I’ve been absent for months fighting United Healthcare Insurance for the right to have a life, a life as normal as I can expect being a right below the knee amputee. This fight is for me, but it is also being used by me to inform and educate future amputees as well as amputees who are experiencing the same unethical and unacceptable behavior from insurance companies.
United Healthcare denied a prescription from my orthopedic doctor for a brand new K4 prosthetic system because the old prosthetic no longer fit properly as well, and this is the important reason why my orthopedic doctor wrote a new prescription….. I am no longer rated as a K2 amputee. On September 9th, 2019 I retook the AMP test which is designed to determine what level an amputee can function and what type of prosthetic that amputee “deserves” to have.
Back on April 17th, 2019 I took my very first K test, which is the AMP test. I passed that K test at a K2 level which meant I would get a basic barely functioning prosthetic because I didn’t score high enough to “deserve” a better and more technologically advanced prosthetic limb. Fast forward to September 9th, 2019 and all the hard work I did from April 17th to September 9th…..when I retook that AMP test and scored a K4 total score, up two levels, which meant I was now “deserving” of a new, technologically advanced, top notch prosthetic, which would include an Active Foot-Ankle Prosthesis.
See, the K2 foot was a fake rubber foot on a block of wood…….
Now lets take a gander at the K4 foot I am supposed to have since September 9th, when I became a K4 Tested amputee…..
Now allow me to explain the journey I’ve been on since September 9th, 2019. No wait…..lets take a look at the entire journey since January 31st, 2019 when I had my right below the knee amputation….THE TIMELINE….
January 31st, 2019…….Amputation.
February 4th, 2019………Discharged Home.
February 14th, 2019…..First Shrinker.
February 19th, 2019….Surgery Follow Up.
April 17th, 2019……AMP Testing…K2 result.
April 17th, 2019 ……..1st Prosthetic Casting.
May 2nd, 2019…..1st Prosthetic Fitting.
May 16th, 2019…..Home With Prosthetic.
May 16th, 2019……Using Crutches To Walk.
May 17th, 2019……Using Walker To Walk.
May 19th, 2019…..Using Cane To Walk.
May 21st, 2019……Walking On My Own.
May 30th, 2019….Prosthetic Adjustment.
June 19th, 2019…..Prosthetic Adjustment.
June 20th, 2019…..New Prosthetic Specialists.
June 27th, 2019…..Doctor Writes NEW Prosthesis Order.
July 3rd, 2019…..Casting For New 2nd Socket (Hanger)
July 15th, 2019….1st fitting for new socket (Hanger)
July 19th, 2019….picked up new 2nd socket (Hanger)
September 5th, 2019…..1st PT evaluation with Top Shape Gym.
September 9th, 2019….K Test ReTest….PCI PT.
September 9th, 2019…KTest results: Now A K4.
September 10th, 2019…1st ever PT session with Top Shape Gym.
September 18th, 2019….orthopedic doctor visit: new prosthetic order.
October 2nd, 9th, 16th……Hanger new prosthetic casting /fitting.
October 29th, 2019…… Denied new K4 Active Foot-Ankle Prosthesis by United Healthcare.
Now by any standard this recovery from amputation to walking unassisted by any and all mobile assist devices is remarkable…..which appears to be my problem. And here’s why……I healed very quickly. I never had any surgery complications. My amputation shrunk quickly. I was ready to have stitches removed quickly. I was on my first prosthetic very quickly. I was walking on my own with no walker, crutches or cane very quickly. You’d think this are all very good things to have happen.
Seems when a patient recovers tooooo fast, that patient throws a monkey wrench into the insurance works. See, insurance companies such as United Healthcare, have protocols and timelines THEY have determined must be used for ALL amputees. Being a quick healer, being a patient that has an agenda for getting his/her life back and is successful at accomplishing that agenda…..is NOT acceptable. I healed too fast. I walked too fast. I needed new sockets and prosthetic systems too fast.
Insurance companies like United Healthcare will only pay for a prosthetic foot once each year……UNLESS THE PATIENT ADVANCES TO A NEW K LEVEL (like I did) OR THE CURRENT FOOT BREAKS OR IS NO LONGER USABLE BY THE PATIENT. So United Healthcare has no right to deny me my new K4 Active Foot-Ankle Prosthesis…..
