Complications and ins

Who said anything about lying?  I completely agree with you...you said it yourself

"Emergency medical condition" means a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain,...

such that the absence of immediate medical attention could
reasonably be expected to result in:    o Serious impairment to any bodily functions;
          o Serious dysfunction of any bodily organ or ...

So no, rogirl is absolutely not right.  I have paid bills of millions of patients admitted for pain reasons on otherwise non emergent surgeries.  The BEST example I can give?  Is gallstones!  When they are not actively bothering the patient, it's considered non emergent and surgery is scheduled outside of the ER.  However, entry into the ER with EMERGENCY LEVEL PAIN does not result in pain medication solely being administered.  It means that if you have active stones stuck (which is what causes the pain) you can and most likely will be admitted on an emergency basis to have your gallbladder removed.  

I never in anyway told her to be "morally bankrupt" nor did I tell her to defraud anyone.  I love how you randomly and obscurely put words in my mouth .  Maybe I should have spelled it out so you could be clear, Next time you have acute pain, go to the ER and get admitted.  But as discussed, it's neither here nor there because the services were already performed.  I would have to know specifics.  As while you were able to google things you are not a claims examiner, and no offense, could not possibly know anything regarding the appeals process nor the technicalities nor the navigation of getting a claim paid, all due respect.  It sounds like you are a broker although you were not specifically clear as to what an "Insurance executive is".  Dealing in policies is night and days away from being a claims examiner.  

Who said anything about pain?  You did, remember. "Go into the ER with severe pain and have them admit you." OP didn't indicate pain in any way.

While painful, gallstones may (or in fact may not be) an emergent surgical case.  Many people present to the ER with a gallstone crisis and are treated simply with a Lidocaine ****tail, fluids, and instructions to change their diet.  Cholecystectomy is never a primary treatment for gallstones unless radilologic evidence is present that there is a majority or complete blockage of the common bile duct that does not respond to non-surgical treatment. I don't argue one with gallstones doesn't ever get surgery to treat them, but I think making the statement that paying 'millions of claims' in this case can be true but suggests both selection bias as well as  limited experience. Just because something does happen,l doesn't mean it always happens, or happens in that way. Think about the millions of claims you haven't paid for the same reason- either because the service wasn't a covered benefit, or because you never received a claim in the first place.  

You told her to "Go into the ER with severe pain and have them admit you.". If you claim to have a medical condition "pain" which she does not have, you're telling her to lie.  Because it's done with premeditation (and incidentally posted on the internet and easily discoverable evidence), it is intent to defraud.  I make that statement as an SIU investigator that has actually sued members for bragging about how they lied to get things covered they shouldn't. 

With respect to your statement "you are not a claims examiner, and no offense, could not possibly know anything regarding the appeals process nor the technicalities nor the navigation of getting a claim paid", well, you're just wrong. I claimed who I am, and I stand by that claim. If we're making judgements, I have to admit you strike me as a low level claims analyst.  The kind I have alot of- just knowledgeable to work on professional claims without much help, but not so much you can do it without support. If you truly are paying millions of these claims, you'd better get a second, stronger skillset, cause you wouldn't be doing this for long. Certainly not in my shop.

And for the record, in the mid- 90s I was a broker.  Nothing wrong with making good money and helping people, and it certainly doesn't mean I don't know what I'm talking about. One of the best skills I learned selling over 20K policies?  Shut up and find an expert when I don't know what I'm talking about. You might learn something from that.

Youre reading comprehension bewilders me.  She never said she didnt have pain .  I assumed she did by her description.  I never in any way told her to lie that's ridiculous. I was saying as i  explained, go into the er with pain and you will be admitted.  I highly doubt as an siu investigator you would find people on the internet who bragged about having services covered who shouldn't. Im not even sure what you ,mean by that as insurance claims are billed by drs offices rarely by the insured.    I know this is hard to grasp but I was using gallstones as the best example i could think of off the top of my head.  I don't know how that would equate to a lack of knowledge .One 5 day hospital stay alone can be upwards of 200 k so yes easily millions.   Id say I've seen about 40 gallbladder surgrries performed on an emergent basis.  Which is why i used it as an EXAMPLE.  I never said all gall spasms result in surgery but once again your reading comprehension is not picking up what i'm putting down.   

