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Insurance requires you to correctly diagnose yourself to get paid for services

Threegoofs

Threegoofs

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Yep. This one is just brilliant.

Anthem is now refusing to pay the cost of ED visits to people who use the ED inappropriately.. meaning they didnt get the diagnosis they thought they might have.

This story is how a woman presented to the ED with abdominal pain because she suspected it might be appendicitis. After a workup, it was determined to be painful ovarian cysts.

So the insurer rejected the $12,000 claim and is making her pay for it.

https://www.vox.com/policy-and-poli...emergency-room-coverage-denials-inappropriate

An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay

A new insurance policy expects patients to diagnose themselves
By Sarah Kliff

Brittany Cloyd was doubled over in pain when she arrived at Frankfort Regional Medical Center’s emergency room on July 21, 2017.

“They got me a wheelchair and wheeled me back to a room immediately,” said Cloyd, 27, who lives in Kentucky.

Cloyd came in after a night of worsening fever and a increasing pain on the right side of her stomach. She called her mother, a former nurse, who thought it sounded like appendicitis and told Cloyd to go to the hospital immediately.

The doctors in the emergency room did multiple tests including a CT scan and ultrasound. They determined that Cloyd had ovarian cysts, not appendicitis. They gave her pain medications that helped her feel better, and an order to follow up with a gynecologist.

A few weeks later, Cloyd received something else: a $12,596 hospital bill her insurance denied — leaving her on the hook for all of it.
Click to expand...

When you hear people say that the US has the 'greatest healthcare in the world' because its the 'greatest country in the world', and that all we need is a little capitalism and free market to fix our healthcare system... just think of this story.
 
I think the insurance company is doing the right thing, though their list of non-emergency conditions needs to be tweaked.

The patient took the correct steps ( appeals ) after the ruling and ultimately won, though she could have avoided the whole thing by following the insurance company's suggestions from the get go.
 
A bit harsh but not a totally unreasonable policy. Note that the ER "treatment" was to run tests, prescribe pain medication and refer the patient to a specialist - all of that is available on a non-emergency basis.

Being in pain, in and of itself, is not an emergency condition - otherwise almost anything is an "emergency". The ER costs totaling about $12K would have been far less (half?) if rendered on a non-emergency basis and there was, in fact, no emergency (immediately life threatening condition) present.

IMHO, only the difference between ER and primary care costs for the medical care treatment provided should have been denied.
 
Mycroft said:
I think the insurance company is doing the right thing, though their list of non-emergency conditions needs to be tweaked.

The patient took the correct steps ( appeals ) after the ruling and ultimately won, though she could have avoided the whole thing by following the insurance company's suggestions from the get go.
Click to expand...

Funny how the part about the ruling being reversed escaped the posts.
 
Threegoofs said:
Yep. This one is just brilliant.

Anthem is now refusing to pay the cost of ED visits to people who use the ED inappropriately.. meaning they didnt get the diagnosis they thought they might have.

This story is how a woman presented to the ED with abdominal pain because she suspected it might be appendicitis. After a workup, it was determined to be painful ovarian cysts.

So the insurer rejected the $12,000 claim and is making her pay for it.

https://www.vox.com/policy-and-poli...emergency-room-coverage-denials-inappropriate



When you hear people say that the US has the 'greatest healthcare in the world' because its the 'greatest country in the world', and that all we need is a little capitalism and free market to fix our healthcare system... just think of this story.
Click to expand...

Now compare that one story to the thousands of people using the ER when they get a minor cold because they are on whatever state funded medical assistance that's available. That's the flip side to your story and the result of the "You can go to the doctor whenever you want for whatever you want and we'll pay for it." mentality of publicly funded healthcare.
 
Threegoofs said:
Yep. This one is just brilliant.

Anthem is now refusing to pay the cost of ED visits to people who use the ED inappropriately.. meaning they didnt get the diagnosis they thought they might have.

This story is how a woman presented to the ED with abdominal pain because she suspected it might be appendicitis. After a workup, it was determined to be painful ovarian cysts.

So the insurer rejected the $12,000 claim and is making her pay for it.

https://www.vox.com/policy-and-poli...emergency-room-coverage-denials-inappropriate



When you hear people say that the US has the 'greatest healthcare in the world' because its the 'greatest country in the world', and that all we need is a little capitalism and free market to fix our healthcare system... just think of this story.
Click to expand...

