Transverse Myelitis Internet Club List: [TMIC] HMO Nightmare

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I have been falling behind on my mail lately, but glad to re-connect =
with all my TM friends. Unfortunately, I have been in a huge battle =
with my HMO (Aetna). When I called about 3 weeks ago to find out my =
last date of therapy and how to request an extension, I was told my PT =
has been denied since 1-18-99. After many questions and few answers, =
this is what I've come to figure out so far. Aetna says my "plan =
changed 9-01-98 from 60 PT visits per calendar year to 60 consecutive =
visits per injury." However, I was never informed by Aetna, my employer =
(who says they were never informed), PT, or anyone else. This is not =
good for two reasons: 1) I have been going to PT from Nov. '98 to April =
'99, and 2) My chances of gettting more PT is bleak (although I will =
fight this until I get more PT). =20
It has taken me 2 weeks to understand all of this and to find out how to =
fight it. I still believe something is wrong with the entire picture =
because I spoke with an insurance rep on the phone during the last 2 =
weeks of February to ask them the same question, "How long will I have =
PT for?" because Voc. Rehab. asked me to call because they were offering =
to pay my $300 co-payments per month. I was told by Aetna that I had =
"60 visits per calendar year (just like my book says) and my start date =
was Jan. 08 and I should exhaust my coverage in the middle of May." =
When I asked if the rep could look back into the computer logs where =
they write their comments for February, I was told they were not madated =
to write comments until March. Isn't that convenient????
I really believe that someone at Aetna screwed up because I had also =
been fighting them to remove from their computers that I was involved in =
a car accident. I was really hurt playing soccer and it never involved =
a car accident. I was receiving bills from doctors who were being =
denied because they were told I was in a car accident and my auto =
insurance should pay. Well, after months of fighting this, I was told =
that my entire case was being reviewed item by item in order to remove =
the auto accident blunder. This review took place in Feb/March. =
Quincidental to me, but maybe I'm just a little paranoid and skeptical =
of insurance right now. =20
Currently, my primary doctor's office is helping me to fight Aetna by =
requesting back coverage and also asking for more PT. All of my doctors =
have stated I need more PT. Hopefully I will hear some good news on =
Monday.
If anyone (Don, I think you posted something about having knowledge of =
insurance) has any thoughts or suggestions, please let me know. I am =
doing as much at home as I can, but it is only about 1/4 of what I could =
do at PT. I do not want to lose all that I have worked hard for.

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I have been falling behind on my = mail lately,=20 but glad to re-connect with all my TM friends. Unfortunately, I = have been=20 in a huge battle with my HMO (Aetna). When I called about 3 weeks = ago to=20 find out my last date of therapy and how to request an extension, I was = told my=20 PT has been denied since 1-18-99. After many questions and few = answers,=20 this is what I've come to figure out so far. Aetna says my = "plan=20 changed 9-01-98 from 60 PT visits per calendar year to 60 consecutive = visits per=20 injury." However, I was never informed by Aetna, my employer = (who=20 says they were never informed), PT, or anyone else. This is not = good for=20 two reasons: 1) I have been going to PT from Nov. '98 to April '99, and = 2) My=20 chances of gettting more PT is bleak (although I will fight this until I = get=20 more PT).

It has taken me 2 weeks to = understand all of=20 this and to find out how to fight it. I still believe something is = wrong=20 with the entire picture because I spoke with an insurance rep on the = phone=20 during the last 2 weeks of February to ask them the same question, = "How=20 long will I have PT for?" because Voc. Rehab. asked me to call = because they=20 were offering to pay my $300 co-payments per month. I was told by = Aetna=20 that I had "60 visits per calendar year (just like my book says) = and my=20 start date was Jan. 08 and I should exhaust my coverage in the middle of = May." When I asked if the rep could look back into the = computer logs=20 where they write their comments for February, I was told they were not = madated=20 to write comments until March. Isn't that = convenient????

I really believe that someone at = Aetna screwed=20 up because I had also been fighting them to remove from their computers = that I=20 was involved in a car accident. I was really hurt playing soccer = and it=20 never involved a car accident. I was receiving bills from doctors = who were=20 being denied because they were told I was in a car accident and my auto=20 insurance should pay. Well, after months of fighting this, I was = told that=20 my entire case was being reviewed item by item in order to remove the = auto=20 accident blunder. This review took place in Feb/March. = Quincidental to me, but maybe I'm just a little paranoid and skeptical = of=20 insurance right now.

Currently, my primary doctor's = office is helping=20 me to fight Aetna by requesting back coverage and also asking for more = PT. =20 All of my doctors have stated I need more PT. Hopefully I will = hear some=20 good news on Monday.

If anyone (Don, I think you posted = something=20 about having knowledge of insurance) has any thoughts or suggestions, = please let=20 me know. I am doing as much at home as I can, but it is only about = 1/4 of=20 what I could do at PT. I do not want to lose all that I have = worked hard=20 for.