Would the fact that a third breast tends to squick people right the fuck out be considered a “medical necessity” or would it only be considered such if it increased the chance of getting breast cancer?
Two responses (based on the intent of the question:
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I present to you the legion Star Trek fans who perceive one of those Kilngon-head-thingies to be “attractive”.
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Our clinicians could go a couple of ways with the 3rd breast. If it was proven to raise the patient’s risk of Breast CA, then they might allow. If it caused blood-flow problems elsewhere in the bosy, they might allow. Long story short, if it were going to conceivably cause problems down the line, they’d allow.
Didn’t Chandler on Friends have a 3rd nipple?
They should have removed him entirely.
-Cem
Is that a Freudian Slip? Are you thinking of cows?? 
Removed Chandler for having a third nipple? That’s a little drastic, don’t you think?
(Sorry, I’ve been working on spreadsheets all morning. I’m cracking up.)
To return to my initial issue with the tri-breasted, looks as though no insurance company is going to approve a reduction on three breasts, though… (You know, doc, I’d like the two on the outsides to be a nice, full C, but the center one? Let’s make that one a B, ok? That one’s just gravy, anyhow.)
Well, isn’t there a rule about the internet which says, “If there’s a webpage dedicated to it, then there’s someone jerking off to it.”?
OK, when I conflated your statement with the mental image of dental-diseased Lampreys, I threw up in my own mouth a little bit.
I’m going to get my Listerine.
-Cem
I had to read this entire thread to get a full overview of where Cemetery Savior is coming from. I feel like he/she resides in Oceania and the Party has brainwashed her into actually believing the things he/she writes.
Does the insurances know more than the doctors? OF COURSE NOT. The doctor is familiar with the actual patient, the person…he knows their symptoms, their history, their mood, their appearance. All the insurance company wants is a code and a number to feed into a computer so it can decide on the fate of the patient that is just that, a number.
Later you stated claims are denied because the codes don’t match the procedure. Who the heck is an insurance company to decide what test to run or what the doctor is trying to rule out? You throw out an arbitrary number of 70% of denials are from coding errors submitted by the providers. Coding errors that the insurance company decides don’t fit into the mold they decide to create. I want my doctor to decide, not some stranger sitting at a desk with a computer in front of them determining what is right for me and my health. Most patients feel the same. Cost containment is one thing. Looking for fraud is another. However, the insurance companies do not do this to improve the health care system. It is all done to increase profits. Which is fine. Just call it what it is.
As far as physicians negotiating fees collectively, there is something called price fixing which negates that right. However, there is no such limitation from insurance companies sharing the rates they negotiate with a provider to their advantage.
In my opinion, UHC is one of the worst insurance companies around. They grow bigger as they gobble up more and more employers with their cheaper rates because they scare providers into accepting fees that are barely enough to cover costs. The providers see the amount of lives insured by UHC in the community and feel if they do not join, they will be unable to stay afloat.
Each year my agent gives me a list of rates from other insurance companies for my employees health insurance renewal. Each year UHC comes out cheaper and each year I push that one aside. I won’t work with them professionally so I am certainly not going to subject the people that work for me to deal with them either.
After reading this thread and specifically Cem’s comments, I am convinced I have been making the correct decision.
First, I’d love to live in Oceania, but the commute would be rough.
Second, your posting is all over the map. I’ll address the points sequentially.
[ol]
[li]When I stated that UHC knows more than the doctors, I meant it on a broader plane that in regards to the individual patient. I agree that the individual PCP will have a better insight into the individual patient. However, we have data/information that dwarfs anything even a hospital system might have. Actually, hospital systems purchase our accreted information FROM us. We hire top-tier clinicians (RNs and MD/DOs) who design our processes. Do we approve every procedure requested by the provider…no. It’s my opinion that we are correct in applying our broad-based knowledge to filter out procedures not within the standard of care. If, through doing this, we save our clients money, so be it.[/li][li]In regards to “forcing” providers to sign with our terriby low reimbursement schedule, we certainly don’t do that. If the provider has a fully-booked schedule, then they’d be foolish to sign up with any managed care network. Typically, providers sign up for potential volume. If it’s not there, they can certainly opt out of their contract at the next negotiation point.[/li][li]The codes. When I read your ranting posting, I can see you have no idea what I’m referring to. When I refer to “CPT” and diagnosis codes, I’m referring to the language the providers use to tell us what they’re doing. If you truly believe we should accept and pay whatever any provider sends us, then you should probably stop reading here. If we receive a CPT (process) code for a angioplasty and an accompanying diagnosis code for “broken left leg”, then we’re not going to pay it. It’s simple fraud protection. Let’s get a little less extrme in the example. Let’s say the CPT code is for angioplasty, and the diagnosis is hypertension. Sounds reasonable, right? It’s not. If that doctor really wants to perform an angio on that high-blood-pressure patient, they’re acting outside the scope of standard of care, and is a maverick.[/li][li]As for Kool-Aid, seems you’ve been drinking some as well. I don’t deny that we act to profit. I’d be stupid to say so. what you need to understand is that not all profit-based decisions are “bad” for the member. The processes and procedures we put in place also benefit the member, from Care Management to Subrogation, to Network and Medical Necessity Review.[/ol] [/li]
You, Ms. Foxy40, are too willing to listen to socialist screeds parroted by the ill-informed. Enjoy your paranoid overreactions.
