[billethkid]

A friend of the family has had a procedure ordered by their cardiologist. The imaging lab won't do the procedure without approval from the insurance carrier. The carrier has had the request for over a week and stated it is under review.
The doctors office has been in contact with both the insurance carrier and the lab provider requesting the procedure be done as soon as possible. Still no reaction from insurance other than it is awaiting approval.

The patient then decided to pay for the procedure out of pocket and deal with the insurance afterwards.

And now the real kicker in the equation of confusion......the lab stated they could not accept self pay without a denial from the insurance.

The insurance is BCBS!!

I have suggested the friend put both BCBS and the lab on notice that if anything serious should develop as a result of the delays that they will be pursued legally. If it were me personally, I would be pursuing legal or any other action ASAP.

Is this a part of the future of health care in America? An isolated incident? An error somewhere?

Time will tell.

[DDoug]

Yes it is and you have only one to blame

[rubicon]

There are so many examples of this type going on and it also applies to Medicare. Watch what you wish for as you just might get it applies here. We want the federal government to fight fraud and waste but the problem is that the federal gov't keeps the water and throws out the baby.

There is a downward pressure on doctors to do more for less under medicare which means patients are going to take the blunt of it.

I had a supplement via my employer. Because of ACA my ex-employer has informed me that I buy a supplement on my own and they will reimburse me. My experience tells me like pension reform going from a defined benefit to a cash plan I am going to take a beating. so what I will need in a medical supplement is going to cost me much more than what I am now paying....and they call that progress but do not define for whom

[blueash]

Interesting how all of you are jumping on blaming the Federal government and the President. This has nothing to do with Federal efforts to fight fraud nor the ACA. This is not new and is due to the contract which the patient signed with the carrier when he was insured and the lab signed when they agreed to be in network and accepted the carrier's patients. This is a private insurance matter. The lab is required to accept the rules of the insurance company when they see one of that company's insured patients.

I am a bit surprised that there would be a prohibition of a patient declining to use their insurance and pay out of pocket as you should, I would think, be able to decline to use your insurance just as you could with a car repair or home fire which might have otherwise been covered by your insurance. Keep in mind that if you go outside your insurance you will be responsible for the full charges, not the reduced charge which the carrier has negotiated with the provider. I wonder if the refusal of the lab to do the test without a denial was an error or just their internal policy.

It is possible that it is taking time to get approval as the patient's condition does not fit the criteria established by the carrier for the test to be covered even though the doctor ordered it.

By the way, threatening everyone with lawsuits is not generally a way to get them to see the wisdom of your position.

[ilovetv]

Originally Posted by blueash

Interesting how all of you are jumping on blaming the Federal government and the President. This has nothing to do with Federal efforts to fight fraud nor the ACA. This is not new and is due to the contract which the patient signed with the carrier when he was insured and the lab signed when they agreed to be in network and accepted the carrier's patients. This is a private insurance matter. The lab is required to accept the rules of the insurance company when they see one of that company's insured patients.

I am a bit surprised that there would be a prohibition of a patient declining to use their insurance and pay out of pocket as you should, I would think, be able to decline to use your insurance just as you could with a car repair or home fire which might have otherwise been covered by your insurance. Keep in mind that if you go outside your insurance you will be responsible for the full charges, not the reduced charge which the carrier has negotiated with the provider. I wonder if the refusal of the lab to do the test without a denial was an error or just their internal policy.

It is possible that it is taking time to get approval as the patient's condition does not fit the criteria established by the carrier for the test to be covered even though the doctor ordered it.

By the way, threatening everyone with lawsuits is not generally a way to get them to see the wisdom of your position.

I think this is probably the crux of the matter as Blueash stated:

Keep in mind that if you go outside your insurance you will be responsible for the full charges, not the reduced charge which the carrier has negotiated with the provider.

Also, I think people often forget or don't know that every not every insurance plan contracted by an employer or group is the same just because it's the same insurance company. Some plans are hefty (and more costly) and some are more meager and cheaper.

Personally, I have no idea why people think denials like this (and worse) would not occur under a national government single-payer system. This is a prime example:

(CNN) -- At least 40 U.S. veterans died waiting for appointments at the Phoenix Veterans Affairs Health Care system, many of whom were placed on a secret waiting list.

The secret list was part of an elaborate scheme designed by Veterans Affairs managers in Phoenix who were trying to hide that 1,400 to 1,600 sick veterans were forced to wait months to see a doctor, according to a recently retired top VA doctor and several high-level sources.

For six months, CNN has been reporting on extended delays in health care appointments suffered by veterans across the country and who died while waiting for appointments and care....

Dr. Sam Foote just retired after spending 24 years with the VA system in Phoenix. The veteran doctor told CNN in an exclusive interview that the Phoenix VA works off two lists for patient appointments:

There's an "official" list that's shared with officials in Washington and shows the VA has been providing timely appointments, which Foote calls a sham list. And then there's the real list that's hidden from outsiders, where wait times can last more than a year...."

A fatal wait: Veterans languish and die on a VA hospital's secret list - CNN.com

[Bizdoc]

Actually, this isn't all that uncommon. Most is "out of sight" of the patient as it gets worked out between the doctor and the insurance company. Yes, the *insurance company*. Not the federal government, not Medicare, not some "nameless faceless bureaucrat". When your Medicare Advantage plan plays this game, it is the insurance company, not Medicare screwing with your mind.

It has been going on for quite some time. The insurance companies are the ones who create the problems. In their rush to "manage care", they routinely put all kinds of roadblocks in place to avoid having to authorize and/or pay for all manner of things.

My DW has a prescription that at least once a year the insurance company refuses to pay for claiming that she could be taking a different drug (which oddly is the same price - I've checked). Now she's be on the same drug for 20 years and her doctors had tried alternatives and her doctor has to waste time answering the silly questions from someone who isn't even a trained medical professional.

[gomoho]

Actually Bizdoc, I believe the insurance carriers for Medicare are paid at rates that are
set by the government. So it does start coming down on your from the top.

And it appears the breakdown is at the insurance company - but we can only guess at
the reason for this. But I'm sure most screw ups of this sort will be blamed on Obamacare because it is such a mess it's hard to believe it isn't somehow responsible
for anything that goes wrong in health care.

[Bizdoc]

The insurance problems predate ObamaCare by many years.

The Medicare Advantage programs justify the premium rates they receive (above standard Medicare rates) based on their "ability" to reduce costs to Medicare. How are they going to do that, especially when they give away money in the form of rebates to attract customers? They do it by finding ways to not authorize treatment or delaying treatment until the patient gives up.

[Cathy H]

My hubby "sweaty' says that his immigrant granny always said; "You pay cheap, you get cheap". Does it take a big brain to understand that no-cost or low-cost Medicare Advantage plans must do things to patients to save $, including denying some expensive services and referrals?

[Carla B]

Originally Posted by Cathy H

My hubby "sweaty' says that his immigrant granny always said; "You pay cheap, you get cheap". Does it take a big brain to understand that no-cost or low-cost Medicare Advantage plans must do things to patients to save $, including denying some expensive services and referrals?

And I'll bet that, in general, Original Medicare pays the provider more and reimburses claims in a timely manner vs. a Medical Advantage insurance company. My daughter expresses much frustration dealing with Aetna on behalf of her employer, a large for-profit hospital chain. No such problems with Medicare.

[Bizdoc]

Always remember that an insurance company does not make money by paying out claims...