How did you manage to type "ED" instead of "ER" three whole times? At first I thought this was about erectile dysfunction. LOL

Just kidding -- I agree with you that we have some bad health policies, and Obamacare did nothing to make them better. As long as the govt. in is bed with the insurance industry, they won't get any better. Four years ago, my elderly mother fell and broke her arm - just below the shoulder. It was a clean fracture all the way through, her bone was completely severed, just hanging there. The ER doctor sent us home, with her in just a floppy sling with her bone moving around and causing pain. They would not admit her or set her arm. It was a full week until we could get her in to see an orthopedic surgeon. A week of intense pain.

I'm conservative but it's clear that we need to kick these insurers to the curb and go to a single payer system. My niece and her husband have no coverage at all so I bought their flu and pneumonia shots last fall. Both of them had bad respiratory complication the previous winter. It came to over $500 for both shots. That's just crazy, but, she's my favorite niece so I'll do it again this coming fall. Supposedly, they'll only need one more round of the pneumonia vaccine and they'll be protected for life. But, there's no reason the cost is so high -- a lot of people can't afford even the subsidized premiums but all of us would benefit if they were vaccinated.
 
humbolt said:
That bit of truth would detract from the intended outrage the OP hoped to inspire.
Click to expand...

Really. It's up to the doctor to diagnose, not the patient, and he orders the tests needed to make the diagnosis.

So it all fire with no fuel.
 
ttwtt78640 said:
A bit harsh but not a totally unreasonable policy. Note that the ER "treatment" was to run tests, prescribe pain medication and refer the patient to a specialist - all of that is available on a non-emergency basis.

Being in pain, in and of itself, is not an emergency condition - otherwise almost anything is an "emergency". The ER costs totaling about $12K would have been far less (half?) if rendered on a non-emergency basis and there was, in fact, no emergency (immediately life threatening condition) present.

IMHO, only the difference between ER and primary care costs for the medical care treatment provided should have been denied.
Click to expand...

Except pain can be and often is.. a primary indicator of a serious life threatening problem. Severe abdominal pain of unknown origin could outline a number of those conditions. not to mention, the pain itself can cause lifethreatening conditions like MI, or CVA in patients with cardiac compromise or high blood pressure.
 
HowardBThiname said:
How did you manage to type "ED" instead of "ER" three whole times? At first I thought this was about erectile dysfunction. LOL

Just kidding -- I agree with you that we have some bad health policies, and Obamacare did nothing to make them better. As long as the govt. in is bed with the insurance industry, they won't get any better. Four years ago, my elderly mother fell and broke her arm - just below the shoulder. It was a clean fracture all the way through, her bone was completely severed, just hanging there. The ER doctor sent us home, with her in just a floppy sling with her bone moving around and causing pain. They would not admit her or set her arm. It was a full week until we could get her in to see an orthopedic surgeon. A week of intense pain.

I'm conservative but it's clear that we need to kick these insurers to the curb and go to a single payer system. My niece and her husband have no coverage at all so I bought their flu and pneumonia shots last fall. Both of them had bad respiratory complication the previous winter. It came to over $500 for both shots. That's just crazy, but, she's my favorite niece so I'll do it again this coming fall. Supposedly, they'll only need one more round of the pneumonia vaccine and they'll be protected for life. But, there's no reason the cost is so high -- a lot of people can't afford even the subsidized premiums but all of us would benefit if they were vaccinated.
Click to expand...

Just to point out.. the type of care you mother got would be what one would expect under a single payer system.. in fact.. probably worse. In all likelihood.. your mother was covered under medicare.. a government insurance. And medicare is far and away better than most single payer government healthcare insurance.
 
Threegoofs said:
Yep. This one is just brilliant.

Anthem is now refusing to pay the cost of ED visits to people who use the ED inappropriately.. meaning they didnt get the diagnosis they thought they might have.

This story is how a woman presented to the ED with abdominal pain because she suspected it might be appendicitis. After a workup, it was determined to be painful ovarian cysts.

So the insurer rejected the $12,000 claim and is making her pay for it.

https://www.vox.com/policy-and-poli...emergency-room-coverage-denials-inappropriate



When you hear people say that the US has the 'greatest healthcare in the world' because its the 'greatest country in the world', and that all we need is a little capitalism and free market to fix our healthcare system... just think of this story.
Click to expand...

Just to note: There is a difference between "healthcare" and "healthcare insurance".
 
