legal question on a response from an insurance company letter

[Guest guest]

A mother brought her 14 year old daughter to see me for low back pain. She is covered under Coquille Indian Tribe Insurance. First thing I did was called the people at the insurance to make sure she was covered. I was told coverage was 100% without any limitations to treatments. Never heard of such a thing, since back in the 1980. I was happy to take the young lady in for the exam. The young girls complaint is low back pain. The young girl is over weight, but is very active with her baseball team, which makes it difficult for her to get regular treatments. My examination revealed B/L pronation of both feet, one more so then the other. This of course was dropping her pelvis and causing muscular imbalance along the lower back and she has an anteriority at L4-L5. This area along with the surrounding muscles were tender

and painful, which she felt was the pain she was feeling. I felt she needed Orthotic by Foot levelers, which most of us know are soft, allowing flexibility to the arch verses hard Orthotics. I requested from this group Orthotic coverage and sent in a billing for them. I treated her three times while waiting for their reply. They have not even paid for the three visits that I sent in. Two weeks later I received a copy of a letter that went out to this young girl. First Paragraph denied coverage for the Orthotics. Second paragraph went like this.

"THE COMMITTEE FELT THE BEST CARE FOR YOU AT THIS TIME IS TO SEEK A CONSULT FROM A PODIATRIST FOR FOOT CARE, AND A CONSULT WITH AN ORHTOPEDIC SPECIALIST FOR BACK PAIN. CONTACT HEALTH IS HERE TO ASSIST YOU WITH OBTAINIING INFORMATION ON POSSIBLE PROVIDERS. "

Third and final paragraph is her appeal rights. This letter was sent by the Contract Health Services Manager. I would like someone's opinion, if possible by an attorney how this committee can interfere with my patient treatment and make this statement that they feel my patients best care is in the medical field.. I know the podiatrist will charge twice the amount and will put her in hard Orthotics.. The Orthopedist will not be in agreement with anything I have begun to do, and because they will both be providers for this tribe and referred from this Contract Health Manager I will assume they will kiss up to this company. The mother had set an appointment the day before this letter came to me and probably the young lady as well.. They did not show for their appointment.

What are you opinions and what legal rights does this company have making such a blatant statement?

Walt DC ND

Eagle Point

[Guest guest]

Walt:

We're all going to begin seeing a lot of this type of "steering" by

the care coordinators of the medical home models. This is something

the state and national associations will hopefully address before it

gets out of hand. Unfortunately, there may not be much we can do

about it, since insurance companies and managed care plans seem to

have a lot of authority to do whatever they want.

Lyndon McGill, D.C.

EvolvHealth Wellness Advisory Council Member

Salem, Oregon

www.SalemSpineClinic.com

www.EvolvingDaily.com

A mother brought her 14 year old

daughter to see me for low back pain. She is

covered under Coquille Indian Tribe

Insurance. First thing I did was called the

people at the insurance to make sure she was

covered. I was told coverage was 100% without

any limitations to treatments. Never heard of

such a thing, since back in the 1980. I was

happy to take the young lady in for the exam.

The young girls complaint is low back pain.

The young girl is over weight, but is very

active with her baseball team, which makes it

difficult for her to get regular treatments.

My examination revealed B/L pronation of both

feet, one more so then the other. This of

course was dropping her pelvis and causing

muscular imbalance along the lower back and

she has an anteriority at L4-L5. This area

along with the surrounding muscles were tender

and painful, which she felt was the pain she

was feeling. I felt she needed Orthotic by

Foot levelers, which most of us know are soft,

allowing flexibility to the arch verses hard

Orthotics. I requested from this group

Orthotic coverage and sent in a billing for

them. I treated her three times while waiting

for their reply. They have not even paid for

the three visits that I sent in. Two weeks

later I received a copy of a letter that went

out to this young girl. First Paragraph

denied coverage for the Orthotics. Second

paragraph went like this.

"THE COMMITTEE FELT THE BEST CARE

FOR YOU AT THIS TIME IS TO SEEK A CONSULT

FROM A PODIATRIST FOR FOOT CARE, AND A

CONSULT WITH AN ORHTOPEDIC SPECIALIST FOR

BACK PAIN. CONTACT HEALTH IS HERE TO

ASSIST YOU WITH OBTAINIING INFORMATION ON

POSSIBLE PROVIDERS. "

Third and final paragraph is her appeal

rights. This letter was sent by the Contract

Health Services Manager. I would like

someone's opinion, if possible by an attorney

how this committee can interfere with my

patient treatment and make this statement that

they feel my patients best care is in

the medical field.. I know the podiatrist will

charge twice the amount and will put her in

hard Orthotics.. The Orthopedist will not be

in agreement with anything I have begun to do,

and because they will both be providers for

this tribe and referred from this Contract

Health Manager I will assume they will kiss up

to this company. The mother had set an

appointment the day before this letter came to

me and probably the young lady as well.. They

did not show for their appointment.

What are you opinions and what legal

rights does this company have making such a

blatant statement?

Walt DC ND

Eagle Point