-Cem
The fact that this debate is occuring kind of proves the original points made by those of us with personal experiences.
The fact that you have to talk at lennnngthhhh about coding with regard to the health and well-being of people shows how absurd the system is and how useless it can be. When I have a near fatal attack I really couldn’t give two shits less what your coding system says and I really don’t need to be spending my rest days post-attack calling the company back after some yayhoo coded NEAR DEATH OF XYZ improperly.
Sesame Street moral of the story: think OUTSIDE the box.
But that would make you a maverick, and that’s clearly bad! Like those docs who managed to successfully cure rabies in a patient. Total mavericks! Much better to give the standard treatment of sedation until the patient expires than to try and save them. (Of course, by them dying, this means that they’ll no longer be able to make those insurance premiums, but hey, that’s long term thinking.)
This has been fascinating and educational. I am still very annoyed at how it took several phone calls and copious notekeeping on my part to get UHC to pay for the speech therapy that had been approved for Fang, but most everything else has been rather forthcoming.
Anyhow - codes are something that have been bothering me. Is there a standard for coding in the medical and insurance industry?
I got one of these. It arrived the day after my ankle reconstruction surgery, and I was confused by the list of questions that seemed designed to find an excuse to deny my claim. Repeated, slightly differently phrased questions about work, work duties, my car, someone else’s car, someone else’s property, old injuries, etc. I was really (really) doped up at the time, and a freaked out and started crying while reading it. My roommate took it away and said I was in no state to make legal statements of any kind, and I could fill it out when I was off the percaset. By that time they’d paid my claim and I’d forgotten about it until just now.
I wonder if they’ll send me another one.
(It was no one’s fault-- I was carrying a pile of books so high I couldn’t see down the stairs of my own house, and I missed a step and fell)
I’m curious. . . is this really true? One or two visits a couple of months later for surgery? (I had ankle surgery, is knee surgery drasticly different?)
I had to go in every week for the first month, for incision inspection and dressing changes, suture removal, cast removal and fitting of a walking boot, monitoring, instructing, etc. (And then once a month until I get certified good to go.) I can’t imagine leaving the hospital in the state I was in and then sort of muddling through on my own for a month or so. If you are not healing OK or have a surigcal infection, wouldn’t waiting that long be a serious problem?
(My surgeon is on staff at Stanford, so I don’t think he’s dumbass)
(Sorry for the double post, somehow I missed the second page and then my edit window.)
Obsidian, I would guess it depends on exactly what was done. A fairly straightforward arthroscopic meniscus removal would not require nearly as much medical supervision as repairing torn ligaments.
I don’t know about United Healthcare but I do know that Aetna is the absolute worst company for paying claims. The place I work stopped using them because the employees complained so much about the lack of payment and denial of claims. It seemed that their first reaction to any claim was to deny it and force the patient to appeal.
Last year, I hurt my back lifting weights and missed work for a month. The company that took care of our short term disability claims had no problem dealing with it and OKing the time off. I went back to work for 4 days and finally had to stop because I couldn’t handle it, my muscles were just spasming too much. In those 4 days, the short term disability company was bought by Aetna. The next Monday, my case worker was gone (he made clear it was because of the purchase, but I wasn’t clear if it was him quiting or if they just fired all the new employees) and my claim was denied.
The medical insurance (BCBS) had no problem believing the doctor that I was in pain and needed the physical therapy I was in 3 days a week, but Aetna said there was nothing showing I was really hurt so they wouldn’t pay the short term disability. I didn’t get paid for the next 5 weeks and ended up going back to work too early because I couldn’t afford to miss more. I wasn’t the only person at work this happened to. If you couldn’t point to an X-ray or MRI showing a broken bone or something on that order, they denied your claim and you were SOL. And the company had a different short term disability provider again this year.
I have had good and bad experiences with a variety of insurance companies over the years, but I absolutely loath Aetna.
Yeah, I had 4 torn ligaments. There were bone anchors involved. Maybe not so straighforward (but it was arthroscopic).
My parents had Aetna. On Thanksgiving day some years back (maybe 10?), my 50-ish father had been complaining of not feeling well, and then wailed and collapsed to the floor in the middle of dinner. My mom called 911.
