topic Re: Getting prior approval is becoming meaningless in Wellness

Getting prior approval is becoming meaningless

Mindy D — Mon, 10 Feb 2020 18:48:46 GMT

This article discusses a trend in which insurance companies are granting prior approval for tests and procedures and then reneging on their approval after treatments and test results come in. Patients are left with huge surprise medical bills. One patient was approved for tests and treatments for transverse myelitis but when testing results showed she had beriberi the insurance company then withheld payment leading to bankrupcy for her and the loss of her home. New approvals are coming with a statement from insurers in legalese that allows the insurance company to escape from the approvals. There’s much more in this article. https://khn.org/news/prior-authorization-revoked-patients-stuck-with-bills-after-insurers-dont-pay-as-promised/

Re: Getting prior approval is becoming meaningless

Snooky60 — Mon, 10 Feb 2020 18:58:01 GMT

@Mindy D That you for posting this information. Something very important for us to think about. Yikes! 💗

Re: Getting prior approval is becoming meaningless

SeaMaiden — Mon, 10 Feb 2020 19:03:43 GMT

Frightening 🙁

Re: Getting prior approval is becoming meaningless

ValuSkr — Mon, 10 Feb 2020 19:06:04 GMT

The situation described - retrospective denial - must be a nightmare for those involved. Thank you shining a light on it. We can only hope the AMA, if not our legislators, addresses it. Our healthcare system - while highly profitable for some - is a mess in so many ways.

Re: Getting prior approval is becoming meaningless

Kachina624 — Mon, 10 Feb 2020 19:11:57 GMT

I've never heard of this practice but it sounds like pressure needs to be put on state insurance regulators to crack down on it. Forget the feds; now they're all for big business.

Re: Getting prior approval is becoming meaningless

chrystaltree — Mon, 10 Feb 2020 19:44:45 GMT

Most patients know nothing about this because the hospitals are the ones who are affected the most. The hospitals are losing the money. The article got it right, I know because this is my world, the world I work in. I work with doctors and patient finance to obtain authorizations that will not result in lost money when the insurers do their retro reviews. Still, the hospital I work for loses millions because the game is rigged. Every authorization from every insurer and Medicare specifies "authorization is not a guarantee of payment" and they can do those retro reviews up to two years after payment. The hospital I work for does not bill the patient for money they must return after a retro review audit so patients never know that the $40,000 they think the insurer paid the hospital a year ago when they were admitted was retracted and the hospital got $0 payment. Why? Because upon admission physicians thought the patient had a heart attack but after admission and tests, it was determined the patient was suffering from acute chest pain, cause unknow. The authorization was for heart attack so, the insurer retracts payment. Years ago, hospitals could appeal a denial like that and produce documentation showing that the patient had all the signs of a heart attack and only after tests did we know he hadn't had one. But! Insurers play hardball now. They don't allow appeals this type of denial, they just take they money back. No, it's not something that any insurance commission can help with. No, it's not something a hospital can sue an insurer for. The right to do retro reviews is in the contracts hospitals have with insurers. But that's a story for another day.

Re: Getting prior approval is becoming meaningless

quilter61 — Wed, 12 Feb 2020 17:18:27 GMT

I also saw this article on CBS News about the state of Kansas jailing people with unpaid medical bills. Here is the link:

The health system really needs fixed.

Re: Getting prior approval is becoming meaningless

NicksmomESQ — Mon, 10 Feb 2020 20:17:48 GMT

That's nuts!! But I've heard through some people I know in the medical field that insurance companies are catching on to many doctors over diagnosing & treating.That's why they are doing this.But it's not right .Nor is it fair to the many patients that pay for health insurance.

There has got to be a better way. Doctors should get paid & patients shouldn't be stuck with the bill. Insurance companies must be forced to live up to their obligations, period.

It's amazing to me that a country as advanced & wealthy as ours can't figure out a way to provide it's tax paying citizens with affordable healthcare!!

Re: Getting prior approval is becoming meaningless

millieshops — Mon, 10 Feb 2020 20:23:53 GMT

Once again Walter Kronkite and his team had it right. Among the many wise observations I remember him making was that anyone wanting to die with money in reserve for their final days and maybe even some left for their heirs needs to wish for good health all the way to the end.

