Dr. Heller: "This is Dr. Heller, on behalf of Major Illness Insurance test authorizations. Who am I speaking to?"
Dr. Grumpy: "Hi, this is Dr. Ibee Grumpy. I'm calling to get an MRI authorized."
Dr. Heller: "Okay, let me look at our file... It looks like we denied the MRI because it isn't clinically indicated."
Dr. Grumpy: "Well, this is a young man with memory problems, and I want to make sure his brain looks okay."
Dr. Heller: "Have you checked labs for metabolic causes? Have you ruled-out depression?"
Dr. Grumpy: "His labs look fine. Depression certainly could be the cause, but I want to make sure he doesn't have a tumor."
Dr. Heller: "Our policy is that he needs to be evaluated by a psychiatrist for this before we do the MRI."
Dr. Grumpy: "I tried that, but your company doesn't cover any psychiatrists."
Dr. Heller: "That's correct."
Dr. Grumpy: "So how do I go about getting this done?"
Dr. Heller: "You're his doctor."
......wow.
ReplyDeleteWell, certainly nice to know they're saving patients money on potentially bogus tests by requiring confirmations via services not covered by them!
ReplyDeleteExtra points for the Heller reference.
ReplyDeleteMore seriously, I am SO glad I no longer have to deal with the US health care delivery system.
this is hysterical. reminds me somewhat of what happens when you try to bill Medicare part b for diabetic supplies for a patient with a m'care advantage plan. B, who normally covers, says bill the advantage plan, advantage plan says no supplies covered. also Patient has secondary insurance but that only covers benzo and OTC. you can't be diabetic with an advantage plan
ReplyDeleteThat is so unbelievably obnoxious, I don't even know what to say.
ReplyDeleteBut at least it's not a government bureaucrat standing between the patient and healthcare! See? The private system keeps the government out of our lives. Isn't this better?
ReplyDeleteI'd rather have a government bureaucrat that doesn't care tan someone who is actively working against me to save money.
Captcha: undead - another pre-existing condition
Is the patient reporting any symptoms of depression? Could the patient receive a depression screening from his PCP?
ReplyDeleteI think it's time for me to move to Canada.
ReplyDelete"....and we also require you to test him for the Zombie virus. If he turns out to be a Zombie, he will be dropped from the plan per contract."
ReplyDeletePsychiatry isn't important. That's what prisons are for.
ReplyDeleteIt's really not so hilarious when you're 6 grand in the hole for an ER admit for observation because your kid was sick and private insurance just dropped him because he met his deductible this year. Yeah. Capitalism all the way; we don't just 'seize the day', but we seize the sucka, sock it to 'em, suck it all outa him.
ReplyDeleteThis is an average Joe. Not someone waiting in line at the free clinic, just because we chose the wrong career path in college. Nope. Someone that unfortunately actually got sick and had to use the insurance.
I'm with Annonymous. Throughout the last year or so as I was diagnosed with and than began treatment for depression I saw my doc and a few psychologists. I considered myself very lucky because as a student I was to access support many can't. By why can't his GP or internist make the diagnosis?
ReplyDeleteI thought the law required them to provide coverage. If they have no psychiatrists in their plan don't they have to accept a non-plan psychiatrist and provide coverage as if he were on the plan?
ReplyDeleteAnd for this same reason my husband's GBM tumor was over 8cm when it was finally taken from his head some 9 months after it started growing. With an MRI when his symptoms first started who knows how many more years we could have had?
ReplyDeleteProblems like this make me pleased Australia has its own system even with its flaws. If I needed a MRI it would go like this.
ReplyDeleteDr: You need a MRI, who do you prefer to go with Company A or Company B?
Me: Company B is closer to my home.
Dr hands me referral for MRI with Company B.
At home, Me calling Company B.
Me: I'd like to book in for a MRI please
Company B: Do you have a referral?
Me: Yes from Dr XYZ.
Company B: Our first available is .... is that convenient?
Me: Yes. Do I need to bring anything?
Company B: Your medicare card and the referral.
Me: See you at ?am/pm.
