Actual Conversation with Dr and Insurance company for procedure approval

[CoachKandSportsguy]

There is a plastic surgeon who wanted to get insurance approval for a procedure for a woman with breast cancer.

She recorded the conversation, but withheld / deleted, any patient information and insurance company information. . .

https://x.com/EPotterMD/status/1943733126741557576

just to publicize what MDs have to go through to get insurance approval for a procedure.

and yes, she is being sued by the insurance company. . .

good luck to us!
We definitely need it!

[Rainger99]

There is a plastic surgeon who wanted to get insurance approval for a procedure for a woman with breast cancer.

She recorded the conversation, but withheld / deleted, any patient information and insurance company information. . .

https://x.com/EPotterMD/status/1943733126741557576

just to publicize what MDs have to go through to get insurance approval for a procedure.

and yes, she is being sued by the insurance company. . .

good luck to us!
We definitely need it!

WOW!

Who is being sued? The doctor that posted it?

It is dated July 11. That is a fast lawsuit! UHC should approve claims as fast as they start lawsuits!

I would think Morgan & Morgan would bring a class action against the insurance companies.

[Rainger99]

It looks like the doctor has a good chance of winning the appeal. You just hope that the patient is alive at the end of the appeal process..

In 2022, MA plans denied 7.4% of prior authorization requests (3.4 million out of 46.2 million).

A 2019 study found 13% of prior authorization denials by 15 large MA plans were inappropriate and should have been covered under Medicare rules.

And 82% of appealed denials in 2021 were overturned.

[CoachKandSportsguy]

WOW!

Who is being sued? The doctor that posted it?


yes, the doctor who posted it. . she started a go fund me page

[Rainger99]

It appears that the lawsuit involves a different incident than the one shown on your OP.

https://ackman-public.s3.us-east-1.amazonaws.com/2025.01.13+-+T.Clare+and+J.+Ede+to+Dr.+Potter+Regarding+Social +Media+Posts.pdf

[BrianL99]

There is a plastic surgeon who wanted to get insurance approval for a procedure for a woman with breast cancer.

She recorded the conversation, but withheld / deleted, any patient information and insurance company information. . .

https://x.com/EPotterMD/status/1943733126741557576

just to publicize what MDs have to go through to get insurance approval for a procedure.

and yes, she is being sued by the insurance company. . .

good luck to us!
We definitely need it!

This is a very controversial situation and the Dr Potter's story is significantly different than her Insurance company's story. It's been going on since January.

Her GoFundMe has raised almost $300,000 to date. (Fundraiser by Elisabeth Potter : Stand with a Surgeon Facing Retaliation (https://www.gofundme.com/f/stand-with-a-surgeon-facing-retaliation))

[CoachKandSportsguy]

See the post from a doctor who tried the insurance review gig. . didn't go well

https://x.com/houmanhemmati/status/1943914540116095102

[CoachKandSportsguy]

This is a very controversial situation and the Dr Potter's story is significantly different than her Insurance company's story. It's been going on since January.

Her GoFundMe has raised almost $300,000 to date. (Fundraiser by Elisabeth Potter : Stand with a Surgeon Facing Retaliation (https://www.gofundme.com/f/stand-with-a-surgeon-facing-retaliation))

but not different from many other MDs' experiences. . .

[BrianL99]

This thread if the epitome of rehashing what everyone should know and what's been going on for the history of the insurance business. In fact, the situations discussed, forms the basis of the Insurance business.

If you pay someone (Insurance company) to minimize your risks, their decisions are going be "reasonable" in the insurance company's mind (business standards), not yours.

If you have automobile insurance and your car is 10 years old when it's damaged in an accident, you're not necessarily getting brand new OEM parts to fix it. Common sense. When buy auto insurance, you're not buying carte blanche, to fix your car the way you want it fixed ... you're agreeing that the Insurance company will essentially put you back to the original condition. 10 year old cars, don't get brand new, OEM parts.

Medical Insurance is the same. The Insurance company's don't give Doctors carte blanche to do whatever they want ... there are standards of care, you may like and may not like. If you don't want an Insurance company making medical decisions for you, self-insure.

