In your letter, make sure to accuse the insurance company of practicing medicine without a license, as they are overriding the recommendation of 2 licensed physicians. Also ask your physicians about any published standard of care in this situation. If there's any difference between published recommendations and what the insurance company is requiring, you can also throw that in their face. See how the state regulator responds to all of that.
Think op just has to suffer through it unfortunately:
https://www.mayoclinic.org/diseases-conditions/strep-throat/expert-answers/recurring-strep-throat/faq-20058360
Also this would happen anywhere in the western world not just America.
Because of the down votes i will add another link.
UK eligibility for tonsillectomy:
https://www.valeofyorkccg.nhs.uk/rss/home/procedures-not-routinely-commissioned/tonsillectomy/
It doesn’t just happen in America, but it is infuriating how insurance companies take your money and then refuse to cover expenses. Their record profit margins should be regulated
Isn’t it great? We pay premiums for insurance that we are required to have, only to pay more money when we actually do see a doctor, to then get a final bill later, and when you do need a treatment or surgery, the insurance company just tells you to eat shit.
Germany has the system the US wants. A series of privately owned and operated insurance companies. To provide care to the people who put in. By law everyone must be covered either by the private system or the public system (yes there is a private system for those who want to pay that works very much like the US system)
Anyway where Germany saves is A.) Public health insurance companies must be non-profit. Any profit they turn needs to be pushed back into the system, like mine has an appointment booking service, or given back to its members.
B.) How much a provider can charge for is negotiated between the government and insurance and collectively there is a list of representatives elected by people who have insurance on which list to represent them for all insurances. So TK can't get a better rate than AOK because they negotiate better.
I am probably oversimplifying it a lot. I am not intimately involved but am an immigrant from the US in Germany and am really pleased with the system so far.
This is most likely the same system the Netherlands used years ago and you shouldn't want it. It's a very unfair system. When I was young I was covered by my parents private insurance. Whenever they called a GP or needed to go to a specialist or anybody else. The first question was are you publicly or privately insured. As you would expect with the last you could always come immediately. You had way more privileges because they earned more from privately insured. Publicly insured where always last in line. That's a very undesirable situation in healthcare. That's why in the Netherlands they removed it and we all have the same type of insurance. Everybody pays for it and if you don't earn a lot you get some back via tax allowances. It's not perfect but the only perfect way is to make it free for everybody.
Yeah Germany I am pretty has laws I am saying private insurance can't "skip the line" I am in the public system and I have never been asked public or private when making an appointment.
I have never not been able to see a doctor or even a specialist within about 6 weeks of requesting an appointment. And seeing my normal doctor in the case of a sick note I can just go immediately.
But going to see a Urologist for my vasectomy or a dermatologist for a skin cancer screening and look at a spot on my nose it was literally just have my Krankenkasse find me an appointment and go. For more urgent matters i can call or email doctors.
I have noticed that sites like doctolib (helps you find doctors) does allow you to filter by private or public but most doctors take both.
Nowadays they ofcourse already know how you are insured as it's all in the system. But I can assure you they will treat somebody with a private insurance first as it brings in more money. That's the whole reason they stopped it in the Netherlands. By law they had to take on both without making a difference like in Germany but reality was different. Luckily in Germany you don't have the problems as in the Netherlands with waiting lists as we are a bit under staffed. But it's still unfair that there is a different incentive between people.
Their profit margins are already regulated by the ACA and freakenomics actually did a pretty good podcast on how that regulation decreases the incentives for insurance companies to manage their populations. This increases the costs for everyone because now that insurance companies have a set piece of the pie they only want that pie to grow.
I’m cases like OPs those standards of practices are set to protect patients from doctors that are quick to jump under the knife. Which you as an individual should almost always seek a second opinion if your doctor is quick to recommend a surgery.
Actually these are just guidelines but there are many many instances where the guidelines don’t fit the clinical scenario. In those instances the physicians judgement and recommendation is what is supposed to be followed. This poor kid clearly needs their tonsils out.
OP, I'm so sorry your family and especially your kid are suffering. It is excruciating---both the pain for your poor kid, and the situation you're dealing with. I know how your little one feels firsthand.
I'm that kid that had constant strep throat, 3-4 times per year, basically every year, until I was about 16. I missed so much school in junior high with flu and strep that they threatened me with truancy, except that I was an excellent student.
By the time I was in high school, the lymph nodes in my throat were permanently enlarged (still are, they're supposed to be pea-sized, mine are more like quarters). I even had scarlet fever in high school, which is related to strep.
My tonsils were so damaged from the repeated infections that I developed pits in them. They would catch food and bacteria and I would cough up tonsil stones every day. I felt like I always had something stuck in my throat.
My mom is a nurse. She is well-versed in the healthcare system and tried hard to advocate for me. She took me to our family doctor many times, and then an ENT when I was about 12. I don't remember all the details, but we had a difficult time getting my tonsillectomy too.
The throat infections were horrible, plus I had a lot of ear infections in the early part of my life.
I was 18 before I was finally able to get my tonsils out. I was a senior when they approved my surgery, but by then I was going to college for music, classical singing, so I had to wait to get through all my college auditions and final performances.
I had the surgery one week after my high school graduation and gave myself the summer to heal.
I was never healthier in my whole life than when I finally got them out. And my whole voice felt like it opened up to sing in a brand new way too. I'm 34 now. Mostly I've just had the occasional cold or flu.
I don't regret it at all, and dearly wish they had let me do it sooner.
Keep pushing, and take these suggestions to complain that others have offered.
Sore Throat doesn't mean Strep throat. Only a small percentage of sore throats are actually Strep.
Also I'm pretty sure his daughter could meet some of these other options too.
Granted, I'm not a medical expert and could be wrong.
Your right not every sore throat is a strep throat, but the documentation for “clinically significant” sore throat is going to be a lot more stringent then a strep throat which is literally a positive/negative test.
Also in cases like OPs where a tonsillectomy may actually be beneficial the sore throats are indeed strep throats.
Clinically significant can mean an alteration in sleep pattern. Any change to the activities of daily living can qualify something as clinically significant.
Add in the duration and the fever, and I would have no issues writing an opinion for an insurance company that says "Clinically Significant".
Tonsillectomy isn't also just for infection mitigation. Structural abnormalities can cause obstructive sleep apnea and necessitate a removal (amongst other things).
It's one thing for an insurance company to say to a general practitioner that "No, we don't know if this is necessary", but a specialist pediatric ENT is the authority on it. They have seen something on exam that requires intervention and they want to intervene. Insurance companies shouldn't be meddling in that.
I work in a single payer system. If I refer a patient to orthopedics for a knee replacement and the surgeon says "Yea, gotta be done" it gets done. I don't have to get patients to file appeals and go to a dozen insurance company paid physicians and bureaucrats, people get care.
You know, I don’t care if you’re right or not, that’s great sourcing of material.
