Depressed woman loses benefits over Facebook photos

[Phoenix]

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.

 

[Ethereal]

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?

 

[Vader]

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.

 

[Ethereal]

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!

:doh

 

[CaptainCourtesy]

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.

 

[CaptainCourtesy]

So? They'll go out of business anyway if they pay for every claim, no matter how wasteful or unnecessary.

I am not talking about wasteful claims. I am talking about the legitimate ones that are denied, unethically.

And if they go out of business because of that...GOOD.

 

[CaptainCourtesy]

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.

If this were true, they would accept the physician's treatment recommendations.

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 you contract with me that you will buy me lunch, and then decide that YOU feel I am not hungry, even though I tell you that I am, then you are breaking your contract. This is what the insurance company is doing. YOU do not tell me whether or not I am hungry.

And if he didn't?

That is a different matter and not what I am discussing.

 

[CaptainCourtesy]

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!

:doh

Logical fallacy.

 

[Ethereal]

If this were true, they would accept the physician's treatment recommendations.

Not necessarily. Two physicians can reach different conclusions based upon the same set of facts. It happens all the time.

If you contract with me that you will buy me lunch, and then decide that YOU feel I am not hungry, even though I tell you that I am, then you are breaking your contract. This is what the insurance company is doing. YOU do not tell me whether or not I am hungry.

This is a spurious analogy since it fails to account for the stipulations inherent to any contract. You can eat when you're hungry but you cannot buy 100 cheeseburgers at a single sitting.

That is a different matter and not what I am discussing.

I don't think it's a different matter. I want to discuss it.

What recourse should an insurance company have against arbitrary treatments?

 

[Ethereal]

Logical fallacy.

Why is it a logical fallacy?

Vader suggested that health insurance companies should have no say in how a doctor treats his or her patient, despite the fact that said company is expected to pay for whatever treatment the attending physician deems "necessary."

What happens if the attending physician orders a CAT-scan on a boy with a gash on his pinky finger? According to Vader, the insurance company should just pay for it no questions asked. That's the logical progression of his argument.

 

[CaptainCourtesy]

Not necessarily. Two physicians can reach different conclusions based upon the same set of facts. It happens all the time.

Sure. When they see an examine the patient. That would be an ethical difference of opinion.

This is a spurious analogy since it fails to account for the stipulations inherent to any contract. You can eat when you're hungry but you cannot buy 100 cheeseburgers at a single sitting.

How do YOU know how hungry I am?

I don't think it's a different matter. I want to discuss it.

What recourse should an insurance company have against arbitrary treatments?

It is a different matter. I would have no problem with a third party arbitrator assessing the situation...for either side, and either requiring the provider to reimburse the insurance company for arbitrary services, or requiring the insurance company to pay for services they denied.

 

[CaptainCourtesy]

Why is it a logical fallacy?

Vader suggested that health insurance companies should have no say in how a doctor treats his or her patient, despite the fact that said company is expected to pay for whatever treatment the attending physician deems "necessary."

What happens if the attending physician orders a CAT-scan on a boy with a gash on his pinky finger? According to Vader, the insurance company should just pay for it no questions asked. That's the logical progression of his argument.

Because that is a ridiculous overgeneralization and would not occur.

 

[Ethereal]

Sure. When they see an examine the patient. That would be an ethical difference of opinion.

You never explained why a physician has to see a patient in order to make an informed decision. Instead, you went in a circle after I stated the attending' physician’s report would be sufficient.

How do YOU know how hungry I am?

I don't know exactly how hungry you are but I know you're not hungry enough to eat 100 cheeseburgers at a single sitting. Why don't you have one cheeseburger, see how you feel, and then get back to me.

It is a different matter. I would have no problem with a third party arbitrator assessing the situation...for either side, and either requiring the provider to reimburse the insurance company for arbitrary services, or requiring the insurance company to pay for services they denied.

Has this "third party arbitrator" seen the patient? If not, what makes them qualified to determine whether or not the treatment was arbitrary?

 

[Ethereal]

Because that is a ridiculous overgeneralization and would not occur.

If Vader had his way how would anyone stop it from occuring?

Could Vader object to such a thing given his earlier statements?

On what grounds could he object to it?

 

[misterman]

I am not talking about wasteful claims. I am talking about the legitimate ones that are denied, unethically.

Aha! So wasteful claims should be denied?

First you were saying the insurance companies should completely stay out, now you say they can deny wasteful claims. Good.

And if they go out of business because of that...GOOD.

They will ALL be out of business, genius.

 

[misterman]

Because that is a ridiculous overgeneralization and would not occur.

Says who?

This is just an extreme hypothetical designed to flush you out of your ridiculous absolutist position. But the point is valid. Are you saying there are never wasteful or unnecessary tests or treatments done?

 

[misterman]

If you contract with me that you will buy me lunch, and then decide that YOU feel I am not hungry, even though I tell you that I am, then you are breaking your contract. This is what the insurance company is doing. YOU do not tell me whether or not I am hungry.

But if I contract to buy you lunch, and you order ten large pizzas, four pounds of french fries, a gallon of Coke, and a whole cake for dessert, I'm going to dispute that all that was necessary.

 

[Fiddytree]

Speaking as someone with chronic depression, we are not allowed to smile at any point in our lives. It just isn't allowed. Ever.

 

[misterman]

Speaking as someone with chronic depression, we are not allowed to smile at any point in our lives. It just isn't allowed. Ever.

Hey, you're smiling right now, aren't you? Stop it.

 

[Fiddytree]

Damnit. I slipped up. I have to quit conning people into believing I get blue more than the average bear.

 

[UtahBill]

Speaking as someone with chronic depression, we are not allowed to smile at any point in our lives. It just isn't allowed. Ever.

North Dakota? Try Arizona for a while. Helped me a lot...

 

[Real Korimyr #9]

I smile widely and show my teeth a lot. I don't want the lesser primates claiming that I didn't give them fair warning.

 

[Fiddytree]

North Dakota? Try Arizona for a while. Helped me a lot...

Nah, I'm quite fine in North Dakota. :mrgreen:

 

[misterman]

Damnit. I slipped up. I have to quit conning people into believing I get blue more than the average bear.

Yeah, just cheer up. Go see a funny movie or something, you'll be fine.

 

[Fiddytree]

Yeah, just cheer up. Go see a funny movie or something, you'll be fine.

I better not take pictures though. Otherwise, I may have to answer to the authorities above for responding positively!