I wonder who has the most control in my health care decisions. Is it me or the doctor or my health insurer? I have to consider who gets to say NO the most.
Here is how I see the flow. I go to the doctor for a variety of reasons from annuals to sick visits. The doctor evaluates my situation, then orders tests, procedures or writes a prescription. The insurer may agree and pay the doctor or not agree and the bill goes to me.
The insurer may get an appeal from the doctor if any treatment isn’t approved but they don’t have to reverse it. And the most interesting part is the insurer is not obligated to give you a medical reason for the denial. Some of the most common denials are:
“This is not medically necessary”
“Our medical staff has reviewed your request and feel it is not necessary”
“We want you to see someone in the network.”
“We would like you to try another medication in our formulary.”
I recently had a case where I specifically requested the insurer to give a medical explanation, if the appeal was denied. I had researched the disease process and discovered, the surgical treatment a several local surgeons wanted to perform, was not supported by the most recent replicated research and data. The long term outcomes were far better than the older method which often resulted in a second surgery. I sent copies of the research with the appeal and felt I had proved my point beyond a doubt.
I didn’t get approval for my client and I didn’t get a medical explanation as to why they supported the old out dated research. I estimated the cost was about the same. The difference was the surgeon my client wanted was out of network. The cost saving philosophy was more important the evidence based research.
Who is responsible if the insurer denies coverage for the current most effective treatment and the patient has a poor outcome? My vote is the insurer.
When many are faced with a serious diagnosis and need extensive care, who controls the care? Many insurance policies limit options or opinions. Patients are making medical decisions based on what their insurance company will pay. Many patients must consider what will be the lowest out of pocket cost to me? No longer can the thought be, where can I get the best care?
I have experienced after many appeals, that complicated cases rarely get approved. Complicated cases often mean more payout. I also have learned that the medical review team are not always the experts in the area being appealed. I had one insurance appeals doctor state to the office RN that it didn’t matter what research or information was sent, he was not going to reverse his decision. He didn’t like the procedure.
Politicians espouse the need to not let government control our healthcare. I say, don’t let the insurance companies control our healthcare.