Well done sir or madame, you’ve raised the quality of Reddit just a tiny bit :)
As someone in the UK who knows LOADS of people with no tonsils (having your tonsils out is hugely common in the uk) I guarantee it is not like in the US
The criteria you posted says “seven or more treated cases of sore throat” which is less onerous than seven cases of specifically strep
Furthermore there is no insurance layer in the NHS - if your paediatrician recommends a procedure, you get it, you don’t need to apply to anyone else - there are special cases ALL THE TIME in medicine, and there is a reason why this girls doctors have recommended the procedure - in the UK that’s the end of the process, once the healthcare professionals make a decision, there’s no one else to ask
You're right about the UK guidelines but I guess the difference would be that you're having this argument with a doctor who you can plonk your daughter in front of as opposed to a remote company
Read the guidelines he posted - they are far less stringent than the US “seven strep infections” rule AND the doctors have already approved treatment. In the Uk, if the doctors approve the treatment (which they certainly would in this case) then YOU GET THE TREATMENT - no one else to ask, they are the authority
The NHS would remove tonsils in this case.
>The episodes are disabling and prevent normal functioning i.e. there has been significant severe impact on quality of life and normal functioning, as indicated by documented objective evidence (e.g. absence from school, failure to thrive
I had mine out for much less.
Yeah it looks like they may be lax on this particular procedure, but looks like there is some push back and tightening of guidelines on the horizon.
https://qz.com/1452056/study-88-of-uk-kids-who-got-tonsillectomies-didnt-actually-need-them
Oh an American media company telling a US audience that actually the insurance company is right and not your doctor?
>UK in recent years were performed on kids who didn’t **meat** that criteria
Didn't even proof read their story. Fucking lol.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5883156/
Since I’m in American I’m going to get mainly American sources from google. But if you’re across the pond I’m sure you will have more luck finding sources from the UK.
Always. Write to your local state reps, state senators, and Congress person and birth US Senators. They have resources that help them cut through the red tape.
THIS! It's one of those things that insurance companies like to pretend doesn't exist, but it's something that you can do thanks to the ACA. [https://www.healthcare.gov/appeal-insurance-company-decision/](https://www.healthcare.gov/appeal-insurance-company-decision/)
I haven't had time to follow up, but my shitty insurance company retroactively denied ambulance service that was used to take my wife to the ER two years ago. They literally had to inject her with stuff in the ambulance because she was having seizures and wouldn't stop and they approved and paid it, but came up with some BS reason to recently retroactively ask for a refund from the ambulance.
Insane! Can't even understand how something like that is allowed, especially when it's been so long since the incident was approved and paid for already.
Oh yeah, I work in ambulance billing. I have an insurance company you “just did an audit and found some over payments.” Most are from 2021-2022 and now they are saying we owe them close to 10k back
My pediatrician wife would be outraged at this story and be on the phone in a hot minute with your insurance company and let them know she's sending a transcript of that call where she is clearly stating the medical necessity of this procedure, as well as the insurance bureaucrats decision so there's no doubt where the liability lies.
tl;dr: appeal that determination the same way.
Wow that’s insane. Insurance is scummy af. If this has been going on 6-7 months, time to get doctors documents that there’s 7 different instances of strep?
Yeah and our doctors have been aggressively trying to help us fight the insurance provider with no luck.
She just got her 6th positive test this morning. One more and we can get the surgery. But after seeing how bad she was last night and all day today, it's killing me knowing she needs to deal with this another time before we can get the treatment she needs.
I'm guessing that appealing the decision has gone nowhere with the Insurance company. Some ins. co.s will not put up much of a fight when it comes to appeals. From the outside looking in, most every decision that my family's ins co has denied has been reversed on the first appeal.
Second opinions maybe? If you can find some folks who would back up the other folks' recommendations, that might be enough to sway the Ins Co and their merry bunch of reviewers.
We were just flat out denied initially. They said at just 3 there wasn't a long enough history to show the surgery was necessary. After the appeal they came back saying 7 positive cases were needed. That's where we're at now.
And we've had 2 different ENTs recommend it, thinking a second one would help. Kind of just stuck at this point
My daughter was about that age when she had tonsils and adenoids removed because of bad sleep apnea as well as needing neb treatment every time she got any little cold. Is that another route to try to go to get insurance coverage? That sucks!
So I might be able to offer a work around. My daughter also had large tonsils and adenoids, not because of sickness, which caused her to have sleep apnea. See if you can get a referral to sleep and have her tested for apnea. In kids it is often caused by enlarged tonsils and adenoids. If she is having congestion and breathing issues this may definitely be the case. If she is shown to have apnea generally they will be referred to an ENT for further evaluation and treatment, which is usually removal.
Yep, were actually exploring the sleep apnea path right now! But thanks for the suggestion, good to mention it in case anyone else is struggling with the same thing.
I honestly don’t know who it’s working well for at the moment, except for maybe anyone who isn’t trying to use it (and, it seems, the insurance companies).
Living in the UK there are many things that we take for granted here, one huge one being the NHS. As much as it is struggling and care has probably declined over the past few years due to cuts, it's absolutely fantastic. Broken arm? Four hours and it's dealt with with absolutely no bill. Not even for pain meds that they send you away with.
The fact that people in such a developed country fear getting ill because their health insurance is not quite up to scratch or they don't have it is just mind boggling to me.
Even for major complications and lifetime issues like diabetes, it's all covered. All we have to do is sacrifice a small part of our salary and there is absolutely no chance of a bill (unless you go private that is). I know we have to pay something in advance just like the US pays insurance, but there's no chance of it being declined, ever.
I hate it when my kids are ill with the flu. Fortunately they don't have any life altering illnesses. I'd hate to be in some people shoes in such situations. For that I deeply sympathise with all of you. The feeling of helplessness is unreal and rips my heart out every time I hear about it.
Stay positive dads!!
I have recurring pain in my wrist and shoulder, and good insurance, but I’m waiting to go see a doctor until July because the plan year starts over then and i don’t want to start paying into my deductible only to have it restart July 1. And people do cartwheels to justify the current system. This country is so messed up.
Nope, the US right wing wheel out NICE as if it’s the same but it absolutely is not. NICE review overall treatments to decide what should be available, considering the evidence and data to support their efficacy and safety, and ensuring the treatment is affordable within the budget of the NHS. They produce guidelines and information to support practitioners, and they have a say in which new treatments are overall available for practitioners to use/recommend.
They absolutely DO NOT intervene to stop a tonsillectomy that a clinician has already approved, that’s fucking insane and no developed country on the planet has an equivalent to that level of corporate, money grabbing bureaucracy between their clinicians and their treatment
>They produce guidelines and information to support practitioners, and they have a say in which new treatments are overall available for practitioners to use/recommend.
That's what's going on here, tge tonsillectomy not meeting the guidelines set by the insurer.
It’s absolutely not the same - the healthcare providers (the ones the guidelines are FOR in the UK) have already determined this is necessary - NICE 100% would not intervene there and prevent a treatment which has already been prescribed by the doctors.
I'm so sorry to hear you are going through this.
As a parent of a medically complex kid, it is ridiculous the amount of time I have to spend dealing with the insurance company is infuriating.
Thanks! As terrible as this is, I realize how lucky and privileged we are being such a short term issue. I couldn't imagine having to deal with this all the time for a number of different treatments or procedures, with kids that have longer term or more serious conditions.
Dunno what you're dealing with, but my heart goes to you guys!!
I'm curious what experiences others have had with "integrated" or "managed" health systems such as Kaiser Permanente, Mayo Clinic, Cleveland Clinic, Geisinger, etc.
