Lies, Damn Lies, and Insurance Company Word Games
When insurance companies play word games, doctors and patients lose. Every week, every day, these companies are up on Wall Street posting record profits while trying to find new ways to avoid paying claims. They’re even bragging about shaving more profits off Medicare and Medicaid, programs that are supposed to serve the poorest and most vulnerable citizens.
Of course, sometimes tried and true methods work just fine, and declaring that treatment is “not medically necessary” is one of those methods. Another method is to play “he said, she said” games. Let’s look at both issues in turn.
“Medical necessity” vs. “Clinical Necessity”.
“Medical necessity” is an insurance-defined term for any condition that will lead to a heart attack or a stroke if treatment is not received. If you’ve ever been baffled and outraged when an insurance company utters a ludicrous statement like, “that cancer treatment isn’t medically necessary” you now know what they mean when they say that. The cancer will still kill your patient, of course, but by golly, it won’t be a heart attack or a stroke that does the deed, so insurance companies feel fully justified in refusing to pay the claim.
In insurance company lingo, the cancer treatment would be called a “clinical necessity” instead. Many policies don’t pay for “clinical necessities.” In essence, “clinical necessity” is the insurance company’s way of saying, “Sure, he needs that treatment if you say so, but it’s not our problem and we’re probably not paying for it.”
Why did the insurance company deny the claim after saying it was fine for me to treat the patient?
Some policies will pay for clinically necessary treatments with prior authorization—at least on paper. When doctors seek authorization the insurance companies must resort to “he said, she said” to deal with the problem instead. The doctor calls up the insurance company and gets authorization. They’ll give that authorization over the phone because they want to see the patient treated. Untreated patients are a PR nightmare for insurance companies. They go to the news. They post on blogs. They tell everyone that the insurance company is happy to kill them. The insurance companies have a vested interest in passing the buck.
But when it’s time for the doctor to get paid for the services they’ve provided the insurance company suddenly develops a bad case of amnesia. They say they never authorized anything. It’s their word against the doctor’s word, and the doctors often lose.
By law, insurance companies are not supposed to dictate the level of care a patient receives…but it happens anyway.
Over the past 15 years many, many laws have been passed which state that the level of a patient’s care is supposed to be determined by the doctor, not by any insurance company. Here in the trenches, however, we know insurance companies do dictate the level of care patients receive, simply because doctors can’t afford to work for free. Sometimes, insurance companies in fact determine whether patients can see a doctor at all.
And the insurance company never bases that decision on a patient’s level of need. They base the decision on whether or not they can safely deny the claim later.
Is it any wonder so many medical facilities are going out of business?
What can be done?
Here at Claims Resolution we specialize in recovering funds from insurance companies so doctors can stay in business. We know how to eliminate many of the loopholes insurance companies use to avoid issuing that check.
We can’t get 100% of all claims approved, but in many cases we can help doctors get enough claims approved to make a living and stay in business. Insurance companies play sinister games with people’s lives and livelihood, but your practice and your patients don’t have to be the victims.