Insurance company denials (the reasons get more and more shady!!)

These days, it’s getting harder for doctors (like me, for example) and hospitals to get paid for the work they do caring for patients who…supposedly…have insurance coverage.  Call me crazy, but I would think that there is a reasonable expectation that when you have coverage, that you have coverage.

I noted a decline in the willingness of insurers to cover care that really accelerated during the Covid pandemic, and continues now.  The attention of the public was on the health crisis, and then as the pandemic issues have wound down, the media has focused on other issues in the news to keep the eyeballs on their screens, but I hear nothing about healthcare or insurance coverage.

While we are all looking away (except for those who need do deal with their healthcare bills), the insurance companies are laughing all the way to the bank.

Look at their business model:
–Take in premiums (revenues),
–Pay for some part of costs of healthcare (expenses),
–Whatever is left over is their profit.

In other words, if they spend a dollar to help you buy your medicine, that is one dollar less that they make.  But on a larger scale, if they can find reasons to deny services that cost greater amounts, like elective orthopedic surgery, the insurer will save literally tens and sometimes hundreds of thousands of dollars.  And…they have all the control over the medical decisions and no liability!

I can share that as a provider, understanding that while many people are happy with their coverage, I have more frustrations.  The denials have become more frequent and ridiculous. Example:  I will see a patient with back pain and order physical therapy.  For some reason, the insurer denies the therapy.  When the patient’s pain gets worse, I order an MRI.  Not surprisingly, the MRI is denied.  The reason given for the MRI denial?  That the patient has not had physical therapy.  Pure genius!!

Insurers also deny care by delaying care. Just like the expression that “justice delayed is justice denied,” same goes for medical care. I have many situations where patients are in significant pain, with treatable conditions, and the insurer always wants another form or report or other document, in a process that seems interminable, all while the patient, with a treatable problem, suffers.  Worse than that, I have had an insurance company, in the middle of therapy (like wound care, or with antibiotics for an infection) tell the patient that they are not authorizing any additional care.  I am quite confident that no insurance executive would stand for any friend or family member of theirs receiving similar treatment.

Though it is patently ridiculous that this type of advice would be needed, and given my impression that many of the denials border on bad faith, here are some tips on filing an appeal:

https://healthyfuturega.org/get-help-with-health-insurance/problems-with-your-health-insurance/

Otherwise, for those occasions where I have written a complaint to the GA Insurance Commissioner about insurance company behavior that I would consider to be bad faith or objectionable, they have sent my complaint to the insurer.  It would be like if I were ripped off by a plumber, and I complained to a state agency, and they just sent my complaint to the plumber.

I would love to be wrong about this issue, but this picture shows my impression of what the Insurance Commissioner does with complaints.

While I grant that there are some docs out there who will run up bills on any patient with an insurance card and a pulse, that percentage of clinical decisions is very small, and the insurance pendulum has swung too far in the direction of obstruction of care options.

Also, given that money is considered speech, and that politicians will need money for their campaigns, and that insurance companies have a lot of money, I don’t see how this situation will change at any point in the near future.

My only suggestion is to keep fighting, keep being a thorn in the side of any regulatory agency, or with the bad press to the insurers on social media, to shine sunlight on this pile of you know what.

Glad I can brighten your day.

😊