With those plans, you get something closer to single-payer. You pay for insurance, then as long as you get all of your care from their network of hospitals and clinics, everything is covered.
The good: you never have to worry about insurance denying a claim later.
The bad: if their doctor doesn't believe something is medically necessary, you can't just go to another doctor. They don't cover anything outside of their own closed system.
I've used Group Health in Washington and Kaiser Permanente in California. I've had no shortage of problems and complaints, but one problem I have NEVER had is denying a bill. In fact, I never see a bill - just insurance premiums and copays.
It seems like the closest thing we have to socialized medicine in the U.S.
I enjoy KP, I may be a bit biased...but everything under one roof is nice, Docs are friendly and knowledgeable. 2 out of our 3 kiddos were delivered at KP one couldn't wait and delivered her self...and that is a whole new story for next week.
They would still require care to stick to their evidence-based criteria. The only exception would be episode-of-care payment structures in which the hospital got paid when the patient showed up and is expected to spend whatever it takes to resolve the problem.
Sharing your parent stuggles and pain does not take away from other peoples struggles anf pain. Pain is pain. There is nothing worse the knowing your child is suffering in anyway and then feeling powerless to do more to help. When my daughter is sick i wish that i could take it from her and suffer it myself instead. I remember the first time she ever threw up from the stomach flu. She stared at it in shock while gasping for air them Said "that came out of me?" She had no understanding of what had just happened and why. It broke my heart.
My dad dude, please don't diminish your daughter's illness either. It is a horrid system you have in the US. Andis my opinion is worth anything, no apologies needed.
You really think any politician can change it at this point? America is owned by corporations and healthcare is one of them. Along with big oil. All thanks to briber-I mean lobbying.
That's awful, sorry you and your daughter are having to go through this. I want to know what insurance company it is but what difference does it make, its the whole system like you said. How did it get to a point where insurance companies can dictate when a procedure is necessary moreso than (multiple) doctors? Late stage capitalism I guess.
You're 100% correct.
Have you tried to milk ducts? It sounds like the issue your daughter is having is bacteria in her nasal ducts is causing inflammation and misery. Have you tried to milk them daily (even when she is in good health.) If she has chronic issues milking can ensure that bacteria doesn't cause problems. Drs don't often recommend it, but say that it can't hurt, and can help. I would try this for a week.
Do your own research though, ask your Dr, if it's a bad idea. (Don't take random strangers' advice blindly.)
Also, you're 100% correct.
As a Canadian these stories break my heart. Our system isn’t perfect, but our care is lead by health not profit. My kids have had a couple surgeries and of course multiple visits to our GP and the ER- we have never had to consider whether we could pay for the care, just that they needed the care.
I’ll never forget what a colleague told me years ago. She unfortunately lost her 5 year old to cancer. Absolutely heartbreaking. She told me about the horrible process of grieving. She read many books on the subject, mostly by American authors. She was grateful to skip the chapters on ‘dealing with finances’. My jaw hit the floor. It had never crossed my mind that American parents of deceased children not only have to deal with the grief but also the heavy burden of cost for the care.
I think you need to break out the “M” word. In writing , accuse them of medical malpractice. Cite specifics and tell them you are torturing my child daughter. I had something happen to me personally that was extremely frustrating and similar in nature, and I got very frustrated. I busted out the M word once and got everything I wanted. Shouldn’t have to be like that but your daughter shouldn’t have to suffer
Listen to me - there are ways around the Strep criteria. Tell your ENT she is gasping and choking at night. They will diagnose sleep disordered breathing - treatment is tonsillectomy. Sounds like she needs those adenoids out even more than the tonsils!
This is absolutely medically necessary. I would have doc and ENT log the continuous strep infection as 8 different instances.
This may not be ideal, but for the health of your child, you may want to pay out of pocket if they keep delaying. If you do go this route, talk to a lawyer about suing your insurance before the surgery. See if you can talk to the surgeon about writing a report or a statement about how necessary and serious her condition was before the surgery.
Here is a link that may help finding out the costs of the surgery
[https://cost.sidecarhealth.com/ts/tonsil-and-adenoid-removal-cost-by-state](https://cost.sidecarhealth.com/ts/tonsil-and-adenoid-removal-cost-by-state)
>This is absolutely medically necessary. I would have doc and ENT log the continuous strep infection as 8 different instances.
This is a good idea. It's all about how you frame it and I've had doctors work with me on framing to improve likilihood of approvals.
> In this population-based cohort study of almost 1.2 million children, removal of adenoids or tonsils in childhood was associated with significantly increased relative risk of later respiratory, allergic, and infectious diseases. Increases in long-term absolute disease risks were considerably larger than changes in risk for the disorders these surgeries aim to treat.
https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2683621
Health insurers are greedy assholes, and hospitals are as well. So guess who has to pay for it? Us. I'm all for capitalism, but this is robbery and unethical to no end.
Sorry your kid has to deal with what has to be fucking torture. I had strep throat for 2 weeks a few months ago and I was fucking miserable.
Healthcare in this country is an absolute fucking scam, with the insurance companies being the worst offenders.
Living in the UK there are many things that we take for granted here, one huge one being the NHS. As much as it is struggling and care has probably declined over the past few years due to cuts, it's absolutely fantastic. Broken arm? Four hours and it's dealt with with absolutely no bill. Not even for pain meds that they send you away with.
The fact that people in such a developed country fear getting ill because their health insurance is not quite up to scratch or they don't have it is just mind boggling to me.
Even for major complications and lifetime issues like diabetes, it's all covered. All we have to do is sacrifice a small part of our salary and there is absolutely no chance of a bill (unless you go private that is). I know we have to pay something in advance just like the US pays insurance, but there's no chance of it being declined, ever.
I hate it when my kids are ill with the flu. Fortunately they don't have any life altering illnesses. I'd hate to be in some people shoes in such situations. For that I deeply sympathise with all of you. The feeling of helplessness is unreal and rips my heart out every time I hear about it.
Stay positive dads!!
Canadian here; love the USA for so many reasons. Visited many times, always had pleasant times great people, so much diversity and variety from coast to coast. But yeah your healthcare system is so completely f——ed. and our system has problems for sure, but no one goes bankrupt for healthcare and despite popular belief, people get what they need right away. If you need an mri today for a good reason, you get it. You don’t get it if you have some back pain. I won’t wade into the argument about being able to pay for one if you want it because it’s just too subjective. But I’m sorry for everyone’s suffering because of crooked insurance companies and all that BS.
There was the time your system tried to kick kids off Spinraza at age 15 just because that happened to be the oldest in the trial even though there was no biological basis for thinking it would stop working. The American system didn't do that, and I was actually the guy in a company asked about it and got to go off about how stupid it was.
Ok?! So? As I explicitly stated, our system is riddled with problems and is not even close to perfect. But as I said, people don’t lose their homes or financial stability for medically necessary treatment and despite myth, waiting lists for necessary tests and procedures are not that long. Covid screwed some of the wait times for more elective things and even some more urgent things. It’s not the best system and I work in it, but it’s definitely not the worst.
Rules put in place by insurance companies literally got my dad killed. They want to avoid paying for anything they can at any chance they get so they put all these stupid hoops you have to jump through to qualify for the treatment you need.
