[ddfjk]

I have been seeing an orthopedic for around 2 years for my lower back and recently had a work related injury to my neck. I was treated for soft tissue but had an MRI done. The MRI showed some degenerative changes and a bulging disk but no new injuries from my accident. So the work comp doc said I could see my ortho for the pre existing issues. Report showed bulging disk and encroachment and some other degenerative changes. My insurance caught wind of the work related injury and is now denying all my visits to my personal ortho. When dealing with someone at my doctors office, I was asking many questions on how to deal with this and placed many calls to the insurance and doctors office to talk with this one specific person. I'll admid I ask to many questions at times but was trying to get all my ducks in a row to deal with this asking about what the work comp and personal insurance companies will do and I may have asked to many questions and may have looked a bit guilty in hindsight. But she scared me when she brought up fraud. I changed the subject and went on. She said the insurance companies would investigate if they suspected fruad and she told me she pulled my file to check a couple of things but she did mention that in the doc notes he said my I may have aggrevated pre-existing issues. So I'm hoping she would see I have issues. I know I havent' done anything wrong because there are objective findings for my lower back and neck issues but that word scares me and wanted to know if anyone knows what would have to happen for her to say something to the doc or if she had enough evidence other than a couple of questions or comments about fraud to be able to do anything. I'm hoping she was having a bad day and I know I was annoying her with all my calls and questions but is that enough to start something? Thanks for any help you can provide.

[shygrneyzs]

If your insurance company is already onto this, they will pursue this with worker's comp and your doctor. You hurt yourself at work and say you can verify that. Worker's Comp will do their best to not pay. They will use any reason possible. You know Worker's Comp. It is an agency that should be disbanded and then rebuilt. Maybe then they could serve the injured worker.

It might serve you well to talk to an attorney who specialized in work related injuries. If your insurance deems this as fraud, you will need to fight it. Your doctor will need his attorney too.

[talaniman]

All insurance companies try not to pay, or pay the least amount. Don't let this scare tactic fool you, the still have to process your claims and that is your doctors job to provide substantiation for any and all treatments. Just continue through the process. It takes time.

[ddfjk]

Thanks for the answer but I probably wasn't clear on some things. My personal insurance has already denied the ortho visits dealing with my neck. What happenend is when I went to the ER for my work related neck injury, the hospital messed up and billed my personal insurance. Once I found out, I helped my personal insurance correct the billing problems and got Work comp to pay those bills which they did with no problem. Well, after I was treated and released from the work comp doc, he said I could see my personal ortho for the incidental degenerative findings in my MRI. When I started to do that my personal insurance obviously now knowing I had a neck injury refused to pay saying it was work related. I can obviously see where there was some confusion but Work c treated me for soft tissue damage and my ortho was treating me for structural damage. I told my ortho of the work related stuff and was completely honest with them. As I was trying to work through this, the lady at my ortho office seemed very knowledgeable on these things and told me that I would have to do all the leg work and get WC to deny these claims before my personal insurance would pay. My fear came as I continued to try and get my ducks in a row and asked her if the denied personal insurance claim would be reviewed until I got them the necessary documentation from WC, she replied they would if they thought fraud was involved. Of course, that word scared me. I was not trying to pull the wool over anyone's eyes and both parties knew what was going on and when she said this she mentioned people say they are hurt when they are not. It seemed as though I was annoying her with all my questions and she was having a bad day, probably thanks to me, and I took that statement kind of personally. My question is I have objective findings from my MRI in the form of bulging disc and other degenerative changes, I'm just curious if this she were to say something to my personal doc that this person was asking a lot of questions in regards to insurance etc, and the doc looks at my chart and sees I had pre-existing issues is there any concern to think I did something wrong. Like they think I'm not being honest about my issues when I have an MRI that says I do. I don't feel as though I did anything wrong and had issues I needed treatment for. I just wanted to check with some experts on this matter and see if annoying someone can create suspicion and if the doc looked at my file, I hoping he would have to see there are issues and even though there were a lot of questions being asked there doesn't appear to be any reason or grounds to stand on for fraud. WC has paid for what they were supposed to and they released me to my personal ortho. Thanks in advance for the help.

