Insurers... yur doin' it rong.

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RustedFox

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Patient yesterday: 56 year old female from Bahhhston. Seen by PMD yesterday with "wicked bad cawffh (cough)" that is productive of yellow, foul-smelling sputum and subjective nocturnal fever. PMD orders outpatient chest x-ray. Denied by insurance for whatever reason. Patient calls PMD.

"Just go to the ER."

Patchy RLL pneumonia. Obviously there. Augmentin. Steroids. Home.

Way to go, insurer; you spent far more on the ER visit than you ever would have if you just approved the CXR to begin with.

Its funny; they want to not pay for "nonemergent" visits to the "Emergency" department, but also deny the "nonemergent" studies ordered in the nonemergent setting.

Hang 'em high, I say.

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Yeah, but what they'll do is deny the claim for the ED visit as well. Only difference is they couldn't act to deny the ED visit faster, because their patient has to get there and be seen first.
 
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The biggest problem in medicine are the insurers, lawyers and administrators. If it weren't for these people, medicine would be more enjoyable, more logical and better for patients. The sheer amount of bloat and stupidity added on by these unnecessary extras is unsustainable.
 
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I have no experience dealing with insurance, so can someone briefly explain how insurance is able to get away with things like this? Aren't they breaking the law, or at least are in breach of contract, by denying payment for blatantly justified services?

We're talking about massive corporations which receive premium flows in the hundreds of billions of dollars a year, there must be an ocean of paperwork regulating when these entities are and aren't allowed to say "we took your money but we're not going to give you anything in return, you're on your own now eff off hahaha!" It's hard to imagine that they can just do this on a whim without any recourse by the affected party in our massively litigious society.
 
Patient yesterday: 56 year old female from Bahhhston. Seen by PMD yesterday with "wicked bad cawffh (cough)" that is productive of yellow, foul-smelling sputum and subjective nocturnal fever. PMD orders outpatient chest x-ray. Denied by insurance for whatever reason. Patient calls PMD.

"Just go to the ER."

Patchy RLL pneumonia. Obviously there. Augmentin. Steroids. Home.

Way to go, insurer; you spent far more on the ER visit than you ever would have if you just approved the CXR to begin with.

Its funny; they want to not pay for "nonemergent" visits to the "Emergency" department, but also deny the "nonemergent" studies ordered in the nonemergent setting.

Hang 'em high, I say.
In my line of work, I get pushback from insurers on imaging all the time, although never for CXR, usually for CT or PET or MRI. I typically just tell them that I'm planning to send the patient to the ER for the test so they can either pay $500 now, or $5K tomorrow. Usually works.
 
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I have no experience dealing with insurance, so can someone briefly explain how insurance is able to get away with things like this? Aren't they breaking the law, or at least are in breach of contract, by denying payment for blatantly justified services?

We're talking about massive corporations which receive premium flows in the hundreds of billions of dollars a year, there must be an ocean of paperwork regulating when these entities are and aren't allowed to say "we took your money but we're not going to give you anything in return, you're on your own now eff off hahaha!" It's hard to imagine that they can just do this on a whim without any recourse by the affected party in our massively litigious society.

I'm hoping the massively litigious society does something right for a change.
 
Yeah, but what they'll do is deny the claim for the ED visit as well. Only difference is they couldn't act to deny the ED visit faster, because their patient has to get there and be seen first.

Can't speak for all insurers, but Anthem Blue Cross/Blue Shield specifically state that they will not deny any claim for a patient referred to the ER by their primary care physician, urgent care, or other medical provider.

I agree, it's a waste of money. $3,000 ER bill vs $200 chest x-ray.
 
Can't speak for all insurers, but Anthem Blue Cross/Blue Shield specifically state that they will not deny any claim for a patient referred to the ER by their primary care physician, urgent care, or other medical provider.

I agree, it's a waste of money. $3,000 ER bill vs $200 chest x-ray.

If that's the case, then I agree that for sure that's a ******ed thing to do for insurance companies.
 
If that's the case, then I agree that for sure that's a ******ed thing to do for insurance companies.

Its criminal what they do.

When I was an early twentysomething, my PMD recommended that I get screened with an echo for HOCM.
PMD set it all up. Lab called and said they wouldn't even schedule the echo without insurance approval.
"No problem", says PMD. Makes a phone call; gets approval.
I went and got my echo. Lots of blue and red colors. Neat to see. Looks good, says the man reading the study.

Insurance later comes back and tries to deny the claim stating that they never approved it.
I got out my little letter stating that the echo couldn't be scheduled until approved.
"Oops", said BCBS.

***Mission failed. We'll get 'em next time.***
 
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I think their game is to put up barricades to not get tests done. I would bet 75% of their denials just stop and quit. That’s a big money saver for them.

They know their books and they deny this stuff because overall it’s a cost saving to them.

No of course they don’t care about the patient.
 
I think their game is to put up barricades to not get tests done. I would bet 75% of their denials just stop and quit. That’s a big money saver for them.

They know their books and they deny this stuff because overall it’s a cost saving to them.

No of course they don’t care about the patient.
I don't think they call them patients.
 
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I think their game is to put up barricades to not get tests done. I would bet 75% of their denials just stop and quit. That’s a big money saver for them.

They know their books and they deny this stuff because overall it’s a cost saving to them.

No of course they don’t care about the patient.
I've also had the experience frequently that when I get an outpatient imaging order denied, or peer-to-peer request, if I just ignore it for a day and re-order it, it will get approved the second time.
 
Ask the reviewer his name, specialty, and board certification. Also tell them that the conversation will be documented and become a part of the medical record.

A dude tried to deny abd/pelvis CT for a patient. I tell him she is uncomfortable and has some guarding. He says sent her to the ER (?). I tell him "well, I think we could save time and money by doing this as an outpt. She doesn't look that sick."

He says he can approve the pelvis but not the abdomen (?).

After some bickering, he said "doc, the way this policy works you can order whatever you want. Do what you think is best."

(Silence)... I just hung up.

Thank you for wasting my time. But really. I have been documenting my conversations with insurance companies and tell them that this is being documented. It can change their attitude.
 
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