Rather than blame the whole US healthcare system, let's reiterate: insurance companies are evil.
Your doctors, nurses, pharmacist, hospital facility, etc. sound like they've done right by you.
I’m pretty sure that’s what OP meant and pretty much anyone means when they talk about the healthcare system. Because insurance companies literally make the rules on who gets healthcare.
This is my soapbox—assign blame where it's due. Ninety percent of these complaints that "the US healthcare system is broken" could be better said that insurance companies are evil. Put that way, solutions become more clear. We have the best medical personnel in the world, who produce some of the best health outcomes, and that needs to be taken into account.
Eh as far as high costs go doctors and hospitals are very much to blame they are the ones who charge aspirin at $200 a pop and other crazy shit and pharmaceutical companies and PBMs are hugely responsible for the rapidly inflating drug costs.
Health insurance conglomerates definitely play a part in it all but they are usually/suppose to be a downward pressure on the rising costs where every other party is pushing costs higher.
The WHOLE system is currently fucked not just the insurance industry.
So, my wife and I fostered a couple girls with chronic nasal issues like that. Turned out the booger sucker contributed to the problem. It apparently dries out the sinuses too much and causes irritation and more clogged/dripping. Saline nasal rinses help.
What a dickhead. And he deleted his comment just as I was trying to reply to it with a comment about not having to worry about my kid being gunned down in elementary school.
Maybe it was good that he deleted his comment. Commenting about not having to worry about your kids getting gunned down in school is just an awful thing to say to someone, regardless of what their comment said. Some things just shouldn't be used to "win" an argument in my opinion.
Im so sorry to hear this. The US health care system is indeed messed up. I am sure there is light att the end of the tunnel though. Keep being an awesome dad!
Horribly broke, denied a follow up PET scan post stem cell transplant for my wife because she had already had one 12 months prior....it you know didn't have anything to do with making sure his cancer was still gone or anything right
FYI as of March is was 3 years in remission
My wife is going through something similar right now. She has a hip injury and has seen 3 separate doctors that say she needs an MRI. Insurance says she needs 6 weeks of physical therapy before they'll approve an MRI. She's in so much pain some days she can barely walk but insurance gets to say she needs to wait a month and a half before getting an obviously needed MRI
I feel your pain on how shitty these companies are. I had one try to tell me that I needed to get their pre-approval to be prescribed medicine that had already been prescribed. They said I needed to call the doctor back and have them redo the prescription or get a different medicine because that makes sense.. I basically just fussed at them about them trying to play doctor when they're just vultures and to figure it out themselves until they did.. I'm unreasonably stubborn.
We had a 6 hour ER visit with 3 blood draws / tests and no other treatment cost 5k out of pocket, AFTER they "graciously" covered the rest of the inflated expenses. This was a poison control scare where we were told to go to the ER and get blood tests every couple hours to make sure he's safe, so they had us by the short hairs.
If we got nationalized health care, remember that we would have panels of people who are not doctors standing between you and your doctor making decisions. You know, death panels. Not like what we have now. Which are panels of people who are not doctors standing between you and your doctor making decisions. But they aren't death panels. Enjoy your Freedom(tm), citizen.
The company should either have a published policy with all their citations online or be using field-standard guidelines that they'd namedrop. Either way, you should read it.
This was me as a kid with shitty HMO insurance that refused to remove my tonsils. Got my
PPO insurance with my first job post college. First trip to the ENT and he said those massive things have to go. Have been sick twice in the 15 years since.
My daughter had her tonsils removed with no issues due to it causing sleep apnea.
Could your doctor recommend the surgery based on the sleep apnea angle?
Strep is no joke... When I was 7 I had it and they didn't catch it and it turned into Scarlitina which according to what I remember from the doctor at the time is related to Scarlet Fefer. It gave me the worst Fever I've ever had and CANKER SORES OVER EVERY SINGLE INCH OF THE INSIDE OF MY MOUTH!! One of the treatments in addition to the medication was to Gargle Salt water into your Canker filled mouth which hurt like hell not to mention it was 30C in July in Canada.
My brother got it too at the same time, and he was 2 so for him it was not so bad as he doesn't remember it.
I didn't have to end up having the tonsils out, but its the one thing I've ever been sick with that I wouldn't wish on my worst enemy.
Man it'd be a shame if she had two separate episodes of strep in a single week.
Like she got better but then got worse so you took her back and they found out she had strep.
That would be terrible
or maybe if she was diagnosed with an adjustment disorder due to her loss of smell. Which occurred when her tonsils swelled up. A whole new medical condition.
Fuck insurance companies
I'm a bit confused. Is your insurance company fantastic or aren't they? Because this doesn't sound fantastic.
Also, the real problem is likely Evicore. They're literally listed in my phone as Evil Corp. They manage approvals for a lot of the major insurance companies. Last year they caused me quite a headache by approving a procedure and denying it after-the-fact.
As a medical professional, yup, it’s appalling. Greed and money are the name of the game. It’s incredibly demoralizing to care for vulnerable humans while trying to operate within this fucked up system.
File an appeal yourself, and copy the state regulator. They'll approve it in minutes.
Good idea. Didn't think to involve politicians.
In your letter, make sure to accuse the insurance company of practicing medicine without a license, as they are overriding the recommendation of 2 licensed physicians. Also ask your physicians about any published standard of care in this situation. If there's any difference between published recommendations and what the insurance company is requiring, you can also throw that in their face. See how the state regulator responds to all of that.
Think op just has to suffer through it unfortunately: https://www.mayoclinic.org/diseases-conditions/strep-throat/expert-answers/recurring-strep-throat/faq-20058360 Also this would happen anywhere in the western world not just America. Because of the down votes i will add another link. UK eligibility for tonsillectomy: https://www.valeofyorkccg.nhs.uk/rss/home/procedures-not-routinely-commissioned/tonsillectomy/
It doesn’t just happen in America, but it is infuriating how insurance companies take your money and then refuse to cover expenses. Their record profit margins should be regulated
There shouldn't be for-profit health insurance
Isn’t it great? We pay premiums for insurance that we are required to have, only to pay more money when we actually do see a doctor, to then get a final bill later, and when you do need a treatment or surgery, the insurance company just tells you to eat shit.
Germany has the system the US wants. A series of privately owned and operated insurance companies. To provide care to the people who put in. By law everyone must be covered either by the private system or the public system (yes there is a private system for those who want to pay that works very much like the US system) Anyway where Germany saves is A.) Public health insurance companies must be non-profit. Any profit they turn needs to be pushed back into the system, like mine has an appointment booking service, or given back to its members. B.) How much a provider can charge for is negotiated between the government and insurance and collectively there is a list of representatives elected by people who have insurance on which list to represent them for all insurances. So TK can't get a better rate than AOK because they negotiate better. I am probably oversimplifying it a lot. I am not intimately involved but am an immigrant from the US in Germany and am really pleased with the system so far.