Unless…..the orthopedic doctor and the prosthetist both are bad at their jobs.
What exactly is a prosthetist you may ask…… A prosthetist also known as an orthotist is a trained health care professional that designs and measures medical supportive devices called prosthesis. A prosthesis is an artificial device that is used to replace a body part that may be missing, malfunctioning, or partially or completely damaged.
I use a prosthetic company named Hanger….
and my prosthetist at Hanger is Tim…..
Tim is very bad at his job…..and I am going to change my prosthetist very soon, but because Tim is incompetent at what he gets paid to do, I suffer. What my common sense tells me is this….Tim should have known submitting a new K test results to an insurance company would be an uphill battle, Tim should have suggested to me, “Let us here at Hanger submit a claim for a new socket, since this current socket is WAAAAAAAAAAAAAAY too big and it being this ill-fitting may cause your amputated limb to blister.” (which is exactly what is happening to me right now)
Because Tim never offered that suggestion, as my prosthetist, I’ve been wearing this ill fitting prosthesis since October 2nd, when I visited him for a new prosthetic system. I now am fighting to heal blisters on my amputated limb caused by the ill-fitting socket. Tim is also very bad at giving information and explaining his reasons to a first time amputee, like me, why he is doing what he does the way he does it.
Now to be fair not all Hanger employees are incompetent like Tim, the good Hanger employees are just not in the Cedar Rapids office….except for the receptionists, Ms. Amy. Ms. Amy greets all patients with a million kilowatt smile and is professional and kind. I also must commend Ms. Sarah, an insurance specialists in the Ames Hanger office who was visiting and filling in at the Iowa City Hanger office when I reached out to that Iowa City office for some advice and guidance.
Ms. Sarah was so informative in our exchange. Sarah told me about United Healthcare and how that insurance company is notorious for denying amputee claims for the express purpose of saving money. Ms. Sarah also guided me to several insurance companies that approved amputee claims like they should. Thank you Ms. Sarah.
Next lets move on to my orthopedic doctor, Dr James Huber….
Dr Huber is the orthopedic doctor who wrote my prosthetic orders to United Healthcare, and he did a very generic, bland, unspecific order writing job…..so much so was his laziness in writing these orders that needed to be very specific as to WHY I needed a complete prosthetic upgrade (Going from a K2 to a K4) that I can understand why United Healthcare just said no.
Dr Huber was so NOT specific as to why he requested United Healthcare pay for a new prosthetic system for me, that they explained to him that he should do it over and add an addendum to his original prescription.
Lastly, lets discuss United Healthcare…….
After being denied my K4 prosthetic system I got on the phone and called a prosthetic company in Florida, out of frustration, and talked to a lady whom gave me more information in that 20 minute conversation about insurance than anyone who is here in my city, ever offered about this entire insurance claim process.
Seems United Healthcare is notorious for denying claims for amputees if the claim is not perfectly filed and gives detailed reasons and descriptions as to what and why a claim is being submitted. The Lady in Florida who works as an insurance specialists for that Florida prosthetic company, told me she fights with United Healthcare ALL THE TIME over prosthetic claims.
I have arranged to meet with an insurance representative and change my carrier from United Healthcare to Aetna insurance.
Here’s what I was told about United Healthcare….this insurance company is not very concerned with approving an insurance claim if United Healthcare deems that claim to not be 1000% absolutely necessary…..by THEIR definition of “necessary.” Your doctor writing an order, especially if said order is not detailed or expressly specific, that doctors order will be denied. The important thing to understand about United Healthcare is: United Healthcare is far more concerned about their bottom line than helping customers who might need their claims approved in a timely fashion.
Finally…..United Healthcare is making my prosthetic company resubmit the claim for my K4 prosthesis as well as making my prosthetic company submit a separate claim for just the socket while the foot denial is being appealed… which means I am still wearing an ill-fitting prosthetic on my amputated limb….for over a month now, since September 9th…and it is now October 31st.
So…..this has been my battle since September 9th, if you may have wondered where I’ve been…..I’ve been in purgatory…..waiting to continue my journey from walking stupid with a prosthetic that does not fit, to wearing a prosthetic/socket that FITS….and allows me to go to the gym, and walk in/on uneven ground and finally, lets me rock climb or ride my bike.
Here’s a tip and some advice, NEVER IGNORE YOUR DIABETES. You’ll end up like me.