Threegoofs said:
Yep. This one is just brilliant.

Anthem is now refusing to pay the cost of ED visits to people who use the ED inappropriately.. meaning they didnt get the diagnosis they thought they might have.

This story is how a woman presented to the ED with abdominal pain because she suspected it might be appendicitis. After a workup, it was determined to be painful ovarian cysts.

So the insurer rejected the $12,000 claim and is making her pay for it.

https://www.vox.com/policy-and-poli...emergency-room-coverage-denials-inappropriate



When you hear people say that the US has the 'greatest healthcare in the world' because its the 'greatest country in the world', and that all we need is a little capitalism and free market to fix our healthcare system... just think of this story.
Click to expand...
You keep saying healthcare, yet, this is clearly about health insurance. They're not the same thing.
 
jaeger19 said:
Except pain can be and often is.. a primary indicator of a serious life threatening problem. Severe abdominal pain of unknown origin could outline a number of those conditions. not to mention, the pain itself can cause lifethreatening conditions like MI, or CVA in patients with cardiac compromise or high blood pressure.
Click to expand...

Lots of things could be symptoms of life threatening conditions. The purpose of this policy is to stop ER abuse which raises the cost of insurance and ER care for everyone. There are many less expensive alternatives to the ER for critical or "after hours" care but when left up to each patient they often choose the ER instead. This should be a good "test case" for EMTALA - simply telling the ER that you can't pay.

Who pays for EMTALA-related medical care?

Ultimately we all do, although EMTALA places the greatest responsibility on hospitals and emergency physicians to provide this health care safety net and shoulder the financial burden of providing EMTALA related medical care.
Click to expand...

https://www.acep.org/news-media-top-banner/emtala/#sm.00000i9tw1nf86dnjspbqyp2z3yo6
 
Mycroft said:
I think the insurance company is doing the right thing, though their list of non-emergency conditions needs to be tweaked.
Click to expand...
The problem is that they only seem to be considering the diagnostic outcome. The symptoms this woman reported could have easily indicated a serious condition and professional medical advice would be to seek urgent attention. The tests she received were emergency care even though they turned out to be negative for the most serious possibilities. The fact her actual diagnosis fits on a list of non-emergency conditions shouldn’t be relevant.

Mycroft said:
The patient took the correct steps ( appeals ) after the ruling and ultimately won, though she could have avoided the whole thing by following the insurance company's suggestions from the get go.
Click to expand...
Only after the media took up an interest. I strongly suspect she would have been brushed off a second time otherwise and I wouldn’t be surprised if there aren’t lots of other patients forced to pay up just because they weren’t able or willing to go through a long and drawn out appeals process.

I’m all for measures to discourage people from using medical services unnecessarily but that should be the direct intent, not using the issue as an easy way to claw back the money from the most vulnerable patients.
 
HonestJoe said:
The problem is that they only seem to be considering the diagnostic outcome. The symptoms this woman reported could have easily indicated a serious condition and professional medical advice would be to seek urgent attention. The tests she received were emergency care even though they turned out to be negative for the most serious possibilities. The fact her actual diagnosis fits on a list of non-emergency conditions shouldn’t be relevant.

Only after the media took up an interest. I strongly suspect she would have been brushed off a second time otherwise and I wouldn’t be surprised if there aren’t lots of other patients forced to pay up just because they weren’t able or willing to go through a long and drawn out appeals process.

I’m all for measures to discourage people from using medical services unnecessarily but that should be the direct intent, not using the issue as an easy way to claw back the money from the most vulnerable patients.
Click to expand...

What makes you think the insurance company's intent was to "claw back the money"? I don't see how they got any money...or spent money...until the appeal process was resolved.

Now...if you are talking about their overall objective, then again...it's not about getting anything back. It's about not paying unnecessary medical costs.

In any case, the lady should have followed the insurance company's suggestions instead of relying on someone else's suggestion. If she had, her coverage problems wouldn't have arisen.

https://cdn.vox-cdn.com/thumbor/U_Y...ile/10098111/mo_er_member_letter_2017__1_.jpg
 
ttwtt78640 said:
Lots of things could be symptoms of life threatening conditions. The purpose of this policy is to stop ER abuse which raises the cost of insurance and ER care for everyone. There are many less expensive alternatives to the ER for critical or "after hours" care but when left up to each patient they often choose the ER instead. This should be a good "test case" for EMTALA - simply telling the ER that you can't pay.
]
Click to expand...