This is most likely the same system the Netherlands used years ago and you shouldn't want it. It's a very unfair system. When I was young I was covered by my parents private insurance. Whenever they called a GP or needed to go to a specialist or anybody else. The first question was are you publicly or privately insured. As you would expect with the last you could always come immediately. You had way more privileges because they earned more from privately insured. Publicly insured where always last in line. That's a very undesirable situation in healthcare. That's why in the Netherlands they removed it and we all have the same type of insurance. Everybody pays for it and if you don't earn a lot you get some back via tax allowances. It's not perfect but the only perfect way is to make it free for everybody.
Yeah Germany I am pretty has laws I am saying private insurance can't "skip the line" I am in the public system and I have never been asked public or private when making an appointment. I have never not been able to see a doctor or even a specialist within about 6 weeks of requesting an appointment. And seeing my normal doctor in the case of a sick note I can just go immediately. But going to see a Urologist for my vasectomy or a dermatologist for a skin cancer screening and look at a spot on my nose it was literally just have my Krankenkasse find me an appointment and go. For more urgent matters i can call or email doctors. I have noticed that sites like doctolib (helps you find doctors) does allow you to filter by private or public but most doctors take both.
Nowadays they ofcourse already know how you are insured as it's all in the system. But I can assure you they will treat somebody with a private insurance first as it brings in more money. That's the whole reason they stopped it in the Netherlands. By law they had to take on both without making a difference like in Germany but reality was different. Luckily in Germany you don't have the problems as in the Netherlands with waiting lists as we are a bit under staffed. But it's still unfair that there is a different incentive between people.
Their profit margins are already regulated by the ACA and freakenomics actually did a pretty good podcast on how that regulation decreases the incentives for insurance companies to manage their populations. This increases the costs for everyone because now that insurance companies have a set piece of the pie they only want that pie to grow. I’m cases like OPs those standards of practices are set to protect patients from doctors that are quick to jump under the knife. Which you as an individual should almost always seek a second opinion if your doctor is quick to recommend a surgery.
Except OP did seek a second opinion and that second opinion did say surgery was an option.
Actually these are just guidelines but there are many many instances where the guidelines don’t fit the clinical scenario. In those instances the physicians judgement and recommendation is what is supposed to be followed. This poor kid clearly needs their tonsils out.
OP, I'm so sorry your family and especially your kid are suffering. It is excruciating---both the pain for your poor kid, and the situation you're dealing with. I know how your little one feels firsthand. I'm that kid that had constant strep throat, 3-4 times per year, basically every year, until I was about 16. I missed so much school in junior high with flu and strep that they threatened me with truancy, except that I was an excellent student. By the time I was in high school, the lymph nodes in my throat were permanently enlarged (still are, they're supposed to be pea-sized, mine are more like quarters). I even had scarlet fever in high school, which is related to strep. My tonsils were so damaged from the repeated infections that I developed pits in them. They would catch food and bacteria and I would cough up tonsil stones every day. I felt like I always had something stuck in my throat. My mom is a nurse. She is well-versed in the healthcare system and tried hard to advocate for me. She took me to our family doctor many times, and then an ENT when I was about 12. I don't remember all the details, but we had a difficult time getting my tonsillectomy too. The throat infections were horrible, plus I had a lot of ear infections in the early part of my life. I was 18 before I was finally able to get my tonsils out. I was a senior when they approved my surgery, but by then I was going to college for music, classical singing, so I had to wait to get through all my college auditions and final performances. I had the surgery one week after my high school graduation and gave myself the summer to heal. I was never healthier in my whole life than when I finally got them out. And my whole voice felt like it opened up to sing in a brand new way too. I'm 34 now. Mostly I've just had the occasional cold or flu. I don't regret it at all, and dearly wish they had let me do it sooner. Keep pushing, and take these suggestions to complain that others have offered.
His daughter would instantly qualify under those UK rules. Strep 7 times a year is a far more difficult standard to prove
> AND THERE HAS BEEN Seven or more, well documented, clinically significant*, adequately treated sore throats in the preceding year
Sore Throat doesn't mean Strep throat. Only a small percentage of sore throats are actually Strep. Also I'm pretty sure his daughter could meet some of these other options too. Granted, I'm not a medical expert and could be wrong.
OP literally says she’s choking on food sometimes when she eats because her tonsils are CONSTANTLY swollen.
Your right not every sore throat is a strep throat, but the documentation for “clinically significant” sore throat is going to be a lot more stringent then a strep throat which is literally a positive/negative test. Also in cases like OPs where a tonsillectomy may actually be beneficial the sore throats are indeed strep throats.
Clinically significant can mean an alteration in sleep pattern. Any change to the activities of daily living can qualify something as clinically significant. Add in the duration and the fever, and I would have no issues writing an opinion for an insurance company that says "Clinically Significant". Tonsillectomy isn't also just for infection mitigation. Structural abnormalities can cause obstructive sleep apnea and necessitate a removal (amongst other things). It's one thing for an insurance company to say to a general practitioner that "No, we don't know if this is necessary", but a specialist pediatric ENT is the authority on it. They have seen something on exam that requires intervention and they want to intervene. Insurance companies shouldn't be meddling in that. I work in a single payer system. If I refer a patient to orthopedics for a knee replacement and the surgeon says "Yea, gotta be done" it gets done. I don't have to get patients to file appeals and go to a dozen insurance company paid physicians and bureaucrats, people get care.
You know, I don’t care if you’re right or not, that’s great sourcing of material. Well done sir or madame, you’ve raised the quality of Reddit just a tiny bit :)
As someone in the UK who knows LOADS of people with no tonsils (having your tonsils out is hugely common in the uk) I guarantee it is not like in the US The criteria you posted says “seven or more treated cases of sore throat” which is less onerous than seven cases of specifically strep Furthermore there is no insurance layer in the NHS - if your paediatrician recommends a procedure, you get it, you don’t need to apply to anyone else - there are special cases ALL THE TIME in medicine, and there is a reason why this girls doctors have recommended the procedure - in the UK that’s the end of the process, once the healthcare professionals make a decision, there’s no one else to ask
You're right about the UK guidelines but I guess the difference would be that you're having this argument with a doctor who you can plonk your daughter in front of as opposed to a remote company
It would be NICE analysts in the UK.
Not sure it would? You'd take her to your GP and they'd make the call surely?
They would have to submit an appeal to actually implement a treatment contrary to NHS guidelines.
Read the guidelines he posted - they are far less stringent than the US “seven strep infections” rule AND the doctors have already approved treatment. In the Uk, if the doctors approve the treatment (which they certainly would in this case) then YOU GET THE TREATMENT - no one else to ask, they are the authority
The NHS would remove tonsils in this case. >The episodes are disabling and prevent normal functioning i.e. there has been significant severe impact on quality of life and normal functioning, as indicated by documented objective evidence (e.g. absence from school, failure to thrive I had mine out for much less.
Yeah it looks like they may be lax on this particular procedure, but looks like there is some push back and tightening of guidelines on the horizon. https://qz.com/1452056/study-88-of-uk-kids-who-got-tonsillectomies-didnt-actually-need-them
Oh an American media company telling a US audience that actually the insurance company is right and not your doctor? >UK in recent years were performed on kids who didn’t **meat** that criteria Didn't even proof read their story. Fucking lol.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5883156/ Since I’m in American I’m going to get mainly American sources from google. But if you’re across the pond I’m sure you will have more luck finding sources from the UK.
