Should a company's health plan tell you ahead of time ...

... what they won't cover?

I'm hearing a lot of stuff about insurance companies denying coverage. Oh, I could care less why they do it. Whatever reason they gave came out of their collective corporate ass.

I'm just wondering if they can deny people, shouldn't they be able to give you a list of things they won't cover when they first hire you?

I work in a doctor's office where we order a lot of lab tests for things like checking for toxic metals and food allergies. We regularly call insurance companies to find out if they will cover these labs, as well as other office procedures. Their response? "Go ahead and do the procedure, file the claim, and then we'll decide."

Insurance companies are practicing medicine without a license. Besides denying tests and procedures after the fact, they also dictate which name brand prescription drug they will or won't cover. I'm not talking the difference between brand name and generic (which makes some sense, cost wise), but rather one name brand drug vs another, both pricey and costing about the same. We have a patient who has a terrible reaction to Name Brand X, but when Doc prescribes Name Brand Y, the pharmacy calls up and says, "The patient's insurance will only cover Name Brand X". So the patient has these choices: Pay hundreds of dollars for a drug that will help her and not make her sick, take the drug that she knows will make her sick, or opt to take no drug at all. I've seen this happen again and again, and so again I say that insurance companies are practicing medicine without a license.

Our new insurance is seriously f'd up. Our son and I had both been on a drug that had been working for awhile. New insurance said they didn't cover it. Thank goodness the new drug for our son is working about as well, but mine sure as hell isn't.

Who the hell are they to decide my healthcare plan?!

the patient to give you a copy of their contract, or if it is a group plan sometimes you can get it on line through the carrier's website.

They deny then put the burden of proof back on the provider for medical necessity. This is particularly true with drug formularies and newer, more expensive drugs. Sometimes I think the drug formulary which is of course a negotiated thing is just designed to provide profit for certain drug companies. It would be fun to prove that, wouldn't it

This is a different issue from the Policy Exclusions and Limitations which will define conditions and procedures that they never cover.

For this post! :kick:

a very lengthy brochure that spells out just what they will and will not cover. When I read ours a few years ago, I was rather horrified by what wasn't covered.

Since I only read through it that once, I can't tell you any specifics, but I'm sure there's some sort of weasel language that is a cya for maybe or maybe not covering things specifically spelled out, such as tests.

the second one is most often applied to conditions where a physician is prescribing a medication (that is indicated by its Product Information for a certain condition)for a different condition NOT listed as an indication.

This is because FDA tests a drug for certain diseases/conditions, they have done all the clinical trials and it is supposed to be safe and effective for say Irritable Bowel Syndrome. So an astute doctor notices that some of his IBS patients are also getting relief for say nausea from this drug. So he starts prescribing it for nausea. But it is an expensive drug with a very specific set of diagnoses for which it is approved. So the insurance company can come back and say..Dr X ..even though it works, use something less expensive, perhaps even something over the counter. .. at which point the doctor then has to make a very good case why this drug ordered for nausea is the only thing that will work for his patients.

Whether you read the book they give you, that's your decision.

I'm sure it's not the first time.

They can change it at any time without telling you.

The reality is, they do have some decisions out in the open, but many of them are made on a case-by-case basis. They might allow that procedure for a cheaper patient but not for one who's been costing them a lot of money. They might okay that drug for you but not for me. It's all about nickel and diming everyone because that adds up to serious money after awhile.

Ask yourself why those companies have 20-30% overhead and why Medicare has a 3% overhead.

the person sitting next to them. FACT.

I have never seen a procedure denied because a person had heavy expense versus one with a low cost ratio. Where they get the people with the heavy expenses is at policy renewal. Either the group is told by the carrier they won't cover them because of prior claims history, or the rates go through the roof.

I have seen a procedure denied because an examiner didn't take the time to think outside the box a bit and figure out why this procedure was ordered. These are production jobs and they all have quotas, so they deny something they can't figure out without some thought or research so they can meet their quota and keep their job. Even in Medicare Part B although that system is pretty well stacked to keep it from doing that.

Of course there are the ever popular coding errors or diagnosis errors

I have seen procedures denied because of the actual payment side..example: the policy may have a cap of payout per diagnosis. Once you max that diagnosis no more benefits for anything (I hate those things by the way. Very very difficult to process and not really very beneficial to the insured but that is the whole point.) Real good on paper absolute hell to make the system pay them

If they can find a way to screw the patient or the provider to keep their money, they will. A few years back, one of the hospitals in Lansing dropped BC/BS for not paying claims going back more than two years. BC/BS claimed that they didn't have the money at first, then that the claims were under investigation, and when the hospital made good on their threat to drop, BC/BS paid it all in a week.

