Classic frustration
Here’s a classic problem we see in the office every day. Humana and United Healthcare are the worst when it comes to problems like these.
CASE:
44 y.o. patient recieved a routine chest x-ray for pre-op evaluation before surgery. The report came back abnormal. The official report read as follows from the radiologist:
IMPRESSION: Abnormal nodular density in the right lung base on the PAfilm. Recommend CT scan of the chest for further, more appropriate,evaluation.
I received this report because I am the patient’s primary care doctor. I did not order the Chest x-ray. After receiving this report, we informed the patient and I told my staff to schedule a CAT scan to evaluate it further and be sure it was not an early Lung cancer.
My staff called Humana who promptly denied the CAT scan. They said the report was not specific enough and they would not approve the test.
So now, as the physician, we are left with telling the patient that their insurance refused approval of the test. We could appeal, wait and repeat the Chest x-ray in a month or do nothing.
This patient was a long time smoker and has a family history of lung cancer. Who in their right mind would choose to wait or do nothing? The Radiologist who read the x-ray felt a CT scan should be done and I agreed, knowing the patient and family history.
These are the problems we contend with every day while Humana and other insurance companies continue to practice medicine without a license or responsibility for these decisions.
We will appeal and eventually get the CT scan done, but it now takes at least one letter and several more phone calls and a lot more staff time all while the patient is left wondering. Who pays for Humana’s decisions? Who should be responsible for the refusal of a test that two independent physicians felt was indicated.
This is one small part of our overall healthcare dilemma that has to be fixed.
CASE:
44 y.o. patient recieved a routine chest x-ray for pre-op evaluation before surgery. The report came back abnormal. The official report read as follows from the radiologist:
IMPRESSION: Abnormal nodular density in the right lung base on the PAfilm. Recommend CT scan of the chest for further, more appropriate,evaluation.
I received this report because I am the patient’s primary care doctor. I did not order the Chest x-ray. After receiving this report, we informed the patient and I told my staff to schedule a CAT scan to evaluate it further and be sure it was not an early Lung cancer.
My staff called Humana who promptly denied the CAT scan. They said the report was not specific enough and they would not approve the test.
So now, as the physician, we are left with telling the patient that their insurance refused approval of the test. We could appeal, wait and repeat the Chest x-ray in a month or do nothing.
This patient was a long time smoker and has a family history of lung cancer. Who in their right mind would choose to wait or do nothing? The Radiologist who read the x-ray felt a CT scan should be done and I agreed, knowing the patient and family history.
These are the problems we contend with every day while Humana and other insurance companies continue to practice medicine without a license or responsibility for these decisions.
We will appeal and eventually get the CT scan done, but it now takes at least one letter and several more phone calls and a lot more staff time all while the patient is left wondering. Who pays for Humana’s decisions? Who should be responsible for the refusal of a test that two independent physicians felt was indicated.
This is one small part of our overall healthcare dilemma that has to be fixed.
posted by Anonymous at 6:08 PM
10 Comments:
Many physicians would love to get back to direct contracting with patients. We could do it so much cheaper and with a lot less hassles.
There are a couple physicians in Louisville who have a practice similar to this philosophy. They seem very happy.
Any rough idea of what a primary care office visit or other very common services might cost under that sort of scheme?
If nothing else, it may allow some people to have "big deal" insurance only. If enough people jumped ship from the insurance companies, they may see the wisdom of lower premiums for everyone.
Bluegill,
I'm guessing that if Dr. Dan started that kind of plan, yours and mine would be pretty high!
I do like the idea. Insurance for the big deal and pay out of your pocket for the other stuff would certainly bring some competition to health care. Several years ago I attempted to find a high deductible health plan and could not find one. I know that some are available now.
Almost forgot...
What's keeping more doctors from offering cash prices now? Are there regulations or is it just considered too much trouble to do both that and insurance?
There are legal issues if you give any discount to someone that has insurance coverage. This is especially true when patients have not met their deductibles for the year and if you were to discount services to help them on their deductibles.
We see cash paying patients and for a routine visit, we charge $25-30. Labs would be extra.
There are legal issues if you give any discount to someone that has insurance coverage.
I'm not disputing what you said, but insurance companies get discounts all the the time. They pay less for the same services than a private individual does. How do those discounts fit with your statement above?
I didn't say it made sense. But that is the legal issue.
If a patient has insurance, we can get in trouble if they find out that we discounted a service when the patient was responsible for all of the bill before they meet their deductible.
Example: Patient has 500 dollar deductible. Office visit comes to 100 dollars and with the insurance writeoff the bill is 75 dollars.
The patient is supposed to pay the 75 since they have not met their deductible.
We are not allowed to give them a break at this point even though they are responsible for the whole 75 dollars.
If their deductible is met, they would typically pay their co-pay and the insurance would pay the rest of the 75 dollars.
If a patient has no insurance and strictly cash pay, I can do whatever I want.
If all patients were cash pay, I could reduce my staff by at least 8 employees and charge a lot less.
Dear Dr.
Your patient chose Humana as his insurer. Any restriction to healthcare is an issue between your patient and Humana. You do not need to make phone calls, or write letters. Yor inform you patient about your professional opinion (needs a chest CT), and your patient should fight for the approval.
As employee's we also see the other side of the story as I'm sure you do too. That is useless orders and proceedures inflicted upon patients. Invasive and difficult tests on patients that are too old or chronic to be tortured when they aren't healthy enough to undergo treatment for the problem. Why does a 90 year old need complete PFT tests? He must be breathing enough;(he's still alive at 90) Many tests are painful and invasive and just add to the bills of the very people that cannot afford them. But then Insurance companies refuse diagonostic studies for patients that may indeed be helped. Its all so confusing; but I am glad to have a forum like this to air my opinions. Keep up the good work Dr. Dan!!!
I understand the comments from anonymous as well as runawaydoc.
I try to ask myself the question: Is this test going to change the way I treat this patient?
In the example you gave, it is probably a rare event that a 90 yo needs a full Pulmonary Function Test.
The rationale would be that if it was possible that he could have a restrictive lung defect rather than the more common obstructive lung defect like COPD/emphysema, then the treatment with bronchodilators may or may not be beneficial. They would likely help the obstructive type but would not help the restrictive type.
Restrictive types in this age group could come from prior chemical and dust exposures from employment or from metastatic diseases from cancer as well as other etiologies.
In addition, if the test is done while in the hospital, the test would be included in the overall DRG fee that medicare pays to the hospital. In that regard, medicare saves money and the hospital essentially performs this test as part of the overall fee they recieve.
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