What options do I have if I have a recurring problem and need an MRI but my provider refuses to give one? Why are my doctors so hesitant to give one?
Over the past year I’ve been dealing with several doctors at Kaiser about my ankle. I’ll meet with one, they’ll tell me to rest, and I’ll come back to see a different one and they’ll give me PT or rest. Only once did I get an actual diagnosis and that was a torn retinaculum, however during the follow up I met with a different doctor who back pedaled and said I wouldn’t need surgery. I asked for an MRI and I did not get an answer. I’m on Physical Therapy now but I doubt it will work since I have been strengthening my ankle for the past year on my own.
It seems like once they find out I’m a triathlete they assume its just overtraining and dont pay much attention to the problem. However I haven’t been able to train for almost a year and any activity past 30 minutes on my feet and my peroneals and tibialis act up the next day. Even swimming agitates it (straightening the ankle).
So I saw a Doctor (Dr. Ritchie in OC) outside my plan and he noticed my ankle moves (8+ mm) and pops during an anterior drawer test, but a true diagnosis cannot be made without an MRI.
At this point I’m planning on going back to Kaiser and I hope to get an MRI, but I’m not optimistic. Is there any obligation they have to do so? I’ve even considered paying it out of pocket.
I don’t have an answer for you other than my experience this past summer with nagging pain associated with my hip. After seeing the doc they ordered an MRI of my spine and a referral to an ortho doc. The only problem is that ortho docs don’t look at spine shots so they sent me back for an MRI of the hip that actually gave the diagnosis. I really didn’t get any push back on the MRI’s though I am on UHG insurance through my employer. I am surprised that they cannot arrive at a diagnosis yet don’t delve into it further with the next logical step. If you do decide to pay out of your own pocket you may be able to negotiate a better price as all health providers prefer cash to insurance company run arounds.
its likely a Kaiser problem. They’re trying to keep utilization (cost) low. Keep trying to get the answer you need. If not, consider switching to a non-Kaiser plan. Though it’ll probably cost you more in your premiums.
its likely a Kaiser problem. They’re trying to keep utilization (cost) low. Keep trying to get the answer you need. If not, consider switching to a non-Kaiser plan. Though it’ll probably cost you more in your premiums.
That is my guess as well. Unfortunately, my plan is not up until July though we are considering either going on my wife’s or using my VA benefits. I dont like to do either since I pay a lot of money to Kaiser.
If its not “medically indicated” they have no obligation to give you one and if they do you run the risk of it not being covered and getting stuck with the bill. The shitty part in your situations that the people determining the need are also ultimately paying for it and for a non serious injury that doesnt affect your activities of daily living it’ll take a bunch of pushing
You probably won’t like this answer, but you can always pay for the MRI yourself. There is nothing that prevents you from only getting healthcare that someone else pays for.
What options do I have if I have a recurring problem and need an MRI but my provider refuses to give one? Why are my doctors so hesitant to give one?
Over the past year I’ve been dealing with several doctors at Kaiser about my ankle. I’ll meet with one, they’ll tell me to rest, and I’ll come back to see a different one and they’ll give me PT or rest. Only once did I get an actual diagnosis and that was a torn retinaculum, however during the follow up I met with a different doctor who back pedaled and said I wouldn’t need surgery. I asked for an MRI and I did not get an answer. I’m on Physical Therapy now but I doubt it will work since I have been strengthening my ankle for the past year on my own.
It seems like once they find out I’m a triathlete they assume its just overtraining and dont pay much attention to the problem. However I haven’t been able to train for almost a year and any activity past 30 minutes on my feet and my peroneals and tibialis act up the next day. Even swimming agitates it (straightening the ankle).
So I saw a Doctor (Dr. Ritchie in OC) outside my plan and he noticed my ankle moves (8+ mm) and pops during an anterior drawer test, but a true diagnosis cannot be made without an MRI.
At this point I’m planning on going back to Kaiser and I hope to get an MRI, but I’m not optimistic. Is there any obligation they have to do so? I’ve even considered paying it out of pocket.
Its a Kaiser issue … their doctors are pounded financially to follow specific criteria that their utilization people draw up that favors Kaiser financially … and they are probably paid bonuses for following those criteria.
If you go out of network and pay yourself… realize that many times you can get a good cash price at some radiology groups … shop around as it may save you a lot. You might also consider seeing a good out of network orthopedic foot and ankle specialist … they may be quite adept at making a diagnosis that might not need an MRI to treat. Lots of times Kaiser will deprive you of a good orthopedic specialist as well and make you see a primary care doc who isn’t as informed.
