Complications and ins

AND once again YOU read way to much into it, as your old biddys helped you to do, You did come across very know it all and argumentative, when differences were pointed out you still argued, WE all see how it is ......  see you in the "other " forum, you know you will :) block baby block!

Your case law is impressive, but you seem to have missed the point.  I reviewed your cases, but to be honest the answer to the question is in your citations. 

These are malpractice cases.  They are not coverage cases.  In fact not one of your citations addresses the OP's actual question, which was regarding financial coverage for the care.  At no point has she alleged malpractice or malfeasance. Your experience with claims notwithstanding, but your experience in court is equally lacking. 

I stand by my statement I made there and here as well.  Your advice is reckless, dangerous, and might get someone hurt or sued.

In terms of the gang mentality, I'm surprised to find I'm part of the "gang" all of a sudden.  A cursory review of my post history would indicate that I actually got into quite the argument with someone you attacked here- a respected veteran and established long term success who I believe actually works in the medical business as well (I could be wrong, it happens sometimes :) ).  I was just as wrong then as you are now.  The difference is, I cooled off, re-read what I posted, realized I was wrong, and not only backed off, but did the right thing and apologized.  I speak much more carefully here now, as you should. 

I don't see any gangs here.  I don't really see any cliques either.  But then I'm not one who is taken with them.  What I do see however, is a group of people who have already accomplished what you and I have not, and have done so long term. In and of itself, that grants them a certain authority on the subject.  Their experience in not only succeeding at losing the weight we all hope to, by keeping it off for multiple years, and by having navigated themselves through all the permutations of nearly every issue related to the process makes them experts in my eye.  They give of their time, helping hundreds of people before you and I came here, and will help many more once our weight is gone and it's a memory that we were all so uneducated on this whole thing. There likely isn't a question they haven't heard, an answer they haven't given, or a behavior they haven't experienced a hundred times over.  And yet they still help. 

That "gang", if you choose to call them that, is a gang I want to know.  A group I can trust. People who will help me far more than someone who isn't even a pre-op yet.  If they choose to blow off steam, so be it.  We all do.  Parents get frustrated with their kids, co-workers get ticked at colleagues, and veteran forum members get annoyed when someone whose mouth fires before their brain.  It happens. Just because they (and I) were annoyed at your bad advice and called you on it doesn't make them an evil gang, it makes them people who care passionately about getting good advice in the correct hands.  You'll notice that's true because people who don't post elsewhere (including that forum) disagreed with you here as well.  You weren't ganged up on.  You were wrong, and were called on it. 

You keep saying you're done and won't respond.  You even sent me an apology, which it seems you've changed your mind on.  I'm ok with that.  Can you keep your word now? 

I teach law classes.  You are absolutely correct in your interpretation of her case law citations Michael. 

Lol, I'm sorry one more thing I can't help it.  These are not malpractice cases.  They are cases which govern worker comp insurance carriers in California Workers Compensation Appeals Board.  They are basically claims where treatment is denied not the claim itself.  The treatment was denied erroneously and the court which governs work comp cases determined that it should have been covered and the applicant was awarded payment for the treatment.  I didn't change my mind about my apology for being rude.  I stand by that.  Have a nice day ;)

LOL< welcome back!

I am going to chime in here, too. I am a former healthcare management consultant with nearly 20 years experience in business office optimization and Medicare/caid fraud and abuse audit, a former Joint Commission examiner, and a former hospital CEO. I am sorry, christinemudd, but he is right. It is irresponsible to tell people to simply present in an ER for the purpose of getting care not otherwise covered under their insurance nor entitled to is, in fact, fraud. The ER is not a "free card" -- it is there to save lives, not provide a smoke screen or work around to get care paid for that hasn't been otherwise approved.

All the ER is required to do is stabilize a patient. If the condition is truly life threatening then surgery may be performed and the policy would most likely pay. (If the policy does not pay because the carrier did not consider it an approved covered event, then the hospital would eat the entire cost after attempting every avenue to collect from the patient.) But if the ER staff does not consider the condition truly life threatening, then they can and should stabilize and release the patient to the care of their regular team of physicians for further care.

To knowingly seek a procedure via the ER as a ruse to "force" insurance to pay is not only morally bankrupt IMHO but also insurance fraud, not in my opinion but rather in the opinion of the law.

Oh and scar tissue forming around the bowel sounds POSITIVELY pain free. I'm sure she discovered the scar tissue through routine inspection of her own bowel using a toothpick ...how utterly preposterous.  

So you're telling me that the heroin junkie that wanted a skin transplant because of all of the bugs under his skin was way more intelligent than the CT scan that couldn't find a single one?  It's possible that the perception of an issue is very different than the actual issue.  

Stick to paying the claims you were told to, and leave the determination of coverage to the people who know what they are talking about. You might look foolish, or in fact hurt someone. 

Have you lost your mind? On what planet does your comparison even remotely relate to my example? It doesn't. First of all Mr. insurance CEO/ broker/ SIU investigator/ Department of Insurance board etc. (misc position which allows you to pretend to have more knowledge than me in every dimension of this topic, i didn't not say a phantom illness with phantom pain would be admitted and surgery would need to be performed. In my EXAMPLE (once again you strangely have an inability to understand what an example is) medical evidence would determine a person has gallstones (in other words a reason for the cause of their pain). As far as "stick to paying the claims you were told to." I am not a bill reviewer. I handle work comp claims. You wouldn't even have a tenth of a fraction of a point of knowledge on how to do my job. If you knew one work comp law and how to apply it to a claim I would fall over in a dead faint. Acting holier than thou and being condescending and rude is not the same as possessing more knowledge than someone else. I really do not understand why you are personally attacking me, being rude, condescending, calling me morally bankrupt, etc. I literally typed two sentences and you inferred all of this random meaning to what my sentence meant. I hate to say this, but I think I would know what my intent behind my statement way more than you. Additionally, that's literally my job. To determine coverage, to determine liability if we have any, and to LITIGATE claims.  I am not going to go into detail of my job description, but I represent my clients in court since I am an examiner for a TPA/ hearing representative.  So, although I appreciate your failed attempt to defer from the actual topic with mockery and ludicrous statements, I'll stay on point.  In conclusion, I grow weary of your absolute lack of any basis for any of your arguments.  I make a point and you skew it into some irrational half brain dead whimsical invention.  I will therefore, at this point, since speaking to you is stupid on my part, and also the definition of pointless refrain from responding to your utter lack of knowledge or for that matter lack of rational thoughts .  The OP had no intention of you hijacking this post and informing me how wrong I am, who cares if i'm wrong.  My response was based on my personal knowledge and experience.  You probably don't even live in the same state as I do, so your knowledge of insurance laws may not even apply.  And You have yet to prove any knowledge of anything you simply keep saying I'm wrong, ok fine...i'm wrong.  You simply continually try to derail the conversation into you being rude to me.  So signing off, thanks for the colossal waste of time.  And my apologies to the OP.