On agreed date (which can be anything from the next day to two weeks), I show up and have the MRI. I sign the medicare form and then leave the building without having paid a cent. My taxes do that.
The end.
This is a crime. My hat is off to you, Doc.
ReplyDeleteCompany Paid Health Insurance is Part of Your Salary
ReplyDeleteMany people misunderstand who pays for health insurance. It is convenient to think that "good" employers provide health insurance, but "mean and stingy" employers leave their employees to scrounge for themselves. They complain that everything would be fine if we forced all employers to be "good".
In reality, an employee's health insurance and all other benefits are part of his earnings, part of the payment he gets for doing his job. The tax law encourages an employee to receive some of his earnings in tax-free health insurance outside of his paystub, with all other earnings reported on his paystub. It is all payment to the employee, from the view of the employer.
People are already personally paying for their "employer-paid" insurance. They don't buy it directly so (1) it doesn't attach to them when they change jobs, (2) and they can't shop for the insurance they might want. The employer writes the check with part of the money earned by the employee.
The worst part is that people like the above patient get insurance purchased by his employer, and all of the "gotchas" are there to lower the employer's cost. The employer may feel that he is doing the best he can, given the economic balance between offering more cash or more insurance.
Untangle the tax mess, remove employers from the middle, and salaries would go up in the amount of the "free" healthcare benefit through employers. Then most people would have enough take-home pay to buy their own health insurance. Doctor's and insurance companies would compete for their business, pressing prices down. That is what healthcare reform should be about, along with removing anti-competitive rules and interest group mandates from the insurance market.
Good old Catch 22!
ReplyDeleteMission aborted?
So what eventually happened? Did your patient get his test? Is he OK?
ReplyDeleteWhen I was having my migraine work up last spring, we wanted a head CT to rule out sinus causes (because I have a history of them), and they wouldn't let my GP order it, it had to be the ENT. So they paid extra for another two appointments with ENT so I could get the MRI (which they happily OKd from ENT). Not surprisingly, it was clear, so wouldn't it have saved everybody, including Aetna, money to let the GP order the test, and then send me to ENT if it had looked funny?
ReplyDeleteSame with the echo, since I have a clotting factor disorder and an arrhythmia - only cardiology can order that test, so that was another two visits to a specialist. Again, if they'd allowed my Neuro to order the test, if it had come back with issues I could have then gone to Cardio. So all told I count four unnecessary specialist visits paid for by Aetna because of their own stupid rules. I don't think it saved them any money.
That is ludicrous! I don't see how medical authorizations people can go to work everyday to spew out authorization guideline nonsense like that! Granted, we have our share of MD offices that despise us based on certain med guidelines we have in place but we suggest alternatives that are covered.....Hmmmm
ReplyDeleteYep. Another day in the life of a pt with a difficult-to-treat illness. And another day for her/his doc.
ReplyDeleteAs someone with a newly dx condition, it is typical of what I am getting. Went for s stress test after a weekend in the hp with chest pain and funny cardiac enzymes. (no infarct) Turns out the nice lady at the admit desk said I had BC from the state I live in.
WRONG
I have BCBS from another state. One that requires pre-auth for the stress test.
Of course, this is not figured out until I've gone to the office after a 12-hour fast. So nice lady at cardiologists' calls and calls this version of BCBS until she gets a HUMAN not the computer.
I got the test. And the results are "abnormal." I love American medicine, but ...
Sorry, Mr. Garland but most companies today use a company sponsored insurance plan. That means a billing agent (like Blue Cross) estimates the cost of each plan per person and family and the company offers a percentage of the premium and the employees pick up the tab for the rest. Blue Cross isn't paying the tab for the bills, however. The Company is actually paying the bills, offset by the amount of the premiums. Blue Cross is only the billing agent, do all the handling. The actual dollars for everything are coming from said employees and Company.
ReplyDeleteIf you are in plan like this, a Company sponsored plan, you can try to work with the Company to get changes made. However, if you are one causing big bills to be run up, that can be dangerous. It is against the law for you to lose your job because of health issues but we all know that it can and does happen.