Luckily, people on Medicare have options. If you opt to stay on Medicare directly and not sell your health for a few bucks and opt for a Medicare Advantage plan, you get to direct your own healthcare (within reason). An Insurance company isn't deciding what's medically necessary or what falls within their standards of care.

Staying away from Medicare Advantage plans, means that the patient and the US Government is determining your standard of care ... not an Insurance company that's in the business of making money.

This is not confusing or complicated. This is common sense and has been standard operating procedure since "insurance" was invented.

Extended Auto Warranties? Home Warranties? Dental Insurance? Pet Insurance? It's all the same insurance business and they all work the same way. You pay $100, the Insurance company uses 15% for management & costs, takes 10% for profits and gives you back $75 in services. What's complicated about that?

[KSSunshine]

This thread if the epitome of rehashing what everyone should know and what's been going on for the history of the insurance business. In fact, the situations discussed, forms the basis of the Insurance business.

If you pay someone (Insurance company) to minimize your risks, their decisions are going be "reasonable" in the insurance company's mind (business standards), not yours.

If you have automobile insurance and your car is 10 years old when it's damaged in an accident, you're not necessarily getting brand new OEM parts to fix it. Common sense. When buy auto insurance, you're not buying carte blanche, to fix your car the way you want it fixed ... you're agreeing that the Insurance company will essentially put you back to the original condition. 10 year old cars, don't get brand new, OEM parts.

Medical Insurance is the same. The Insurance company's don't give Doctors carte blanche to do whatever they want ... there are standards of care, you may like and may not like. If you don't want an Insurance company making medical decisions for you, self-insure.

Luckily, people on Medicare have options. If you opt to stay on Medicare directly and not sell your health for a few bucks and opt for a Medicare Advantage plan, you get to direct your own healthcare (within reason). An Insurance company isn't deciding what's medically necessary or what falls within their standards of care.

Staying away from Medicare Advantage plans, means that the patient and the US Government is determining your standard of care ... not an Insurance company that's in the business of making money.

This is not confusing or complicated. This is common sense and has been standard operating procedure since "insurance" was invented.

Extended Auto Warranties? Home Warranties? Dental Insurance? Pet Insurance? It's all the same insurance business and they all work the same way. You pay $100, the Insurance company uses 15% for management & costs, takes 10% for profits and gives you back $75 in services. What's complicated about that?

Ummm...You don't get new "parts" when you have bilateral reconstruction for breast cancer. Most women would love to have kept their "original" breasts, but chose to minimize their risk of death with the substitute "part" which also has product risk.

[rsmurano]

I’m guessing this person has an advantage plan! Because, if you had straight Medicare and or with a supplement, you don’t need prior approval. This is for 99.999% of the time, but you could have an outlier.

Here is a stat that everybody should look at when getting an advantage plan:

Almost all Medicare Advantage enrollees — 99% according to KKF — must obtain prior authorization for some services.

Advantage plans make the insurance companies rich while their clients usually give up trying to get a procedure approved.

I had a long conversation with an advantage plan salesman and he told me that my hospital procedure would have been $0 cost to me using his advantage plan compared to having my supplement plan. But then I asked him can you not approve my procedure? He said of course they look at all procedures and can approve or disapprove a request. I told him Medicare doesn’t require an approval to get something done so why do you? He said they are trying to be fiscally responsible.

Why do you think more and more hospitals are not taking advantage plan? Why has congress been working on this criminal procedures from the insurance companies when Medicare doesn’t require approvals.

[BrianL99]

I’m guessing this person has an advantage plan! Because, if you had straight Medicare and or with a supplement, you don’t need prior approval. This is for 99.999% of the time, but you could have an outlier.


I told him Medicare doesn’t require an approval to get something done so why do you? He said they are trying to be fiscally responsible.

.


Close. Apparently Medicare requires pre-approval on about 1% of claims/procedures.

As has been pointed out 6 zillion times on this site and others, Medicare Advantage plans require pre-approval much more often. At least twice as often.

[goneil2024]

Deciding on whether to elect traditional Medicare or a Medicare Advantage (MA) plan is an important and in my view complex decision for most seniors approaching the age when they are eligible.