Based on the womans symptoms.. this was not ER abuse.

As far as saving money.. a policy such as this actually increases cost to the insurance company.. because people will avoid going to the ER with potentially life threatening situations until they get dramatically worse.. (such as pass out, go into shock, or organ failure).. and the resulting medical treatment will be tremendously costly.

What people don't realize.. is that if you prevent one person from having a severe issue because they come into the ER early.. that prevention pays literally for hundreds of people with non emergent problems who come to the ER
 
jaeger19 said:
Based on the womans symptoms.. this was not ER abuse.

As far as saving money.. a policy such as this actually increases cost to the insurance company.. because people will avoid going to the ER with potentially life threatening situations until they get dramatically worse.. (such as pass out, go into shock, or organ failure).. and the resulting medical treatment will be tremendously costly.

What people don't realize.. is that if you prevent one person from having a severe issue because they come into the ER early.. that prevention pays literally for hundreds of people with non emergent problems who come to the ER
Click to expand...

Why do you ignore alternatives to the ER?
 
Mycroft said:
What makes you think the insurance company's intent was to "claw back the money"? I don't see how they got any money...or spent money...until the appeal process was resolved.

Now...if you are talking about their overall objective, then again...it's not about getting anything back. It's about not paying unnecessary medical costs.

In any case, the lady should have followed the insurance company's suggestions instead of relying on someone else's suggestion. If she had, her coverage problems wouldn't have arisen.

https://cdn.vox-cdn.com/thumbor/U_Y...ile/10098111/mo_er_member_letter_2017__1_.jpg
Click to expand...

Actually the intent of the insurance company is really two fold.. to change patient and physician behavior.. so that you treat the patient based on their insurance coverage, rather than on what is medically necessary.

So even though..it was appropriate that the woman went to the ER, and it was appropriate based on her symptoms to order the tests that they did...

She is now less likely to go to the ER with severe pain..

And the ER physician will be less likely to order the appropriate tests..
 
ttwtt78640 said:
Why do you ignore alternatives to the ER?
Click to expand...

I don't.

I simply realize that the ER has a purpose. Why do you ignore that? The womans symptoms were significant enough that the ER was warranted.

In fact.. with the symptoms that she had.. urgent care. or a doctors office would have sent her right to the ER.
 
jaeger19 said:
I don't.

I simply realize that the ER has a purpose. Why do you ignore that? The womans symptoms were significant enough that the ER was warranted.

In fact.. with the symptoms that she had.. urgent care. or a doctors office would have sent her right to the ER.
Click to expand...

In that (bolded above) case her insurance issues would likely not exist.
 
Threegoofs said:
Yep. This one is just brilliant.

Anthem is now refusing to pay the cost of ED visits to people who use the ED inappropriately.. meaning they didnt get the diagnosis they thought they might have.

This story is how a woman presented to the ED with abdominal pain because she suspected it might be appendicitis. After a workup, it was determined to be painful ovarian cysts.

So the insurer rejected the $12,000 claim and is making her pay for it.

https://www.vox.com/policy-and-poli...emergency-room-coverage-denials-inappropriate



When you hear people say that the US has the 'greatest healthcare in the world' because its the 'greatest country in the world', and that all we need is a little capitalism and free market to fix our healthcare system... just think of this story.
Click to expand...





So you base the entire health care system over one assholic denial? Seems a bit unscientific.
 
ttwtt78640 said:
In that (bolded above) case her insurance issues would likely not exist.
Click to expand...




They also sent a letter to these people about going to urgent care, etc. if more people did that than the emergency room there would be less need for this. Anthem is wrong here and I'm suprised the appeal was denied as the symptons indicated a serious medical emergency. I wont be surprised that this will get fixed and no one will notice as we move on.
 
jaeger19 said:
Actually the intent of the insurance company is really two fold.. to change patient and physician behavior.. so that you treat the patient based on their insurance coverage, rather than on what is medically necessary.

So even though..it was appropriate that the woman went to the ER, and it was appropriate based on her symptoms to order the tests that they did...

She is now less likely to go to the ER with severe pain..

And the ER physician will be less likely to order the appropriate tests..
Click to expand...

I disagree.

I think the intent of the insurance company is to change patient behavior from running to the ER for every little thing to using alternative methods. I didn't get the impression that the insurance company disputed the diagnostic tests or actions of the ER at all.
 
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