I would rethink your insurance choice next signup if you have a choice … but for now … shop, but pay cash for your MRI if needed.
If its not “medically indicated” they have no obligation to give you one and if they do you run the risk of it not being covered and getting stuck with the bill. The shitty part in your situations that the people determining the need are also ultimately paying for it and for a non serious injury that doesnt affect your activities of daily living it’ll take a bunch of pushing
Right now all the ankle does is cause tendonitis in the peroneals, anterior tibialis, and achilles tendon. Its not painful, I just get a click when I move it. If I train moderately something is going to snap, and I want to prevent that.
Unfortunately, they dont really care if one of my tendons snap, I’d rather get the MRI and find out what is wrong before that happens. The Podiatrist I saw outside Kaiser gave me a prescription, and a recommendation for an MRI, so that is covered. The cheapest I’ve found so far is $500.
You can’t “just pay for it yourself” without a doctor’s order. Just like you can’t get a script with out a doctor’s order-doesn’t matter how you pay.
This is false. You can get almost any noninvasive study if you are willing to pay out of pocket for it. The invasive ones are more problemstic due to liability if something goes wrong but mris you can def get without an order.
He has already paid for it - through his insurance premiums.
You probably won’t like this answer, but you can always pay for the MRI yourself. There is nothing that prevents you from only getting healthcare that someone else pays for.
Unless you are not in the USA, you can not get a radiology test without an order. I’ve worked in radiology for 15 years. Invasive or not.That sounds bizarre. I’m in Canada and looked at paying for an MRI for my wife’s hip. I called a couple of US clinics and wouldn’t have had any problem getting a scan (although as I recall they were more expensive than local clinics). It seems odd that an American can’t walk in and get an MRA without a referral.
He has already paid for it - through his insurance premiums.
You probably won’t like this answer, but you can always pay for the MRI yourself. There is nothing that prevents you from only getting healthcare that someone else pays for.
It is your health…take control of it.
Not if an MD judges that it’s medically not indicated. A lot folks believe that their problems warrant a battery of studies and treatments, but that’s why we have doctors - to save us from ourselves. (Not that the OP doesn’t have a legitimate problem.)
He has already paid for it - through his insurance premiums.
You probably won’t like this answer, but you can always pay for the MRI yourself. There is nothing that prevents you from only getting healthcare that someone else pays for.
It is your health…take control of it.
Seems pretty clear that he isn’t going to get it through his insurance / current docs.
Well, then he can continue to ask his doc(s) for an MRI, he can continue to get denied and not get better, or he can try and find a way to solve the issue.
Unless you are not in the USA, you can not get a radiology test without an order. I’ve worked in radiology for 15 years. Invasive or not.
You’re partly right … and partly wrong.
When insurance is in play for payment, a referral from a network provider is required for payment to the radiology facility/ physician.
Often, a radiologist doesn’t want to just do radiology on demand because they would then have some responsibility clinically and legally for explaining the meaning of the results to the purchaser … including some responsibility for coordinating their care.
The radiologist is a fully licensed MD and could indeed agree to do a test on demand without another providers order … actually that is not infrequently done when cash prices are offered.
The reality is that even your Kaiser provider won’t care about giving you an “order” … so long as it isn’t done under your Kaiser insurance and you pay for it yourself.
He has already paid for it - through his insurance premiums.
You probably won’t like this answer, but you can always pay for the MRI yourself. There is nothing that prevents you from only getting healthcare that someone else pays for.
It is your health…take control of it.
Hahahah…that is the typical american medical consumer mentality. People think paying their premiums => you get everything YOU want. But, medical insurance is just like every other insurance. If you have dental insurance, is everything covered under your premium? Nope. You still gotta pay extra for root canals, or cavities, braces or whatever. If you have car insurance, do they cover everything. Nope. You still gotta pay your traffic violations, you still have to pay for your OEM glass, you still have to pay to go to a different bodyshop, etc. There are limitations to all coverages. Your premium is really a monthly membership fee that gives you access to basic medical care. Yes, plans vary to how comprehensive your coverage will be. But ultimately YOU do not get to choose what you get. That is what the MDs are for. They pay the MDs to make educated and professional assessments of what you have and need. Do they get it right everytime? Nope, they are not gods. They are people with expertise. If they gave every person that walked in that door what they wanted, our premiums would be even more crazy! What you do have control over–which doctor you see. If you are not getting the “care” you want–then get another opinion. If you plan is not covering what you want–stop being cheap and pay for a better plan. You get what you pay for. If you want to make all decisions–pay cash. I hear Conrad Murray is not doing much these days.