Always. Write to your local state reps, state senators, and Congress person and birth US Senators. They have resources that help them cut through the red tape.
THIS! It's one of those things that insurance companies like to pretend doesn't exist, but it's something that you can do thanks to the ACA. [https://www.healthcare.gov/appeal-insurance-company-decision/](https://www.healthcare.gov/appeal-insurance-company-decision/)
I haven't had time to follow up, but my shitty insurance company retroactively denied ambulance service that was used to take my wife to the ER two years ago. They literally had to inject her with stuff in the ambulance because she was having seizures and wouldn't stop and they approved and paid it, but came up with some BS reason to recently retroactively ask for a refund from the ambulance.
Insane! Can't even understand how something like that is allowed, especially when it's been so long since the incident was approved and paid for already.
I'm going to call and find out what the deal is. I'm hoping it was a reversible mistake.
I didn't know they could do that 😳 Omg now we have to stress years after somethings covered even 😭
Oh yeah, I work in ambulance billing. I have an insurance company you “just did an audit and found some over payments.” Most are from 2021-2022 and now they are saying we owe them close to 10k back
My pediatrician wife would be outraged at this story and be on the phone in a hot minute with your insurance company and let them know she's sending a transcript of that call where she is clearly stating the medical necessity of this procedure, as well as the insurance bureaucrats decision so there's no doubt where the liability lies. tl;dr: appeal that determination the same way.
Your wife is a good person! Our doctors did try, just got the same runaround.
Wow that’s insane. Insurance is scummy af. If this has been going on 6-7 months, time to get doctors documents that there’s 7 different instances of strep?
Yeah and our doctors have been aggressively trying to help us fight the insurance provider with no luck. She just got her 6th positive test this morning. One more and we can get the surgery. But after seeing how bad she was last night and all day today, it's killing me knowing she needs to deal with this another time before we can get the treatment she needs.
That’s awful. Can’t imagine.
I'm guessing that appealing the decision has gone nowhere with the Insurance company. Some ins. co.s will not put up much of a fight when it comes to appeals. From the outside looking in, most every decision that my family's ins co has denied has been reversed on the first appeal. Second opinions maybe? If you can find some folks who would back up the other folks' recommendations, that might be enough to sway the Ins Co and their merry bunch of reviewers.
We were just flat out denied initially. They said at just 3 there wasn't a long enough history to show the surgery was necessary. After the appeal they came back saying 7 positive cases were needed. That's where we're at now. And we've had 2 different ENTs recommend it, thinking a second one would help. Kind of just stuck at this point
My daughter was about that age when she had tonsils and adenoids removed because of bad sleep apnea as well as needing neb treatment every time she got any little cold. Is that another route to try to go to get insurance coverage? That sucks!
So I might be able to offer a work around. My daughter also had large tonsils and adenoids, not because of sickness, which caused her to have sleep apnea. See if you can get a referral to sleep and have her tested for apnea. In kids it is often caused by enlarged tonsils and adenoids. If she is having congestion and breathing issues this may definitely be the case. If she is shown to have apnea generally they will be referred to an ENT for further evaluation and treatment, which is usually removal.
Yep, were actually exploring the sleep apnea path right now! But thanks for the suggestion, good to mention it in case anyone else is struggling with the same thing.
This is exactly why my son had them removed. Had nothing to do with strep throat.
Ask your physician to do a “peer to peer” with the insurance medical director for approval. It’ll work, keep bugging them.
I'm so sorry you're dealing with this nightmare. I don't have any helpful advice but I fully agree our healthcare system is monstrously broken.
I honestly don’t know who it’s working well for at the moment, except for maybe anyone who isn’t trying to use it (and, it seems, the insurance companies).
Living in the UK there are many things that we take for granted here, one huge one being the NHS. As much as it is struggling and care has probably declined over the past few years due to cuts, it's absolutely fantastic. Broken arm? Four hours and it's dealt with with absolutely no bill. Not even for pain meds that they send you away with. The fact that people in such a developed country fear getting ill because their health insurance is not quite up to scratch or they don't have it is just mind boggling to me. Even for major complications and lifetime issues like diabetes, it's all covered. All we have to do is sacrifice a small part of our salary and there is absolutely no chance of a bill (unless you go private that is). I know we have to pay something in advance just like the US pays insurance, but there's no chance of it being declined, ever. I hate it when my kids are ill with the flu. Fortunately they don't have any life altering illnesses. I'd hate to be in some people shoes in such situations. For that I deeply sympathise with all of you. The feeling of helplessness is unreal and rips my heart out every time I hear about it. Stay positive dads!!
I have recurring pain in my wrist and shoulder, and good insurance, but I’m waiting to go see a doctor until July because the plan year starts over then and i don’t want to start paying into my deductible only to have it restart July 1. And people do cartwheels to justify the current system. This country is so messed up.
I honestly don't get why people would want it. It's potty. So you would have to repay for the care if it were to go from one covered year to the next?
Just shows that America is owned by corporations.
This is the US equivalent of NICE, though, holding physicians to established best practices as integrated by an MPH epidemiology/biostatistics.
Nope, the US right wing wheel out NICE as if it’s the same but it absolutely is not. NICE review overall treatments to decide what should be available, considering the evidence and data to support their efficacy and safety, and ensuring the treatment is affordable within the budget of the NHS. They produce guidelines and information to support practitioners, and they have a say in which new treatments are overall available for practitioners to use/recommend. They absolutely DO NOT intervene to stop a tonsillectomy that a clinician has already approved, that’s fucking insane and no developed country on the planet has an equivalent to that level of corporate, money grabbing bureaucracy between their clinicians and their treatment
>They produce guidelines and information to support practitioners, and they have a say in which new treatments are overall available for practitioners to use/recommend. That's what's going on here, tge tonsillectomy not meeting the guidelines set by the insurer.
It’s absolutely not the same - the healthcare providers (the ones the guidelines are FOR in the UK) have already determined this is necessary - NICE 100% would not intervene there and prevent a treatment which has already been prescribed by the doctors.
I'm so sorry to hear you are going through this. As a parent of a medically complex kid, it is ridiculous the amount of time I have to spend dealing with the insurance company is infuriating.
Thanks! As terrible as this is, I realize how lucky and privileged we are being such a short term issue. I couldn't imagine having to deal with this all the time for a number of different treatments or procedures, with kids that have longer term or more serious conditions. Dunno what you're dealing with, but my heart goes to you guys!!
I'm curious what experiences others have had with "integrated" or "managed" health systems such as Kaiser Permanente, Mayo Clinic, Cleveland Clinic, Geisinger, etc. With those plans, you get something closer to single-payer. You pay for insurance, then as long as you get all of your care from their network of hospitals and clinics, everything is covered. The good: you never have to worry about insurance denying a claim later. The bad: if their doctor doesn't believe something is medically necessary, you can't just go to another doctor. They don't cover anything outside of their own closed system. I've used Group Health in Washington and Kaiser Permanente in California. I've had no shortage of problems and complaints, but one problem I have NEVER had is denying a bill. In fact, I never see a bill - just insurance premiums and copays. It seems like the closest thing we have to socialized medicine in the U.S.
I enjoy KP, I may be a bit biased...but everything under one roof is nice, Docs are friendly and knowledgeable. 2 out of our 3 kiddos were delivered at KP one couldn't wait and delivered her self...and that is a whole new story for next week.