MA plans are heavily marketed and for those that did not perform their due diligence they often ask a friend for suggestions, or make the decision based simply on price or other factors. That being said, any such decision should consider multiple factors to include individual and family health history, economic situation, ability to absorb out of pocket expenses, the availability of services and delivery by the provider among others.

For some a MA plan may be the right choice, and according to published sources more than half of eligible Medicare beneficiaries are enrolled in MA plans as of 2024 (per KFF 54%). However It is striking to note that in 2007 only 19% of eligible enrollees elected MA plans and today that number has nearly tripled.

The challenge as I see it for most of us with all insurance purchases, be they property, casualty or health, is that we really don’t know how the agreement/policy will perform until we have a loss, or experience a medical event. Even though state insurance departments are in place looking out for consumers, there is only so much that can be regulated. Also, as noted, most insurers are in business to make a profit for their owners/stockholders, it’s simply a fact of business life.

Insurance in theory is designed to take uncertainty out of the equation, e.g., pay an amount certain agreed premium today for when an unknown and likely fortuitous event occurs. However, it is only at the time of a loss that most of us actually read (if at all) their insurance policies and learn what is and isn’t covered.

Conclusion - perform your diligence and make a decision based on what is best for you and your needs. Always consult legal, financial and subject matter experts before making important financial decisions.

[ElDiabloJoe]

This thread if the epitome of rehashing what everyone should know and what's been going on for the history of the insurance business. In fact, the situations discussed, forms the basis of the Insurance business.

If you pay someone (Insurance company) to minimize your risks, their decisions are going be "reasonable" in the insurance company's mind (business standards), not yours.

If you have automobile insurance and your car is 10 years old when it's damaged in an accident, you're not necessarily getting brand new OEM parts to fix it. Common sense. When buy auto insurance, you're not buying carte blanche, to fix your car the way you want it fixed ... you're agreeing that the Insurance company will essentially put you back to the original condition. 10 year old cars, don't get brand new, OEM parts.

Medical Insurance is the same. The Insurance company's don't give Doctors carte blanche to do whatever they want ... there are standards of care, you may like and may not like. If you don't want an Insurance company making medical decisions for you, self-insure.

Luckily, people on Medicare have options. If you opt to stay on Medicare directly and not sell your health for a few bucks and opt for a Medicare Advantage plan, you get to direct your own healthcare (within reason). An Insurance company isn't deciding what's medically necessary or what falls within their standards of care.

Staying away from Medicare Advantage plans, means that the patient and the US Government is determining your standard of care ... not an Insurance company that's in the business of making money.

This is not confusing or complicated. This is common sense and has been standard operating procedure since "insurance" was invented.

Extended Auto Warranties? Home Warranties? Dental Insurance? Pet Insurance? It's all the same insurance business and they all work the same way. You pay $100, the Insurance company uses 15% for management & costs, takes 10% for profits and gives you back $75 in services. What's complicated about that?
Ummmmm, did you conflate Advantage plans with Supplemental plans in your above-quoted missive?

[rsmurano]

IMO, the advantage plans are no good for anybody. You can look at your past, look at your parents health, but we are all getting older, getting more fragile, still want to act like you are still in your twenties, so nobody know what tomorrow will bring you. A supplement is cheap for what you get. Why do you think that insurance companies can offer you all these little benefits to get their MA plan? You know they have to make money so they give you bread crumbs to entice you then refuse a procedure.
MA plans are only as good when you don’t need them, then when you do, nothing. Later if you decide to get out of a MA plan, a supplement plan doesn’t have to accept you, so you’re stuck possibly forever.
Also with all the issues with MA plans, congress is going to have to make some drastic changes. Here is 1:
Medicare Advantage Plans Get Higher-Than-Expected Rate Increase - ACHI (https://achi.net/newsroom/medicare-advantage-plans-get-higher-than-expected-rate-increase/)

It’s only the start

[BrianL99]

Ummmmm, did you conflate Advantage plans with Supplemental plans in your above-quoted missive?

Not that I'm aware of, but I'm happy to re-word something, if you're confused?