There isn’t an approve button.

There’s a system that’s really fucking old but never ever breaks down so they absolutely refuse to upgrade it. It’s been modified to keep up with regulations over the years but it DOES NOT BREAK. I did some poking around and I think I have a decent idea of what this machine actually is and if I’m correct, it will outlast our patients, all employees, it will outlast their offspring, probably the damn company. It’s a bitch to use but it’s super reliable. It doesn’t get confused, it doesn’t do batshit insane things because an AI told it to. It doesn’t choke on windows updates or even run windows at all. It will survive the heat death of the universe. And we fucking hate using it. But the priority is patient care and this does that better than any of the modern shit so it stays and we suffer. It is rigid, inflexible, literal. It is brutally straightforward and that is the only thing I can truly appreciate about it. There’s no guessing why it rejects a claim. It tells you exactly what it’s pissed about and we can help you or your provider feed it what it wants within reason.

Generally it’s a matter of something was presented to it in a weird way legal wouldn’t like so it rejects it now rather than surprises people with lawsuits later. We actually catch a lot of things months before Medicare does. (If you are on Medicare, look out for catheters you never ordered from Florida. It’s a thing and our system is catching damn near all of them. Fuck these scammers.)

So rather than spend money on keeping up with everyone else, they spend the money on patient care and just brace for impact for the day all the developers of that old system die off. It’s a big priority here that we spend as much as possible on patient care, which leads to some annoying situations where some things get outsourced that really shouldn’t be, but less money spent here means more money spent on medical care.

That old system is the fastest piece of tech we have in the entire operation. It gets all the pampering and attention. And while that TUI is a bear it’s never been wrong. It’s battle tested. It basically says yay or nay based on how it’s been programmed to evaluate a claim. EVERY rule it uses to evaluate claims is in the documentation given to providers while they are signing contracts to go in network with us as well as the messages it tells us to relay to callers. It has no secrets. It has no magic approve button. It doesn’t need one. We know there are a lot of rules, that’s why both patients and providers can call us.

It’s the only damn thing that reliably works around here honestly. All the new shit bolted onto it sucks ass. We are changing the front ends used to access it to modernize but it’s a really broken Microsoft product trying to tie into this old IBM mainframe and it’s just awful at it. As janky as the old stuff is, it works. The new stuff is easier to use but broken in so many different ways we take forever boxing with it only to go back to the mainframe and ask it directly what it wants.

Could have been worse. They could have gone with Oracle.

Anyway to your situation. There are firm rules to these contracts. They are cold and lifeless. There is no humanity in them because we just can’t afford sympathy. We would approve everything that comes in. That’s why we have this system. It keeps things locked on to the terms of the contracts. But the contracts make things predictable, something our company can plan for and prepare for. While some companies can and do want to fuck you over to give your surgery money to some fucking shareholder, not everyone works that way, not even within those companies.

Fun bit of trivia you might appreciate: you know how insurance companies insist on physical therapy before certain surgeries? There’s actually a couple VERY good reasons for that.

1. Sometimes, people don’t need surgery at all after physical therapy. That means far fewer risks for our patients as therapy is much less risky.

2. Patients who struggle through physical therapy, no matter how badly it goes, have dramatically better outcomes after surgery. They heal better. They recover faster. They have fewer complications. Yes it’s an asinine thing to ask and in some cases seems ridiculous but nobody wants to fix this because we’ve seen the data and these people do so MUCH better long term when they put in the effort beforehand.

That didn’t just help the patient either. The surgeons numbers look better, meaning they are less averse to performing the surgery in the first place. Some surgeons outright refuse surgery without PT happening first. They don’t care how much improvement you get out of physical therapy. It’s more about preparing your body to heal. That means we can send more people their way to get care. It costs less for us too because the outcomes are better so we spend less on the individual patients, so we can cover a greater number of total surgery patients. It slows the rate of healthcare costs increases.

Unless you have exceeded some cartoonishly high limit, we will NOT turn down physical therapy. It’s the cheapest, most effective, lowest risk way to dramatically improve health outcomes. Seriously, if you saw the numbers you would understand why we have conversations like ”we understand your knees feel like sandpaper but the physical therapy will help, please continue.” It DOES help, but sometimes the benefit shows up later.

So yes, we know you need the surgery. Yes we know the bureaucracy is annoying. But in some cases, like physical therapy, there is a very good reason we do not change it. If it isn’t actively killing you, people, just do the PT.

How does this relate to your case?

Well you tried a pharmaceutical approach. It works for the most part but it sounds like it’s not fixing a problem so much as trading it for a different set of problems. That’s not helping you. It’s not helping your insurance company either. The surgery is a one-time expense whereas medication has to keep being paid out until someone dies.

You ever watch Mike Holmes back in the pre-flatscreen TV days? He was a Canadian contractor who had a TV show where he fixed houses and he was strict about do it right or pay more to do it twice. That’s kind of what’s happening here. It costs less to get the surgery than to drug you up forever.

At the end of the day, remember this: health insurance companies are very good at math. They all agree on one thing. Dead people don’t pay premiums. The more people you keep alive and healthy, the more additional people you can serve the same way and the lower your risk. It’s in our best interest to keep you well because your death means missing revenue not just for you but for everyone else we have to care for. It’s literally in everyone’s best interest we take care of you. And since my company has no shareholders, I get to focus on doing just that. :)