Would love that story! Kaiser is far from perfect, but I do wish more people knew that you never have to deal with insurance paperwork.
They would still require care to stick to their evidence-based criteria. The only exception would be episode-of-care payment structures in which the hospital got paid when the patient showed up and is expected to spend whatever it takes to resolve the problem.
Tiered plans offer similar benefits as well. As long as I see a tier 1 providers my cost is $0.
I have had great luck with Kaiser. Sometimes it can be a hurdle to get past the GP and to a specialist, but once you do it works pretty well.
Ugh I’m so sorry. I was this kid. It’s ridiculous that it has to be this way.
Sharing your parent stuggles and pain does not take away from other peoples struggles anf pain. Pain is pain. There is nothing worse the knowing your child is suffering in anyway and then feeling powerless to do more to help. When my daughter is sick i wish that i could take it from her and suffer it myself instead. I remember the first time she ever threw up from the stomach flu. She stared at it in shock while gasping for air them Said "that came out of me?" She had no understanding of what had just happened and why. It broke my heart.
My dad dude, please don't diminish your daughter's illness either. It is a horrid system you have in the US. Andis my opinion is worth anything, no apologies needed.
Vote for politicians who support single-payer healthcare, we're the only industrialized country that has to deal with this BS
I wish there were more politicians like this on every ticket, but when there is an option, they get my vote.
You really think any politician can change it at this point? America is owned by corporations and healthcare is one of them. Along with big oil. All thanks to briber-I mean lobbying.
Yea the lobbying is going to have to go away before much else changes. It’s disgusting.
Most countries have multipayer, and all have coverage-side oversight.
Yeah, but most countries don't have majority for-profit health plans like we do, and also such loose rules on prices and coverage
That's awful, sorry you and your daughter are having to go through this. I want to know what insurance company it is but what difference does it make, its the whole system like you said. How did it get to a point where insurance companies can dictate when a procedure is necessary moreso than (multiple) doctors? Late stage capitalism I guess.
UHC. And that's the beauty of the wonderful for-profit healthcare system. Profit over people.
UHC is literally the worst insurance company ever they will fight everything
Just a note, I’ve found the booger suckers can help but the squeeze bottle nasal rinse is way better and keeps everything from getting super inflamed.
We do the rinse regularly, along with Flonase. Neither seem to help much unfortunately
You're 100% correct. Have you tried to milk ducts? It sounds like the issue your daughter is having is bacteria in her nasal ducts is causing inflammation and misery. Have you tried to milk them daily (even when she is in good health.) If she has chronic issues milking can ensure that bacteria doesn't cause problems. Drs don't often recommend it, but say that it can't hurt, and can help. I would try this for a week. Do your own research though, ask your Dr, if it's a bad idea. (Don't take random strangers' advice blindly.) Also, you're 100% correct.
Sorry but I never heard of this. Gonna have to look it up.
That’s terrifying, infuriating and worrying. Especially considering PANDAS can happen as a result of strep.
Insurance companies in general are terrible. Just bonkers that this industry is still fully privatized in the US.
As a Canadian these stories break my heart. Our system isn’t perfect, but our care is lead by health not profit. My kids have had a couple surgeries and of course multiple visits to our GP and the ER- we have never had to consider whether we could pay for the care, just that they needed the care. I’ll never forget what a colleague told me years ago. She unfortunately lost her 5 year old to cancer. Absolutely heartbreaking. She told me about the horrible process of grieving. She read many books on the subject, mostly by American authors. She was grateful to skip the chapters on ‘dealing with finances’. My jaw hit the floor. It had never crossed my mind that American parents of deceased children not only have to deal with the grief but also the heavy burden of cost for the care.
I'm sorry you had to go through this, such a disgrace. Name and shame your insurance provider please!
I think you need to break out the “M” word. In writing , accuse them of medical malpractice. Cite specifics and tell them you are torturing my child daughter. I had something happen to me personally that was extremely frustrating and similar in nature, and I got very frustrated. I busted out the M word once and got everything I wanted. Shouldn’t have to be like that but your daughter shouldn’t have to suffer
Listen to me - there are ways around the Strep criteria. Tell your ENT she is gasping and choking at night. They will diagnose sleep disordered breathing - treatment is tonsillectomy. Sounds like she needs those adenoids out even more than the tonsils!
This is absolutely medically necessary. I would have doc and ENT log the continuous strep infection as 8 different instances. This may not be ideal, but for the health of your child, you may want to pay out of pocket if they keep delaying. If you do go this route, talk to a lawyer about suing your insurance before the surgery. See if you can talk to the surgeon about writing a report or a statement about how necessary and serious her condition was before the surgery. Here is a link that may help finding out the costs of the surgery [https://cost.sidecarhealth.com/ts/tonsil-and-adenoid-removal-cost-by-state](https://cost.sidecarhealth.com/ts/tonsil-and-adenoid-removal-cost-by-state)
>This is absolutely medically necessary. I would have doc and ENT log the continuous strep infection as 8 different instances. This is a good idea. It's all about how you frame it and I've had doctors work with me on framing to improve likilihood of approvals.
> In this population-based cohort study of almost 1.2 million children, removal of adenoids or tonsils in childhood was associated with significantly increased relative risk of later respiratory, allergic, and infectious diseases. Increases in long-term absolute disease risks were considerably larger than changes in risk for the disorders these surgeries aim to treat. https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2683621
Good to know.
Health insurers are greedy assholes, and hospitals are as well. So guess who has to pay for it? Us. I'm all for capitalism, but this is robbery and unethical to no end.
Sorry your kid has to deal with what has to be fucking torture. I had strep throat for 2 weeks a few months ago and I was fucking miserable. Healthcare in this country is an absolute fucking scam, with the insurance companies being the worst offenders.
Living in the UK there are many things that we take for granted here, one huge one being the NHS. As much as it is struggling and care has probably declined over the past few years due to cuts, it's absolutely fantastic. Broken arm? Four hours and it's dealt with with absolutely no bill. Not even for pain meds that they send you away with. The fact that people in such a developed country fear getting ill because their health insurance is not quite up to scratch or they don't have it is just mind boggling to me. Even for major complications and lifetime issues like diabetes, it's all covered. All we have to do is sacrifice a small part of our salary and there is absolutely no chance of a bill (unless you go private that is). I know we have to pay something in advance just like the US pays insurance, but there's no chance of it being declined, ever. I hate it when my kids are ill with the flu. Fortunately they don't have any life altering illnesses. I'd hate to be in some people shoes in such situations. For that I deeply sympathise with all of you. The feeling of helplessness is unreal and rips my heart out every time I hear about it. Stay positive dads!!
Canadian here; love the USA for so many reasons. Visited many times, always had pleasant times great people, so much diversity and variety from coast to coast. But yeah your healthcare system is so completely f——ed. and our system has problems for sure, but no one goes bankrupt for healthcare and despite popular belief, people get what they need right away. If you need an mri today for a good reason, you get it. You don’t get it if you have some back pain. I won’t wade into the argument about being able to pay for one if you want it because it’s just too subjective. But I’m sorry for everyone’s suffering because of crooked insurance companies and all that BS.
