OrthoNet

I was due to have my spinal cord stimulator put in today and I get a phone call from my doctor telling me that orthonet denied it the day before I was due to have it done. I am highly pissed off there doctor don’t know anything about me to make that call. I’m in pain every day of my life my back is messed up.My pain management drs. Have tried everything and nothing else is working I’m tired of living this painful life everyday it causes me days of depression because I’m so sick of being in this much pain and to top it all off I was in a car accident and my neck and shoulders and back hurts even more I will be forwarding a email to Mr Broussard

Review: GEHA, [redacted] use [redacted] for approval of services such as physical therapy, pain management injections, etc. My Doctor office sent the information for approval of the services rendered by the Doctor. Orthonet, responded that they will not approve this procedures because the Doctor never sent the medical notes for review. Dr.[redacted] office advise me that all the document needed for this process were fax to this office. Ref number: [redacted]. The [redacted] Injection was done to treat constant back pain. I was referred to this office by my specialist to so I could get this treatment. The problem I find is that this office always look for some way to deny the claims. As it happened in the past with my daughter physical therapy needed due to a stress fracture on her leg. She have to stop going due to the denial. I called to find a solutions. Mr. [redacted] told me that this was the Medical reviewer decision and there was nothing else that can be done. I asked If I could get the Doctor to send the info again. Was told that the reviewer was done with it and the claim was not going to change. I asked if they follow up with the office and was told no. This is not their job. There is not need to ask for my other Doctors medical note. I was a referral. I depend on this insurance to take care of our claims. It is seem that this office always find a problem so they do not approve the claim.Desired Settlement: I am requesting this office to review this request and make sure that they are approved accordingly for the services so insurance can pay the percentage required. If more info is needed, Orthonet need to contact the Dr. office requesting the process to be approved. Due to their actions I should not be punished and been left hanging with a bill due to the lack of follow up with the Dr. office.

Consumer

Response:

At this time, I have not been contacted by [redacted] regarding complaint ID [redacted].

Sincerely,

Business

Response:

To whom it may concern:

Thank you for providing us with the opportunity to respond to this individual's concerns. As the individual stated,

his physician gave him a steroid injection

for back pain, for which he has sought coverage from his carrier

Government Employees Health

Association, Inc. (GEHA). GEHA,

a self­ insured non-profit association, is the nation's second

largest provider of health insurance

benefit plans to federal employees and retirees and their dependents. Please note that beyond what the patient himself

has disclosed, we are constrained by federal privacy

laws that prevent

us from disclosing additional information

about his condition, treatment, or healthcare coverage.

GEHA's

insurance contracts require

its members, or the member's

providers, to obtain prior authorization for ce11ain

services, including specified

pain procedures. When complied

with, this prior authorization process ensures

that both patients

and providers know in advance

whether proposed treatments are medically necessat)' covered

benefits that GEHA will reimburse.

GEHA

has retained [redacted]

to

provide these medical necessity

determinations, and every one of our pain-management decisions is made

by a licensed

healthcare professional under the supervision of a physician

medical director who is board ce11ified in an appropriate clinical specialty. 011h0Net's medical directors are experienced in pain

management and fully endorse the use of pain procedures when they are medically appropriate. But each year thousands of patients

receive spinal injections that predictably do nothing to alleviate their

pain, while exposing them to risks including infections, such as last year's situation in which hundreds

of

spine-injection patients suffered

after being injected

with bad serum. Utilization management reduces risks by minimizing patients' exposure to treatments they do not need or that will not work. A pa11icular benefit of01thoNet's prior authorization reviews

is that when our physicians have questions about

the medical appropriateness of a proposed

treatment, they can discuss the case with the treating

doctor to seek agreement on a medically

appropriate treatment plan that is in the patient's best interests.

In this case, as the patient indicates, his physician sought after-the-fact authorization for "services

rendered by the doctor," instead

of requesting the required prior (pre-service) approval. Many carriers would deny payment on this basis alone.

However, as a courtesy

to the member and provider,

GEHA would pay for the services,

despite the lack of prior authorization, if a retrospective (post-se1vice) review of information submitted by the provider demonstrated the services were medically necessary. In this case the minimal

information that the provider submitted

did not support a finding

of medical

necessity.

This patient

and the provider were informed

in writing of the reason for

the decision and the steps to take to have the decision

reconsidered. While [redacted]'s decisions are overwhelmingly upheld

on appeal,

the likelihood of an overturn

is enhanced when the patient's

physician gives the appeal panel more complete information than he or she submitted

to 01th0Net's physician reviewers.

The patient

appears to be unsure about how to verify that he received all of the insurance benefits

to which he is entitled under his contract

with GEHA. We suggest that he should

contact the GEHA's Customer Service

Depaitment, which can be reached

toll free at [redacted], Monday

through Friday from 8 a.m. to 6:30 p.m. Information on how to contact

GEHA is also listed on the patient's GEHA ID card and on the health

plan's website, geha.com.

Again, thank you for allowing us the chance

to respond to this individual's concern.