Your lack of logic is a bit bewildering too.  Because she did not say she had pain we can assume she does?  She did not say she has Ebola, may we assume she has that as well?

Going to an ER complaining of pain will not necessarily get you admitted any more than it will get you pain medicine.  Have you heard of drug seekers perhaps? In addition to admit or not isn't the patient's decision.  It's the physician's. Physicians may choose to consider the patient's opinion when making a call for a patient 'on the bubble', but bottom line you cannot just decide to admit yourself for surgery. Ain't. Gonna. Happen. 

And yes, I did investigate claims online.  And in people's homes, and their doctor's offices, and their work, and many many other places. If I thought there was a likeleyhood of fraud I would go wherever I needed to to prove or disprove it. Google is your friend here- there are tons of examples of malingering to downright fraud based on pain alone.  

I appreciate that you're insulted by my response, and that you perhaps feel a bit foolish, but it might just be best to walk away at this point. You gave bad advice. You picked on a vet (****rogirl).  You made a mistake. The same mistake I've made, with the same person in fact.   Accept, move on.  I'm no vet and I won't pretend to have all the answers, but this is something I know a great deal about. Attacking me is not helping your case.  If you have specific citations in legal or regulatory precedent that refute my position, I'd love to see them.  Absent that, I've stated my case, cited specific legal and regulatory sources, and established my authority on the subject.  You've done none of these things.  You've provided anecdotal evidence at best.  I read alot of emotion, and alot of "trust me", but not many objective facts. If it is as simple as you suggested to just prove your point with google, I encourage you to do so. Please prove me wrong and teach everyone here something new, including me.  

You've been here for a hot minute and you're giving advice like it's your job.  It isn't, and alot of your recent posts have included some pretty spectacularly bad guidance to people who are not experienced enough to know you're making it up as you go. You do realize that people- sensitive people, people who are here to get help, people who are making one of the most important decisions of their lives- may be acting on your guidance?  This isn't a game, and you can really hurt someone. 

 EBOLA !!!! LMBO !! Her posts are making my eyes bleed,,,,,,,I may have Ebola !

Sounds like you probably do.  If you go to the ER, they will admit you.  I don't know if your insurance covers ebola though.

LOL.

LOL !!  I will check my policy......Ebola can be found on pages 1,249- 1250 between DEATH and EMBALMING........cuz they don't cover those either. 

Thank you for speaking for many Michael!!!!

I actually didn't see this response till just now.  I know you all come from a different section of the forum (thank you to the source who showed me their post).  She explained your gang mentality and how you go out of your way to gang up on people.  I've explained myself over and over again.  If you want me to cite case law, I sure can.  Boston's Gourmet Pizza VS Childers, Yellow Transportation Inc V WCAB 77 Cal comp cases 211, Labor Code 4600, Labor code 4602, Labor Code 4610 Simmons V California, Sandhagen V WCAB, Supreme Court decision, Braewood Convalescent Hospital V WCAB 34 Cal. 3d 159 [103 Cal. Rpttr. 157, 66 pd 2d 14 LA NO 31683 California is a no fault state and also you take the applicant as you get them.  This is my experience with claims, which I tried to clarify and explain 10 times.  

As per my post in your so eloquently labeled post "Dumb and rude" in the rants section, I stated I come here to give the best advice I can. I'm sorry if you find me "dangerous".  I think that claim is hilarious.  I apologized to you in a message for being rude earlier, and as in my post, I do not know it all, and actually learned from multiple posts and people's experiences with their carriers.  At any rate, as stated, I will not respond to any of you anymore, as you clarified in your post in the other section your point is to "prove me wrong" and in your minds you did that.  So kindly go about your business and have a nice day.  I'll see you guys around the forum.  Hopefully, one of you will be assigned to me so I don't endanger anyone's lives by referring them to the ER.