Hubby started at his new practice a year and a half ago, and he still has some outstanding billing from when he first started. A year is pretty normal, actually, with a lot of insurance companies. His practice only gets 60% of what they bill out--and that's taking the lower payments into account.

its own section in the policy.
Nowadays you can view your coverage on line.

When the plans are presented, best thing to do is call the customer service line for the plan and ask.

Most exclusions and limitations are fairly standard, by the way and fairly interchangeable. A particular group may write the plan without some standard exclusions, such as in vitro fertilization or breast reduction because it is something the group really wants.

edited to add: I have spent much of the last 30 years interpreting insurance policies for claims payment or explanation to customers and/or providers. It's there.

And they do.

Is it deductible - is it out of pocket - is it copay - is it not covered?

I've had real problems with how clinic codes things (all this medical coding was placed by the health care industry), then gives insurance an "out" to not pay -- then try to get clinics (who depends on contracts from insurance companies) to change the code!

Check out Medical Economics for their regular column on it (memag.com). A doctor has to pick a billing code (among hundreds of options) and then make sure the chart backs up that code. It's a mess.

are owned in some round about way by the insurance companies!

I spent three months writing a module to handle those codes on the insurer's side, because there is just no way the adjusters can manage that on their own and ever be right in what payouts are authorized.

Still, it is a bit of a zoo. Thousands of codes, all modified by thousands of other codes.

Wheeeeee!

Drives him nuts. His former practice had one that helped with coding, and he misses it. It was a lot easier to use than paper charts. His current practice is in the process of figuring out which one to get.

I have worked in several different settings, processing claims. Any change in the policy will be applicable to an entire group at once. That information should be made available to the group members at enrollment time and would advise an effective date. Individual plans will often effect these changes on the policy anniversary and advise by letter 30 to 60 days in advance to allow the person to seek replacement coverage if they wished.

When I was pregnant, our BCBS individual plan sent us a letter in August advising Maternity benefits would no longer be in the base policy effective October 1. My due date was November. However since I was already pregnant, the current pregnancy was covered.

As processors, we had to know if a plan changed its benefits and the actual effective date of that change, so those advisements also came to the claims shop. We usually knew about 10 days before the actual effective date of the change.

The real catch clause is in "other conditions deemed not medically necessary" at which point your physician has to prove it is.

Insured plans are pretty strictly regulated by the insurance commissions in the various states. No Department of Insurance I know of would let that stand.

And self-funded plans are regulated under ERISA, which would also prevent the plan from just changing the terms of coverage at will.

Plans can be changed at the time of renewal, and the purchaser then has the option of not renewing and seeking coverage elsewhere.

Formularies--they'll say a certain drug is covered, have covered it for awhile, and then all of a sudden say that they don't anymore.

The best thing would be to scrap them all and have a nationalized single payer plan.

If you have paid in to an insurance plan, they should not be allowed to refuse to cover medical care. They should not be allowed to determine what medical care someone receives, since they are not qualified to do so.

They determine what medical care they will pay for.

Are changes required? Yes. However ignorance of the current system and silly rhetoric is not the way to affect change.

For example, the medicine our new company wouldn't pay for cost me and my son each $160/mo. Now, we have the money to make it work, if need be, but I don't know that many people up here in Michigan who have an extra $320 a month lying around. So, we switched to the meds the company would pay for, and while it's working okay for my son, it's not working that great for me. We might have to suck it up (since our company is known amongst medical billing types for being awful about paying for anything) and just pay for the one for me--that's on top of a $60 co-pay (after we meet the $2400 deductible) for almost every prescription we're on (three of us have asthma, and two of us have severe GERD, and I have other health problems).

Most people cannot afford to pay the difference, and too many people don't meet Pharma's requirements for help with scrips. So, by denying coverage or denying procedures or meds, they do determine care.

It's not affordable but it is available.

I'm not endorsing the practice - I find the insurance situation in the states today appalling but if we're going to take it on, we have to address it properly. This will be the response from Republicans if we try to say that HMOs should not be determining care. They will say the HMOs don't determine care.

They've already said it! I'll look up the McCain person who said that all Americans already have health care coverage because they have access to an emergency room. It's wrong, it's heartless and it's appalling but we have to fight it with facts, not rhetoric. Fight it on the grounds that it's unaffordable to the average American, that uninsured citizens are charged more for the same services HMO insured citizens are, but don't give them ammunition to nitpick, distract and thereby win this important debate.

It's not a problem, since they're still on the market, right? Everyone who needs a car can totally figure out how to get a Lamborghini, right? Their argument is that it's okay to settle for less than the best care--going to the ER instead and paying the thousands in bills from one visit for years instead of seeing a doctor in a timely manner and getting the right meds and the best care.

