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LegalGems
LegalGems, Lawyer
Category: Consumer Protection Law
Satisfied Customers: 3457
Experience:  Research Attorney; Private Practice; Attorney Mentor; Mediator
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I am seeing a pain specialist for back pain.In April he recommended

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I am seeing a pain specialist for back pain.In April he recommended that I have a procedure called MILD.The authorization department was supposed to request authorization I waited for a phone call.However after approximately2 weeks.I called the office for an update. They informed me that the insurance company denied authorization. I called Physicians choice for instructions for filing an appeal. The physicians,choice representative told me that they had no record of receiving a request for authorization. She told me to have the doctor resubmit the request. I called the doctor's office numerous times with the same request. Finally the authorization staff told me that her supervisor would not permit her to submit the request because she read somewhere on line that Blue Cross deemed the procedure to be medically unnecessary.After 2 or 3 more calls from me they finally allowed me to make a fpllow-up appointment with the doctor. During that appointment I explained my dilemma to the doctor. He made some phone calls and learned that Blue Cross will authorize that procedure. Since it was late on Friday afternoon, he told me the authorization request would be to Physicians' Choice. I waited another two weeks then called the doctors authorization staff. They were rude and argumentative. They again said they would not submit the request because it would be denied.I begged for her help because my back pain is steadily worsening.I am losing sensation in my leg and foot.
At that point I was angry and frustrated. I couldn't understand how the doctor's office staff could have the right and authority to deny me necessary treatment,and effectively force me to endure continued worsening pain. I called the Santa Maria office and was finally able to speak with the office manager. The office manager informed the doctor of my situation. He called the San Luis office insisted that they submit the authorization request. The request was submitted on Tuesday and was approved on Wednesday. I am now scheduled for the procedure for August 5which was the earliest appointment available.
If the request had been submitted in April as expected. I would very likely be
living a back pain free life. Instead I am being forced to deal with almost 6 more weeks of pain which becomes so severe at times that I have to lie down for short periods throughout the work day or alternatively leave work early and take narcotic pain medication which has several very annoying side effects.
Diana the manager of the authorization department has not even had the courtesy of giving me a phone call.
Is there anything I can do from a legal standpoint.I believe that I have been denied my rights as a patient.
Char HillXXX@XXXXXX.XXX
XXX-XXX-XXXX
Submitted: 1 year ago.
Category: Consumer Protection Law
Expert:  LegalGems replied 1 year ago.

LegalGems :

Hi! LegalGems here. My goal: To Do My Best To Assist You. Please remember, I can only provide general information,as this is a public forum. I am very sorry to hear of this, as ongoing pain can be extremely difficult to deal with. Let me look into a few things.

LegalGems :

California's Health and Safety code governs Patient's rights, in addition to the contract between the patient, the insurance company, and the authorized provider. A few more minutes please.

LegalGems :

You can file a complaint against the doctor here: http://www.calpatientguide.org/vi.html. They will investigate and determine what administrative action should be taken.

LegalGems :

Here is the complaint form: http://www.dmhc.ca.gov/library/pc/multilang/complaintEN.pdf

LegalGems :

This form is for complaints against both providers and/or insurance companies.

LegalGems :

Here is the regulating agency that oversees complaints regarding doctors: http://www.mbc.ca.gov/consumer/complaint_info.html

LegalGems :

None of the above solutions will result in monetary compensation, however; but rather is focused on disciplinary action. If you are interested in monetary compensation for the additional delay, the option would be to file a lawsuit for medical malpractice, and negligence; based on the provider's agent's (office staff) negligent action in acting with due diligence in obtaining the necessary authorization for your procedure. Medical malpractice cases are very time consuming, and expensive (as expert witnesses are generally involved). You may, however, be able to find an attorney that will handle this on contingency; meaning the plaintiff/patient generally will not have to pay money unless a monetary judgment is obtained. Generally, the damages would include expenses incurred as a result of delay (i.e. additional pain pills, additional home care, lost wages) along with possible pain and suffering; and if malice is found, then sometimes punitive damages, so as to discourage this action by others.

LegalGems :

You mention you are in California, so I will link you to the state bar's referral page.

LegalGems :

It would be best to find an attorney that focuses primarily on medical malpractice cases, as they generally have a network of expert witnesses that can help accurately assess the situation.

LegalGems :

I see you are offline. If you have any questions on the above, please post them here and I will respond as soon as I see it. If you have no further questions, and I have answered your questions in a satisfactory manner, please consider rating my services positively as that is how I receive compensation for my services. Either way, I hope that you are able to resolve this in your favor, with minimal pain. Under the circumstances, you may want to see if the doctor will push your procedure up, so that you are not having to experience additional pain.

LegalGems, Lawyer
Satisfied Customers: 3457
Experience: Research Attorney; Private Practice; Attorney Mentor; Mediator
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