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Thread: Depressed woman loses benefits over Facebook photos

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    Re: Depressed woman loses benefits over Facebook photos

    Quote Originally Posted by misterman View Post
    They aren't, for the most part. They are simply determining how much the physician should charge, not whether he should undertake the treatment.
    That is not true and that is the problem. As a provider, I have had insurance companies deny payment for services because they did not deem it clinically necessary. This is without seeing the patient and seeing my documentation identifying the necessity of the treatment. I have had this occur as a patient, too. The physician determines the medical necessity of the treatment...not someone who has never seen the patient or someone who has a vested interest in NOT providing treatment.

    On the other hand, you are basically arguing that a doctor can do whatever he wants and expect unlimited payment. It doesn't work that way. If someone is paying for something, they have a legitimate interest in it, and have a right to second-guess decisions to a certain extent.
    If the physician determines, with documentation, that the treatment is medically necessary, and the treatment is covered under the patient's insurance plan, then the insurance company needs to pay for the treatment. Period.
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    Re: Depressed woman loses benefits over Facebook photos

    Quote Originally Posted by misterman View Post
    If they were required to do that, what's likely is that they would pay - and then drop you and/or your doctor from all further coverage. Not a good way to do business.
    And if they do that often enough, they will have no subscribers or providers...and go out of business themselves. Not a good practice.

    Of course, part of what the insurance company is doing when it reviews payments is deciding whether ethical standards of practice were followed. Is it ethical to do completely unnecessary treatments or tests? I don't think so.
    I am uninterested in unnecessary tests. I have little problem with insurance companies refusing to pay for this, but their way of determining this is completely arbitrary. My issue, however, is their refusal to pay for medically indicated treatment, not unnecessary, because they disagree..something that happens REGULARLY.
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    Quote Originally Posted by Wiseone View Post
    This is what I hate about politics the most, it turns people in snobbish egotistical self righteous dicks who allow their political beliefs, partisan attitudes, and 'us vs. them' mentality, to force them to deny reality.

    Quote Originally Posted by Navy Pride View Post
    You can't paint everone with the same brush.......It does not work tht way.


    Quote Originally Posted by Wessexman View Post
    See with you around Captain we don't even have to make arguments, as you already know everything .
    Quote Originally Posted by CriticalThought View Post
    Had you been born elsewhere or at a different time you may very well have chosen a different belief system.
    Quote Originally Posted by ernst barkmann View Post
    It a person has faith they dont need to convince another of it, and when a non believer is not interested in listening to the word of the lord, " you shake the dust from your sandels and move on"

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    Re: Depressed woman loses benefits over Facebook photos

    Quote Originally Posted by misterman View Post
    The insurance company already has a long list of tests and procedures that it will, and will not, pay for.
    And yet, they can refuse to pay for these tests if THEY decide that it isn't medically necessary...even if the provider believes they are and even though they have never seen the patient.
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    Quote Originally Posted by Wiseone View Post
    This is what I hate about politics the most, it turns people in snobbish egotistical self righteous dicks who allow their political beliefs, partisan attitudes, and 'us vs. them' mentality, to force them to deny reality.

    Quote Originally Posted by Navy Pride View Post
    You can't paint everone with the same brush.......It does not work tht way.


    Quote Originally Posted by Wessexman View Post
    See with you around Captain we don't even have to make arguments, as you already know everything .
    Quote Originally Posted by CriticalThought View Post
    Had you been born elsewhere or at a different time you may very well have chosen a different belief system.
    Quote Originally Posted by ernst barkmann View Post
    It a person has faith they dont need to convince another of it, and when a non believer is not interested in listening to the word of the lord, " you shake the dust from your sandels and move on"

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    Re: Depressed woman loses benefits over Facebook photos

    Quote Originally Posted by CaptainCourtesy View Post
    That is not true and that is the problem. As a provider, I have had insurance companies deny payment for services because they did not deem it clinically necessary. This is without seeing the patient and seeing my documentation identifying the necessity of the treatment. I have had this occur as a patient, too. The physician determines the medical necessity of the treatment...not someone who has never seen the patient or someone who has a vested interest in NOT providing treatment.
    Then they should have seen the documentation. Doesn't mean they can't ever question it.

