How horrible. I can't even imagine how you feel. The denial of needed care happens nearly every day. There are REAL consequences to these denials as you well know. Some physicians have gotten the names of these doctors and reported them to their medical boards. Of course that sort of thing brings retaliation.

Jb, I am so sorry for your loss. Heartbreaking and worse, preventable.
Zs is completely correct here; it’s all about denials and keeping the $. I remember filing paper claims where if the “x” was not completely and perfectly in the square to be checked, the entire claim would be denied. Mind you, the paper claims were being sent to people, not computers- we’d already started shifting to eclaims and electronic submissions- these paper claim folks were the holdouts. Each LINE on the claim cost money… so we’d have to resubmit, and someone would double their take. Small and petty, but yet another way to delay payment on a claim- to both the provider AND patient. High schoolers are going off scripts as “reps”, and they just aren’t qualified. It’s incredibly sad, and again, it’s all about the $.
NTA.

quote:

Originally posted by irreverent:
I remember filing paper claims where if the “x” was not completely and perfectly in the square to be checked, the entire claim would be denied. Mind you, the paper claims were being sent to people, not computers- we’d already started shifting to eclaims and electronic submissions- these paper claim folks were the holdouts. Each LINE on the claim cost money… so we’d have to resubmit, and someone would double their take. Small and petty, but yet another way to delay payment on a claim- to both the provider AND patient.

My ex is a psychologist, billing medicare, medicaid, and private insurance. She has said for many years now it is standard to get the first submission denied as if the claim isn't even looked at, just rejected. So then they have to resubmit once or twice more before getting approved.

All of this costs money for the provider, which raises their prices to patients, and costs money for the insurance racket which is passed on to patients as higher premiums or onto taxpayers as higher taxes.

Wait until you turn 65 and have to go on Medicare. First off, Copay assistance is forbidden once you are on Medicare. So if you have to take an expensive drug for cancer or something else you'll pay 25% of the full price until your Deductable is met and 5% IIRC the rest of the year. Basically if your on a high dollar script that costs something in the range of 4000 dollar per 30 you'll be spending 5 to 6 K per year for that drug.

Then there is the yearly Physical, something that was supposed to be free for everyone under Obamacare. Except for those over 65, once you are on Medicare you'll have to pay full price for a yearly physical. IMO that is actual evidence that Medicare does want their "clients" to die, as quickly as possible.

It's not just Medicare. Under the high-deductible plans offered by most employers that 'free' physical for people over 40 isn't free. Instead, there are a bunch of required labs and the cost last time I got a quote was $1900.

No more physicals after you're 40, better for pharma and others if they way for something serious to have developed before you get help.

I always told people the thing I liked best about my 20+ year practice with a group model HMO was that I NEVER had to call an insurance company to get authorization for anything up to and including a cardiac transplant.

Physicians set the guidelines, there was some feedback if they thought you were overdoing testing or whatever, but in my case I was on the national guidelines committee with other physicians.

I hate stupid little acronyms. Jeez, use proper English.

quote:

Originally posted by ZSMICHAEL:
Because the company hasn't updated its guidelines, I'll have to talk to an oncologist at the insurance company to get an override.

No shit, Sherlock. Sorry, I meant to say No shit, Dr. Sherlock.

You would think they would triage the calls from the information they have as to who needs to talk to whom. That first call certainly was a waste of time.

quote:

You would think they would triage the calls from the information they have as to who needs to talk to whom. That first call certainly was a waste of time.

^^^^^^^^^^^
That was purposeful to waste the physician's time. It is not unusual to be directed to a urologist when your specialty is cardiology.

I have sat in a official capacity monitoring CS agents whose whole duty is to talk to insurance companies. This was a while ago, however it’s amazing to see these people who have memorized the phone menus and know the exact words to say in order to get through the bullshit.

It’s a remarkable process to watch. I think it was some religious hospital group as my client.

Yes, I’ve never done it myself, but know of folks who immediately started swearing to get them escalated immediately. Probably these days the phone just disconnects.
Anyway, the key I’ve used is repeating “representative” until I get an actual person, then immediately requesting a supervisor.. who typically isn’t immediately available, and requires a callback to me. If I’m in a really bad mood, I can get through relatively quickly by chewing that “representative” someone out, but it’s truly disheartening for us both. I shouldn’t have to bitch someone out to get a logical answer from someone who actually knows what’s going on instead of a simpleminded screener, and I’m sure they don’t enjoy me doing it. It’s awful.