would be walking and recovering now.

Now if he does the therapy and then has to have surgery it is setting him back 2 more months.

If he pays for the MRI out of pocket it will not be credited to the deductible, that has been verified.

Sounds like if the doc suspects a torn meniscus how can Coventry insist on the therapy if it could cause more damage. As I said before, sure a company has a right to maybe question a procedure but come on! If the doc insists they should just authorize it before the condition gets worse. Who is better qualified to determine whether the test is necessary, the person who actually SAW the patient, or someone in an office far away. Also, seems to me it could cost them more in the long run, even with the higher deductible.

I just got my Feb comm statement from Coventry so I am even more pissed off hearing about this, and this isn't even my client. Nice to work harder for less money huh? Especially if the client wants to blame you too.

 

[somarco]

Dan, how long has the policy been in force?

 

[dandan]

policy effective date 07/01/2010, he just called and said he was faxing the letter he received denying the claim based on not medically necessary!

 

[somarco]

Based on what you have posted, sounds like Coventry is just being stupid, and they should lose that fight.

They MIGHT try to fight on pre-ex but they would have a hard time proving he has had a gimp knee for 8 months.

 

[dandan]

Here is the letter

Coventry has received a request to authorize coverage for MRI of left Knee. This request is not approved for reimbursement based on the medical information supllied. The decision is based on the definition of Medically necessary set forth in the Definition Section of the Coventry Member Contract.

In your case, this request for services does not appear to be medically necessarry because there is no documentation of conservative treatment including physical therapy and activity modifications for at least four weeks.

hello!!!!! an MRI is medically necessary based on the doctors request to find "wth" is wrong with it!!!!

So going to fight them and so going to pull them from my portfolio!

 

[AndreaSti]

So going to fight them and so going to pull them from my portfolio!

Your client's doc might just do the same if he is able.

 

[dandan]

Update

I just got a call from my client with his doctors office on the line, the doctor spent 45 minutes on the phone arguing with Coventry about the need for an MRI and explaining that if the injury is a tear in the crtiledge it would o more harm also stated the 4 weeks of physical therapy would be more expensive than the MRI... they would not budge.

 

[AndreaSti]

Update

I just got a call from my client with his doctors office on the line, the doctor spent 45 minutes on the phone arguing with Coventry about the need for an MRI and explaining that if the injury is a tear in the crtiledge it would o more harm also stated the 4 weeks of physical therapy would be more expensive than the MRI... they would not budge.

Never thought I would be amazed anymore at the idiocy of some companies, but I am wrong. Unbelievable. Of course they know you can't move him to another carrier.
- - - - - - - - - - - - - - - - - -

Update

I just got a call from my client with his doctors office on the line, the doctor spent 45 minutes on the phone arguing with Coventry about the need for an MRI and explaining that if the injury is a tear in the crtiledge it would o more harm also stated the 4 weeks of physical therapy would be more expensive than the MRI... they would not budge.

Never thought I would be amazed anymore at the idiocy of some companies, but I am wrong. Unbelievable. Of course they know you can't move him to another carrier.

 

[dandan]

It keeps getting better, my clients next step is to do an appeal himself, he has already wrote the letter and called me to get a fax number to send it to, I called and was told it cannot be faxed it has to be mailed!



</IMG>

 

[somarco]

The DOI is mostly worthless, but would not hurt to file a complaint with them. Also shows good faith on your part.

Coventry must be in a world of financial pain right now to be this stupid.

The chickens are coming home to roost.