Coverage denial scandal

Here at work, when we were evaluating possible changes to our group health insurance to contain the cost increases, Aetna came in with the lowest bid. The HR director and I reviewed the bids and decided to go with the next lowest bid (for many reasons). Looks like we may have dodged a bullet that time.

I have had UHC and/or BCBS for many years and never had a flat-out rejection of treatment. Yes, they did exclude some particular meds from their formularies, but properly documented treatment requests were always approved. I have heard quite the opposite about Aetna, which was one of our reasons for declining their proposal.

My heart goes out to all who have that insurance, because most of the time we, the patients, have no choice of which company our employers choose.

dbell said...
Horizon BC/BS denied me an MRI and also told my RO, no treatment until a G7 or a G6 with a PSA over 20!

Your stats look like they should not treat. Be thankful. watch and wait

My DH has BCBS of Alabama (we live in Georgia, but his company is based in Alabama) and I am happy to report that we have never even had BCBS question anything is doctors ordered.

After reading the CNN article, the story was crafted to lead the reader to a conclusion which unfortunately is routinely practiced by media. The patient that was a major actor in this story had some culpability in this situation. I'm not taking sides but I am suggesting that readers exercise critical thinking and avoid the assumption trap.

At least 90% of claims are straightforward and by the book and do not require the Medical Director to review them. There are not enough potential Medical directors to be found that can review each and every claim and medical record. That's why we have a lot of well trained professionals that are probably better at the review and claim confirmation process than most of the Medical Directors. Artificial Intelligence and algorithms are also employed so that claims are affirmed and paid appropriately at the lowest cost possible. Last week I saw my urologist and had blood drawn for a PSA test. Do I expect the Medical Director of both Medicare and my Medicare supplement insurance company to personally review my claim and medical records to affirm the claim? Or my $25.00 flu shot at Walgreens? Of course not.

Many denials are by the book and most often are because the insured and doctors have not provided appropriate and required information. That appears obvious in this case. The insured did not provide current blood work, Aetna requested it, the insured and doctors did not provide it, so Aetna denied the coverage. Once the insured and doctors provided the current blood work, Aetna paid the claim.

Getting a claim paid depends on the insured and doctors to do what is required by the insurance contract. That the Medical Director stated that he did not regularly review the medical record is a red herring and just adds to the sensationalism of the report.

I am not here to defend the insurance company. For the system of third party payors to work, the insured patient must meet their responsibilities under the contract. When the payor inappropriately denies coverage I am the first to criticize them. When that has happened to us, I have rigorously appealed the decision. Thankfully it has been rare and I have prevailed each time. I am now in the process of opening an appeal on some lab work that Medicare has routinely covered for three years and has just now denied. I am sure the Medicare Medical Director had nothing to do with the denial nor looked at the medical records. And I doubt the appeal of a $250 procedure will reach their desk either.

My brother was denied MRI and Scan twice.

He has never had any.

Seems crazy.

Urk told him that was what he first needed before proceeding. Then, it wasn't approved and Drs. acted like oh, it doesn't matter.

Very confusing

The Council on Afordable Quality Healthcare is the lead ngo that tracks healthcare in the US. In an annual study they do it is reported that private insurance companies in the US covering 146 million people process 5.6 billion claims each year. And you expect medical directors to manage each one. That would be like Tim Cook managing time cards and attendance at Apple. Further a recent study by the AMA reported great improvements by insurance companies processing more claims more quickly and with fewer denials than ever before. If you expect and desire the medical director to make every claim determination it will takes years for yours to be made. Not a smart way to meet patient’s needs.

The realization has to be understood that no Medical Director will be expert in every tough claim. The cancer patient wants the oncologist, the liver problem wants a gastro, the bone issue wants a ortho, the eye problem wants an ophthalmologist and they all get a world class pediatrician. However every company has well trained specialists in each area of speciality to adjudicate the tough claims. that business specialization is the best practice and it is why all companies use it.

And yes, in this case the insured needs to be blamed as was pointed out clearly by the writer of the article. If his care was so important why did he cause a three year delay in getting a simple blood test to the insurance company when they repeatedly requested it?

And as to denials of mri before biopsies, just because a doctor orders it doesn’t mean it is usual customary or necessary. TA has regularly pointed out that an mri is rarely useful before an initial biopsy. Please remember that it has been shown that nearly 30% of the added cost in the US medical system is for unnecessary tests. We can’t gripe about our high costs and then do nothing about it. Other medical systems that many here applaud as being far superior to the US do not provide these tests or impose many months or years to wait on the test that are routinely provided here nearly immediately.

Third party payers are not perfect in every situation but they a necessary in a delivery system like ours. And before you say that a single pay or Medicare for all would be better, remember that Medicare contracts the private sector insurance companies to do the claims payment process. Medicare does not do the claims processing and payments.

Allen,

No dispute from me on your points regarding the Aetna situation. Routine denials without studied justification are in bad faith and spoil the value of the insurance proposition. I certainly hope this isn't the norm and if it is this publicity will no doubt help correct the situation. There is certainly no perfect or near perfect situation anywhere in the world. Before I give up on the private/public system that the US and most all countries use and go to a mostly public system like the one you reference, I am reminded that just a month or so ago that system arbitrarily canceled tens of thousands of scheduled surgeries because they didn't have adequate funds.

As you mention most countries have a combination of pubic/private coverage very similar to our Medicare system (most were patterned after it) where the government pays a portion (usually 50-80%) and the patient is responsible for the rest, but can buy private insurance to cover some or all, similar to a Medicare Supplement Plan. At the present the only countries that have a true single payor system that cover all the costs and do not use private insurance are Cuba and North Korea. Taiwan and Viet Nam are then fairly close. None of these ever show up on the top lists of medical healthcare systems that produce the results we want in the USA. Even Canada several years ago started opening up the private care and insurance market so people could have greater choices and quicker response times for treatments as the UK did decades ago So, most all countries have found they can not cover all the costs and thus allow and/or require the citizen to have private insurance to cover their part.

And regulating costs, while absolutely necessary, is another way of saying treatment rationing. In this case Aetna was rationing treatment. Under our system it appears to have been inappropriate. In many other systems the same action wouldn't have been inappropriate.

John T well said

halbert said...
.... She spent 30 days with a nasal feeding tube, and was intubated twice--which damaged her vocal cords and she lost the ability to speak. To express that I have doubts about whether it was the best choice is putting it mildly--and yet, I saw the sequence of events that took us there, and each decision seemed to make sense at the time......

My wife is an RN and worked in hospitals for several years and she frequently encountered situations like yours with a family loved one at/near end of life. In many cases, the family wouldn't let go - they wanted everything possible done to prolong life. In other situations the physician was the one that would press for procedures and tests no matter how invasive and how futile.