    You can have whatever test or treatment you want. You just can't expect someone else to pay for it unless it meets the terms of the contract between you and the other party.

    If the physician determines, with documentation, that the treatment is medically necessary, and the treatment is covered under the patient's insurance plan, then the insurance company needs to pay for the treatment. Period.
    Then negotiate a new contract with the insurance company that says so. Good luck with that.

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    Re: Depressed woman loses benefits over Facebook photos

    Quote Originally Posted by CaptainCourtesy View Post
    And if they do that often enough, they will have no subscribers or providers...and go out of business themselves. Not a good practice.
    So? They'll go out of business anyway if they pay for every claim, no matter how wasteful or unnecessary.

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    Re: Depressed woman loses benefits over Facebook photos

    At least in this case the insurance company isn't diagnosing anything.
    They are making a determination if the level of disability this person has is greater than she can work with. The article clearly states other factors were considered than just FB pictures. I don't really see the big issue here, except a controversial headline that doesn't reveal the whole story.
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    Re: Depressed woman loses benefits over Facebook photos

    Quote Originally Posted by CaptainCourtesy View Post
    These physicians never see the patient. Their determination is unethical, without merit and a conflict of interest. Under no circumstances should they be allowed to make medical decisions on a patient that they have not seen, nor should they be allowed to overrule a medical decision by the treating provider.
    First, why do they actually have to see the patient in order to make an informed decision? The attending physician's report should be sufficient.

    Secondly, they aren't overriding a treatment option. They are simply refusing to pay for it. If I don't give you money for lunch am I denying you access to cheeseburgers?

    If the doctor made the decision based on ethical standards of practice and in an effort to treat you, absolutely.
    And if he didn't?

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    Re: Depressed woman loses benefits over Facebook photos

    Quote Originally Posted by misterman View Post
    The insurance company already has a long list of tests and procedures that it will, and will not, pay for.
    Yes, and that list, and whomever approved it needs to be abolished.

    Insurance companies are not qualified to decide who needs what. This type of behavior needs to lead to charges being filed against company executives for practicing medicine without a license.

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    Re: Depressed woman loses benefits over Facebook photos

    Quote Originally Posted by Vader View Post
    It's not your insurance company's place to decide what tests you need and which you do not.

    That is beyond their scope. They should never involve themselves in such matters.
    Patient: Doc, I've got a runny nose. Can you help me?

    Doctor: That depends. You got insurance?

    Patient: Yup. Sure do.

    Doctor: Excellent! Nurse, prep this patient for a CAT-scan and an incisional biopsy, stat!


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    Re: Depressed woman loses benefits over Facebook photos

    Quote Originally Posted by misterman View Post
    Then they should have seen the documentation. Doesn't mean they can't ever question it.
    They can question all they like. If it is medically necessary by the treating physician, it is unethical for a non-treating physician to deem it NOT medically necessary.

    You can have whatever test or treatment you want. You just can't expect someone else to pay for it unless it meets the terms of the contract between you and the other party.
    And if it is part of the contract, the expectation is that it will be paid, not that an unethical loophole will be used to NOT pay.



    Then negotiate a new contract with the insurance company that says so. Good luck with that.
    This is why I support regulations to eliminate all utilization review. The treating physician makes the call. Period.
    "Never fear. Him is here" - Captain Chaos (Dom DeLuise), Cannonball Run

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    Quote Originally Posted by Wiseone View Post
    This is what I hate about politics the most, it turns people in snobbish egotistical self righteous dicks who allow their political beliefs, partisan attitudes, and 'us vs. them' mentality, to force them to deny reality.

    Quote Originally Posted by Navy Pride View Post
    You can't paint everone with the same brush.......It does not work tht way.


    Quote Originally Posted by Wessexman View Post
    See with you around Captain we don't even have to make arguments, as you already know everything .
    Quote Originally Posted by CriticalThought View Post
    Had you been born elsewhere or at a different time you may very well have chosen a different belief system.
    Quote Originally Posted by ernst barkmann View Post
    It a person has faith they dont need to convince another of it, and when a non believer is not interested in listening to the word of the lord, " you shake the dust from your sandels and move on"

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