Quote:
Originally Posted by echoes long ago
i dont know the answers to your questions about if the alj can overule medicaid guidelines but i just wanted to say that i think you did a great job and gave it the good fight. You should have directly asked the insurance people about wether they ever received the paperwork from the orthotics place for authorization and reminded them that they were under oath.ha! They are all full of doggy diamonds. Did Alan get another pair of shoes paid for by the insurance company? Its not clear at the end of your post it seems he got another pair of shoes but i might be misinterpreting. I wish you luck and hope he gets the orthotics. This is where our "ADVOCACY" organizations should be involved in the fight.
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Thanks for the nice words.
Yes (read the very last line of my original post.
this is what I said:
"So again, Alan HAS the shoes with the orthotics. His HMO only paid for Shoes, but refuse to pay for othotics. "
What this means is that Alan got a new pair of shoes in 2009, and his HMO paid for the shoes, but they refuse to pay for the Orthotics that were fitted to go INSIDE of the shoes.
In 2008, his HMO paid for BOTH shoes and orthotics. But in 2009, they only paid for shoes.
Then they said they never pay for shoes and orthotics unless a person is diabetic or unless the orthotics are fitted with a brace.
That's when I politely interrupted and said ""But oh, you DID INDEED pay for the shoes and orthos in 2008 and you paid for the shoes in 2009" and the Judge then said: "why did you pay for these items?" and the girl said "Well, to tell you the truth Your Honor, I have no idea why we paid for these items, this was a mistake, and we are not going to ask to recover that money".
Can you imagine this? They first indicate that they never pay for these things and then they admit they paid and made a mistake.
I think Alan has a fighting chance. And the Judge asked them if they ever received a pre-authorization about the orthotics and they lied and said: "no we received nothing from the shoe company"
Oh Really?? then how come Alan got SHOES!!!! Because the submission was made at the same time, both shoes and orthos were molded at the same time.
This whole thing makes me nervous.
I know insurance companies try to get out of paying for stuff, I know this. But the best was when the Judge said "Let me get this straight, Alan has neuropathy, you acknowledge that Alan has neuropathy, he has the same condition as a diabetic but you won't pay for the shoes because he's NOT A DIABETIC?? Even the judge sounded skeptical.
But the other side admitted this was so.
So how does one change the medicare guidelines anyway. I'm up for it.
Maybe that judge might think "oh my goodness, what if my mother or father gets neuropathy, but isn't a diabetic, you mean medicare won't cover shoes for them?
It's something to think about, no??
We shall see. And I'll update you all.
This will be a MAJOR discussion at the next Neuropathy Support group meeting.
Melody