Most people I've talked with about this, even right-wing Republicans, realize that their insurance companies determine what care they receive, especially if they don't have the money to make up the difference.

they only look at what's cheaper in the short run.

Several years ago I went to my internist with a sore knee. After checking the x-ray he told me he could prescribe the anti-inflammatory thaty would work or the one my insurance company would pay for. He added that, if I went with the insurance approved drug he'd also make an appointment with an orthopedic surgeon because he'd guarantee that I'd be having surgery. Fortunately, the non-approved drug wasn't that expensive (and certainly cheaper than surgery) and I went with that. Cleared up the problem in a matter of days.

A more serious case was my friend's mom. She was on Lipitor and the insurance company decided they wouldn't pay for that but would cover a similar cheaper drug (something else may have gone generic, Lipitor has not done that yet). She couldn't afford to pay for the Lipitor out of pocket so she went with the new drug - which didn't work for her, but the insurance company didn't care.

This is why we need single payer and need to get the profit motive out of health care coverage.

and no freaking pre existing allowed. Medicare was supposed to be the pilot program for national health insurance. The best they could get was Medicaid for those under certain income and situational levels.

I used to argue with doctors who wouldn't accept assignment on Part B claims ..their complaint was that we cut it back too much..I replied "well, when we pay it you know you are going to get paid and you know exactly how much. If you don't take assignment you have to depend on the patient to fork up the coinsurance and deductible and maybe they can't afford it "

I have either been insured under or processed just about every type of plan there is. The smoothest run, least overhead is Medicare.

The worst are those bogus plans they market to self employed persons with teeny tiny groups. Huge premiums, lousy benefits.

I worry about the uninsured, and under insured and the ones who just don't know how to get the most out of their insurance.

The payout is low, so most doctors keep their Medicare census to a certain percentage, if possible, but at least you get your money.

If that doesn't work, the patient can then "choose" to pay for the more expensive treatment. I put "choose" in quotes because for many this is not an option. Many cannot afford to pay and so it is not really a choice at all. They must either accept sub-optimal treatment or nothing. That is not a real choice in my opinion. My point, which you may find to be ignorant and silly rhetoric if you so choose, is that insurance companies and the medical system should not be forcing people to make such choices. They should be providing real and honest medical coverage that meets the needs of the people. Such changes can only occur when people stop pandering to and making excuses for these companies and the corrupt government officials that support them.

they can do so legally, then they should put it in plain English. Like my husband's policy was very specific that they didn't cover end stage renal disease, so what did my husband get? End stage renal disease. But at least we knew. Fortunately Medicare covered it. I think we really just need Medicare to cover everything and everybody and the Hell with the insurance companies. No middle men needed. Just let them stick to insuring things like cars and houses not people.

after a certain amt of time with ESRD you are eligible for Medicare..forget exactly the time frames. Some group I serviced at my last insurance employer covered the ESRD as a secondary, so we coordinated benefits with Medicare on it.
same with Black Lung which is a subset of Medicare

I absolutely agree with you on just put everybody in Medicare and have the government subsidize premiums on the low income members or just make the premiums sliding scale. Employers would still kick in their 2/3 of the premium. It would take about 2 years before everybody got used to it but it would be easier all the way around.

Another 50 million people in the group many of whom are actually quite healthy would skew the tables big time, stabilizing the system quite well.

you will see non covereds like lasix, breast enhancement or reduction, any kind of procedure that can even remotely be considered cosmetic, (and I love this one)..tubal Ligations (but will cover reversal of same!) I seriously did service a policy that did that. Weird things like certain sinus surgery because doctors used to bill nose jobs as sinus surgeries. I worked a group of plans that required pre determination of benefits on any sinus surgery, with documentation of the sinus history.

And leave us not forget the many policies that will cover Viagra and its siblings but will not cover any type of contraceptives.

Or the ones that only cover maternity if you purchase a sidekick rider and won't cover BCPills.

nose surgery and it was treated as sinus surgery as our insurance wouldn't cover it. He was very good looking before, but with the nose job he was so handsome, I couldn't scrape the girls off of him so he'd get his work done.

stuff. I enjoy the exchange of ideas, experience and knowledge that a board like this can offer.

Oh yeah and the silly side too.

As much as I love me some crazy Palin crap, I do miss hearing more about the issues.

Seriously, you and I have lots of background and experience from both sides of the fence and came to the same conclusions, for the most part.

You from a doctor's wife perspective, and me from the insurance world.

And no doubt about it, it gets worse and worse essentially every day