I'm with @Kachina624 - write and call your state representatives.

Re: Getting prior approval is becoming meaningless

50Mickey — Mon, 10 Feb 2020 20:24:00 GMT

@quilter61 wrote:
I also saw this article on CBS News about the state of Kansas jailing people with unpaid medical bills. Here is the link:

https://www.cbsnews.com/news/coffeyville-kansas-medical-debt-county-in-rural-kansas-is-jailing-people-over-unpaid-medical-debt/

The health system really needs fixed.

I read the article. They were not jailed for owning a medical debt. They were arrested for contempt of court for failing to appear in court twice about said bill. Not a smart thing to do.

Re: Getting prior approval is becoming meaningless

Nuttmeg — Mon, 10 Feb 2020 20:47:32 GMT

@50Mickey wrote:

I also saw this article on CBS News about the state of Kansas jailing people with unpaid medical bills. Here is the link:

https://www.cbsnews.com/news/coffeyville-kansas-medical-debt-county-in-rural-kansas-is-jailing-people-over-unpaid-medical-debt/

The health system really needs fixed.
I read the article. They were not jailed for owning a medical debt. They were arrested for contempt of court for failing to appear in court twice about said bill. Not a smart thing to do.

@50Mickey

I watched the video on CBSN. The court is making people pay money $500 that do not have. Would you want someone to force you to appear in court, because you can't pay. Does this serve justice?

Re: Getting prior approval is becoming meaningless

Lipstickdiva — Mon, 10 Feb 2020 22:10:19 GMT

We have Medical Mutual for our insurance. I'm not sure if this is just their policy or if it's state law but if you go to an in-network hospital for treatment, receive the treatment and then your insurance company denies the claim, you do not have to pay one dime of the bill.

This happened with my DH. He went to the ER with tightness in his chest. He was admitted through the ER and assigned a cardiologist. After speaking with my DH, checking symptoms, etc. the cardiologist wanted to do a heart cath.

Long story short, it was done and my husband had to have a stent because he had 99% blockage in his widowmaker. His insurance company denied payment because they said he didn't need to be hospitalized for this procedure. They took the stance that because all his test in the ER came back normal, he could have been sent home and returned for the heart cath and stent rather than being admitted. The bill was in excess of $56,000.00 and we never paid a dime. The hospital resubmitted it a number of times and our insurance continally rejected it.

Re: Getting prior approval is becoming meaningless

ladyann45 — Mon, 10 Feb 2020 22:35:21 GMT

You are partially right, the only reason they were going to court was because they didn't pay the hospital bills in the first place. The husband was working two jobs and they couldn't get coverage because of preexisting illness. The lawyer involved got the courts in it because he was hired to collect the debt. He also got paid part of the bail money if it was part of the judgement.. Some people can't afford to pay the bills and they miss a days work that still don't help the situation. The working poor pays a price no matter how hard they try.

Re: Getting prior approval is becoming meaningless

Carmie — Tue, 11 Feb 2020 04:30:46 GMT

I worked for a health insurance company for 25+ years, so I have seen preapprovals get denied..not often, but it does happen.

When you apply for a preapproval, your records supplied by your doctor are sent to the the Medical Director for review for medical necessity. The Medical Director does not have privy to your benefits, claims or any other information other than what was sent by your doctor. A determination is made by reviewing the information sent.

If the service is deemed medically necessary, your doctor and the patient are sent a letter of approval. The letter states that the service is medically necessary, but payment is not guaranteed. The claim will be processed according to the terms and conditions of your insurance contract on the date of service.

Sometimes a medically necessary service is not covered under a person's insurance plan. Sometimes the insurance is cancelled retroactively prior to the date of service. This happens mostly with employer sponsored insurance plans.

It is always prudent to make sure you have benefits for medically necessary services and then hold your breath that your employer does not cancel your coverage retroactively.

An approval does not mean your claim will be paid. Sometimes the doctor sends in the claim with incomplete information or changes the procedure or diagnosis code. If the information sent does not match the preapproval info, it will deny.

Most of the time, this can be straightened out by having the doctor resubmit the claim correctly.

All of this is part of the HIPAA regulations. People who work for health insurance companies are not allowed to view all of your information. They only get to see what pertains to the job that they do. Medical Directors and nurses are not able to view your claims or benefits.

