They Really Do Want to Take Your Money and Hope You End Up Dead… Another real yet sad tale of what’s wrong with the healthcare system.

In June of last year, 2018, a woman, let’s call her Sue, went to her doctor complaining of significant pain and some other health-related issues.  The doctor did a work up and told her she needed surgery, immediately! Sue should call her insurance company for approval and they could schedule it right away.  

Insurance company time machine
Insurance Company Time machine

The insurance company balked.  More than a month passed.  Then they sent a denial.  They questioned a medical detail. Because in the surgeon’s notes it said she had, for example, fatigue, and fatigue is not associated with the problem the surgeon wanted to treat, the insurance company would not approve paying for the surgery. 

The surgeon sent paperwork back to the insurance company documenting that the detail they used as an excuse to deny the surgery was the result of a separate medical issue and, thus, was not relevant.  An appeal was filed.  Another several weeks passed.

The insurance company denied the surgery again saying they did not have proper documentation to approve the surgery.  Before they could approve, they needed a detailed report from the doctor discussion the reason for the surgery and why the “fatigue” wasn’t relevant.  

The surgeon then wrote the report, according to the insurance company specifications, explaining why the surgery was essential.  Another rejection was sent from an insurance doctor who reviewed the case.   

When the surgeon spoke to Sue, he was incensed.  “The guy who looked at this wasn’t even a “Bleep Bleep” surgeon.  It’s like having some idiot decide your fate, when they know nothing about the problem  and have never practiced in this area.”   

The surgeon was so mad, he called the “doctor” who reviewed this case to yell at him. After the conversation, the surgeon called Sue with the good news.  

“The guy  said based on his conversation with me (the surgeon,) he would reevaluate, and likely approve.” That was at the beginning of November.  The surgeon said that as soon as it was approved, he would schedule Sue’s surgery immediately.

On December 17th,, 2018, the patient got the letter approving the surgery.  If you looked at the approval letter closely, you notice that the period the surgery was approved for was between August 16, 2018 and November 14, 2018.  Oh joy; but no joy.

This meant that only if our friend Sue had a time machine could she get her surgery because she would have to go back in time.  The approval had expired before it was sent.  

You’d think the insurance company would say this was a mistake, they’d correct it, and the surgery could proceed.   Think again.   A mistake, they said, it is not.    

When called by both the patient and the doctor to see if they could correct the error and allow the surgery, the insurance company said no way.  “Error or no, and we are not saying this is an error, you have to go through the approval process again.  The claim must be resubmitted!”

For Sue, this delay has been disastrous.  Since June, her condition has significantly deteriorated.  Some of the issues she had, which could have been corrected had she had the surgery early enough, are now permanent.  Had she had cancer or some other life threatening affliction, Sue would have lost her life instead of just her quality of life.

Commentary:

The law protects the insurance company.  They have 90 days to make a decision after submission and each submission and/or appeal is considered an independent event which starts the clock all over again. This is why the statement “delay, deny, die” is considered the motto for those who review claims.

Delays like this have a bunch of advantages for the insurance company.  The first is, if they succeed in delaying the claim to the next year, if the insured had changed policies this insurance company would be off the hook.  They would not have to pay.  The second is even more sinister.  This patient had met their deductible and their out of pocket maximum.  If the surgery had happened in 2018, the insurance company would have been on the hook for the entire cost of the surgery.  

By putting it off to the following year, the patient is now starting a new deductible.  The insurance company pays nothing. The patient has to pay 100% of the cost until they meet their deductible PLUS their co-pay PLUS their co-insurance.  Even after they meet the deductible, they still are on the hook for their co-insurance. A surgery which would have cost this zero in 2018 now,  in 2019, will cost the patient thousands of dollars.  

Delays like this make life miserable for the doctor. The cost to the doctor for fighting these denials is substantial.  The report the doctor wrote took, at a minimum, several hours to produce. Patients should know doctors do not get paid one penny when they do this.  Nor do they get paid for the calls to the insurance company or for the staff time involved; nor do they get paid for anything else. After a full day of seeing patients, the personal and professional cost of undertaking these fights become more and more difficult.

Patients pay and then the insurance company pays.  Remember, according to the CDC, the insurance company pays less than 10% of every premium dollar for care.

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