Turned out to be kidney stones, one shifted and the pain was so bad he passed out. How could there be any option other than to call 911? (We thought it was a heart attack) But because it turned out to be non life threataning, Aetna denied the claim-- hospital, ambulance, everything-- because my mother had not called the pre-approval line before calling an ambulance.
She had actually tried to call from an ER phone later in the day. They were closed for the holiday. Aetna told her that because it was not a real emergency, they should have waited until Friday when they could get through. And leave my unconcious dad on the dining room floor for a day or two, right?
People hate getting these. In its most basic form, it’s a way to help the insurance company determine liability. They want to know if:
[list=a]
[li]It was an accident, in which case someone’s car insurance, homeowner’s insurance, or some other insurance may be liable before the Health Insurance company.[/li][li]If it IS a car accident, the Health Insurance company needs to know who to go after for subrogation purposes (LTS, we’ll pay and then pursue against the auto insurance carrier).[/li][li]They’d also want to know (this would be after a few more letters (I know, they suck) ) if a drug with odd side-effects caused this accident.[/li][/list]
I’m sure people would love to get a phone call instead…but it’s a volume game. If we had enough outreach personnel (yeah, we call them that), we’d be swimming in salaries. Not cost-efficient.
-Cem
Maus, there is absolutely a standard for coding in the industry. The Insurance companies, providers, and all ancillary industries know about these codes.
The ones it behooves you to know:
[ol]
[li]CPT Codes. These are 5-digit codes (you’ll see them on your EOB) that tell the Insurance company what the doctor is doing/has done. They get down to an almost absurd level of specificity. For example (not real codes here), 59845 could mean ulnar surgery for a spiral fracture, 59846 coudll mean ulnar surgery for a straight fracture.[/li][li]Diagnosis codes. These tell the Insurance company what’s wrong with you medically. They are 3-digit codes with up to two decimal points following. They’re even more specific. For example, 250 means Diabetes. 250.xx could mean diabetes adult-onset with obesity factors. [/li][/ol]
To be frank, Speech Therapy is a trouble spot for almost all Insurance companies. Standard processes (these can differ if your company is very large (@5,000 lives+)) state that SPT (our lingo) is allowed only in instances of injury, congenital deformity, or congenital cause. What we’re seeing a lot of nowadays is SPT prescribed for Autism. Since doctors don’t view Autism (in many cases) as congenital, we tend to deny SPT as a non-covered expense. Oftentimes, an appeal wil overturn this, as upon discussion, Autism can be defined as congenital (tricky for our clinicians, but I’ve seen it happen often).
-Cem
Sesame Street moral of your story…don’t blame the insurance company, blame your provider who coded it incorrectly.
That’s harsh. Having said that, there’s a computer-age chestnut that is summarized by “GIGO”. If your provider can’t code accurately, what are our computers supposed to do? Unless HAL has been conscripted into UHC, I don’t see AI systems that can read a doctor’s mind.
If we were in a socialized medicine construct, I don’t see how your situation would have been any different. Coding needs to come in clean for the processing to work cleanly.
I sympathize with your rest period being taken up with calls to the provider…really. In the system we have, we need to make sure that you are getting accurately-prescribed care for what ails you. Pre-Certification is one of those ways. If it’s an accident, we allow you to pre-cert (really, your doc should be doing this) retroactively.
-Cem
Hysterics before bedtime, Tuckerfan?
Standards of care are not defined by the insurance companies. We rely on professional organizations to update us on new procedures and processes for cures.
UHC is in constant touch (through our aforementioned clinicians) with the American Medical Association, various specialized boards (Orthopedic Association, Asthma, American Cardiovascular Surgeons, etc.) [I may have gotten some of those orgs wrong], precisely so we can get our processes “correct” per prevailing medical wisdom.
And before we bring out the “Alternative Medicine” folks (not referring to **Tuckerfan ** here), we keep up to speed on all of those as well. We have a network of qualified practitioners of Naturopathy, Acupuncture, Holistic Therapy, and others (all of my clients currently offer Acupuncture to their members).
As ror Rabies…from what I understand, it’s a needle-intensive “cure”. For my own personal self, I think I’d rather start foaming and howling at the moon.
-Cem
Actually, you’re completely wrong. Rabies, if caught before symptoms appear, can be treated with a mere seven injections in the arm. Shitloads better than the ol’ “21 to the tummy.” However, that was not the cure I was referring to. I suggest that if you can’t access the full article on line, you track down a copy in your local library as it describes, in detail, how a team of doctors for the first time ever, successfully treated rabies after the victim displayed symptoms of the disease.
So, wherever they are now, I hope that the OP is cheering on Luigi.