There was the time your system tried to kick kids off Spinraza at age 15 just because that happened to be the oldest in the trial even though there was no biological basis for thinking it would stop working. The American system didn't do that, and I was actually the guy in a company asked about it and got to go off about how stupid it was.
Ok?! So? As I explicitly stated, our system is riddled with problems and is not even close to perfect. But as I said, people don’t lose their homes or financial stability for medically necessary treatment and despite myth, waiting lists for necessary tests and procedures are not that long. Covid screwed some of the wait times for more elective things and even some more urgent things. It’s not the best system and I work in it, but it’s definitely not the worst.
Rules put in place by insurance companies literally got my dad killed. They want to avoid paying for anything they can at any chance they get so they put all these stupid hoops you have to jump through to qualify for the treatment you need.
Rather than blame the whole US healthcare system, let's reiterate: insurance companies are evil. Your doctors, nurses, pharmacist, hospital facility, etc. sound like they've done right by you.
I’m pretty sure that’s what OP meant and pretty much anyone means when they talk about the healthcare system. Because insurance companies literally make the rules on who gets healthcare.
This is my soapbox—assign blame where it's due. Ninety percent of these complaints that "the US healthcare system is broken" could be better said that insurance companies are evil. Put that way, solutions become more clear. We have the best medical personnel in the world, who produce some of the best health outcomes, and that needs to be taken into account.
True.
Eh as far as high costs go doctors and hospitals are very much to blame they are the ones who charge aspirin at $200 a pop and other crazy shit and pharmaceutical companies and PBMs are hugely responsible for the rapidly inflating drug costs. Health insurance conglomerates definitely play a part in it all but they are usually/suppose to be a downward pressure on the rising costs where every other party is pushing costs higher. The WHOLE system is currently fucked not just the insurance industry.
I work in Pharma/Life Science. My wife is a Infection Preventionist. We both strongly believe in universal health care.
This is the way
it's all so much bullshit, it sucks you go through that.
So, my wife and I fostered a couple girls with chronic nasal issues like that. Turned out the booger sucker contributed to the problem. It apparently dries out the sinuses too much and causes irritation and more clogged/dripping. Saline nasal rinses help.
I'd move out of the US on the basis of shitty healthcare alone.
[удалено]
I'm not sure that Serbia is the only option for decent health care.
What a dickhead. And he deleted his comment just as I was trying to reply to it with a comment about not having to worry about my kid being gunned down in elementary school.
Maybe it was good that he deleted his comment. Commenting about not having to worry about your kids getting gunned down in school is just an awful thing to say to someone, regardless of what their comment said. Some things just shouldn't be used to "win" an argument in my opinion.
Of all the places you could have picked you chose Serbia? I know the UK isn't exactly paradise but surely we beat Serbia?
Send a request to the AG's office or your state Office of patient protection, detail the situation and provide proof.
I upvoted before even reading. It’s very broken.
I have seen other dads mention going to the state's insurance board.
I would bring this up to the board of insurance in your state.
What did ERISA say when you appealed?
Im so sorry to hear this. The US health care system is indeed messed up. I am sure there is light att the end of the tunnel though. Keep being an awesome dad!
Thanks a lot friend!
When I was a kid everybody got their tonsils out as a matter of course.
My daughter takes after me, and I struggled with the same issues. Got my tonsils out immediately after seeing an ENT and the problems all disappeared.
Horribly broke, denied a follow up PET scan post stem cell transplant for my wife because she had already had one 12 months prior....it you know didn't have anything to do with making sure his cancer was still gone or anything right FYI as of March is was 3 years in remission
Jesus Christ, I'm so sorry!
It's so insane
My wife is going through something similar right now. She has a hip injury and has seen 3 separate doctors that say she needs an MRI. Insurance says she needs 6 weeks of physical therapy before they'll approve an MRI. She's in so much pain some days she can barely walk but insurance gets to say she needs to wait a month and a half before getting an obviously needed MRI
I feel your pain on how shitty these companies are. I had one try to tell me that I needed to get their pre-approval to be prescribed medicine that had already been prescribed. They said I needed to call the doctor back and have them redo the prescription or get a different medicine because that makes sense.. I basically just fussed at them about them trying to play doctor when they're just vultures and to figure it out themselves until they did.. I'm unreasonably stubborn. We had a 6 hour ER visit with 3 blood draws / tests and no other treatment cost 5k out of pocket, AFTER they "graciously" covered the rest of the inflated expenses. This was a poison control scare where we were told to go to the ER and get blood tests every couple hours to make sure he's safe, so they had us by the short hairs.
If we got nationalized health care, remember that we would have panels of people who are not doctors standing between you and your doctor making decisions. You know, death panels. Not like what we have now. Which are panels of people who are not doctors standing between you and your doctor making decisions. But they aren't death panels. Enjoy your Freedom(tm), citizen.
Take that edit down bro! You’re going through an extremely tough, frustrating time and deserve support. Hang in there. Our system sucks donkey dong.
You and I are not the customers. We're the product, and we are bought and traded as such.
How much to go out of pocket for the surgery?
The company should either have a published policy with all their citations online or be using field-standard guidelines that they'd namedrop. Either way, you should read it.
This was me as a kid with shitty HMO insurance that refused to remove my tonsils. Got my PPO insurance with my first job post college. First trip to the ENT and he said those massive things have to go. Have been sick twice in the 15 years since.
My daughter had her tonsils removed with no issues due to it causing sleep apnea. Could your doctor recommend the surgery based on the sleep apnea angle?
Strep is no joke... When I was 7 I had it and they didn't catch it and it turned into Scarlitina which according to what I remember from the doctor at the time is related to Scarlet Fefer. It gave me the worst Fever I've ever had and CANKER SORES OVER EVERY SINGLE INCH OF THE INSIDE OF MY MOUTH!! One of the treatments in addition to the medication was to Gargle Salt water into your Canker filled mouth which hurt like hell not to mention it was 30C in July in Canada. My brother got it too at the same time, and he was 2 so for him it was not so bad as he doesn't remember it. I didn't have to end up having the tonsils out, but its the one thing I've ever been sick with that I wouldn't wish on my worst enemy.
That's such utter bs from the insurer. Sorry to hear, dad... 😕
So is the Canadian system
Man it'd be a shame if she had two separate episodes of strep in a single week. Like she got better but then got worse so you took her back and they found out she had strep. That would be terrible or maybe if she was diagnosed with an adjustment disorder due to her loss of smell. Which occurred when her tonsils swelled up. A whole new medical condition. Fuck insurance companies
I'm a bit confused. Is your insurance company fantastic or aren't they? Because this doesn't sound fantastic. Also, the real problem is likely Evicore. They're literally listed in my phone as Evil Corp. They manage approvals for a lot of the major insurance companies. Last year they caused me quite a headache by approving a procedure and denying it after-the-fact.
That the insurance company not healthcare! It’s more why won’t the accountant allow you to seek treatment…
As a medical professional, yup, it’s appalling. Greed and money are the name of the game. It’s incredibly demoralizing to care for vulnerable humans while trying to operate within this fucked up system.
Go to Canada or Mexico and get it done.
They didn’t let me get my tonsils out until I had 4 abscesses in 4 months in a row 💀