[Fr_Chuck]

This is normaly, if your private insurance has any reason to believe your workers comp should be paying, they will deny it.

Your workers comp will about 60 percent of the time, just deny it anyway hoping not to pay.

But even if you had pre-existing conditions, if you hurt these at work, it will be workers comp.
But often you will end up in a court of law with an attorney to get someone to pay.

I will give you may story, I had stopped by the lumber yard to pick up some supplies for work, I had a serious car wreck after I left the lumber yard. The workers comp denied payment because I had not made it to work to "clock in" The private insurance refused to pay because I had already started working picking up supplies. My medical bills were around 400,000 dollars. It took 10 years of legal work for these to finally get paid and in the mean while they got judgements against me and I lost everything I owned. I learned a lot of what not to do during that time.

So if you hurt this during work, it is a workers comp and they should be paying, not your private insurance, even if this was a old injury, your workers comp people will lie to you about it, so they don't have to pay.

And your private insurnce will not automatically pay just because WC denies it, if they believe it was related to work. If they use the word fraud, agree it sounds like fruad to you, fraud on their part for not paying your bills. The WC people will do and say many things to not pay.

[ddfjk]

Thanks for helping me clear up some of the insurance stuff. I still have one concern about the lady in my ortho's office. I'm not great with words so I'll try to make this shorter. The billing lady at my personal orthos office made meniton of fraud if the insurance company thinks something is up. My questions would be, if her and I had a conversation where she brought up fraud and just inquiring I asker her what would be considered medical insurance fraud, she replies anyone who says they are hurt but are not. Maybe I was reading too much into it because I know I had been a pain in her behind with questions, but I got the feeling she was talking about me. I brought them an MRI that showed I have issues in my neck, bulging disk, etc. with this being said if she, just because of a few questions and was irritated with me and she went to the doc and said this guy was being a pain and asking questions regarding fraud, would this prompt the doc or his office, knowing I have issues in my neck, to get in touch with my personal insurance and start an investigation, would they draw that attention to themselves and would it be worth it when they saw my MRI and treated me for bulging disk and other issues? I feel as though I have done nothing wrong, but it made me nervous when she mentioned that word. It has nothing to do with WC, I'm pretty much done with them, I'm just wondering if my orthos office would have any sort of reason to contact my personal insurance about this issue. I'm a worry type person unfortunately and just wanted to put my mind at ease that nothing could come of this even though I have done nothing wrong and she even mentioned in one of our conversations that she read the doc notes and said I had aggrevated pre existing issues. So I'm trying to convince myself that they can't say I'm lying about my injuries because they are right in front of them and I'm not. If the doc looks at my chart, he treated me for what he saw in my MRI, so I wondering if they would go through the motions of contacting my insurance knowing I have neck issues, but only because I asked an office worker a couple of questions after she brought up fraud. Thanks again for all the insurance answers, I just need to find out if doctors are that apt to contact insurance over something so small and with MRI evidence that I have neck issues. Thanks for the help this board was nice to come across.

[talaniman]

If your injuries are legit and you are doing what the doctor says, that's all you need to worry about. Typically your job is the one to start the questions if your off work. Are you??

[ddfjk]

No I'm not off work and I read the MRI report and spoke with my doc and he showed me a few things in the MRI. Nothing real major yet but some degenerative stuff. I just had a worker from his office say something after I annoyed her unintentinally and I wondered if she went to the doc and twisted my questions around to make it sound like I was quilty of something if there was any reason he would turn this into something. I can't imagine they would say anything to insurance unless it was pretty blatant but I just wanted to find out. I haven't been on short term and have used nothing but a couple of sick days because if my issues. For my neck issues, I have had to pay the bills because insurance denied them so I would think the insurance wouldn't worry about it because they denied the claims already and are waiting for me to submit documentation if I decide to. So as far as I can tell the original claims are just hanging out there in limbo.