Re: Getting prior approval is becoming meaningless

Carmie — Tue, 11 Feb 2020 04:38:28 GMT

@Lipstickdiva wrote:
We have Medical Mutual for our insurance. I'm not sure if this is just their policy or if it's state law but if you go to an in-network hospital for treatment, receive the treatment and then your insurance company denies the claim, you do not have to pay one dime of the bill.

This happened with my DH. He went to the ER with tightness in his chest. He was admitted through the ER and assigned a cardiologist. After speaking with my DH, checking symptoms, etc. the cardiologist wanted to do a heart cath.

Long story short, it was done and my husband had to have a stent because he had 99% blockage in his widowmaker. His insurance company denied payment because they said he didn't need to be hospitalized for this procedure. They took the stance that because all his test in the ER came back normal, he could have been sent home and returned for the heart cath and stent rather than being admitted. The bill was in excess of $56,000.00 and we never paid a dime. The hospital resubmitted it a number of times and our insurance continally rejected it.

This is quite common. If the hospital is in network, they cannot bill the patient if inpatient services were denied as not medically necessary. Often they will change the bill to reflect observation care and not an inpatient admission to at least get part of the bill paid. This can be done because the hospital signed a contract with the insurance company to not admit patients for services that can be done on an outpatient basis.

I have also seen a hospital get paid more money than their submitted bill showed. They are contracted to receive a certain amount of money for each procedure. It doesn't matter if they bill more or less than their contracted amount, they will get the contracted amount.

Re: Getting prior approval is becoming meaningless

Drythe — Tue, 11 Feb 2020 04:58:33 GMT

One thing this article does not factor in is that Mayo balance bills. In other words, even if insurance had paid to their full limit, Mayo does not write off any balance remaining, but considers that the patient’s responsibility.

These balance charges likely added to the patient’s financial burden.

Re: Getting prior approval is becoming meaningless

chrystaltree — Tue, 11 Feb 2020 13:52:56 GMT

@Nuttmeg wrote:
@
@50Mickey wrote:

I also saw this article on CBS News about the state of Kansas jailing people with unpaid medical bills. Here is the link:

https://www.cbsnews.com/news/coffeyville-kansas-medical-debt-county-in-rural-kansas-is-jailing-people-over-unpaid-medical-debt/

The health system really needs fixed.
I read the article. They were not jailed for owning a medical debt. They were arrested for contempt of court for failing to appear in court twice about said bill. Not a smart thing to do.
@50Mickey

I watched the video on CBSN. The court is making people pay money $500 that do not have. Would you want someone to force you to appear in court, because you can't pay. Does this serve justice?

Indeed it does! As a previous poster said, they didn't show up in court! That's why the judgement went against them. Like it or not, a medical bill is no different than credit card bill or department store bill. It's a debt. They could have made a payment plan with the doctor or hospital. That happens ALL the time because people often don't have their out of pocket charge, they don't even know how much they will owe until they get billed. So, they make payment agreement because they don't want to skip out on a valid debt and end up in court.

Re: Getting prior approval is becoming meaningless

Lipstickdiva — Tue, 11 Feb 2020 14:59:17 GMT

More and more hospitals around here are requiring payment for services before you leave the hospital. And you always have to pay your co-pay prior to any service.

Anytime I go to my doctor's office, when I check in I also have to pay my $15.00 co-pay. When I was in the ER with a relative, someone came right into her room and told her they needed her $100.00 co-pay for her ER visit. The poor woman was in massive pain and vomiting from a kidney stone.

About a month ago, the hospital contacted me to set up a medical test my doctor had ordered. The hospital had already run my insurance and knew what my portion of the bill was going to be and asked for payment right then and there. I'm not sure what would have happened had I told her I was going to wait for my bill.

Re: Getting prior approval is becoming meaningless

Cakers3 — Wed, 12 Feb 2020 00:10:22 GMT

@quilter61 wrote:
I also saw this article on CBS News about the state of Kansas jailing people with unpaid medical bills. Here is the link:

https://www.cbsnews.com/news/coffeyville-kansas-medical-debt-county-in-rural-kansas-is-jailing-people-over-unpaid-medical-debt/

The health system really needs fixed.

@quilter61 He was jailed for failure to appear in court, not for the debt.

The court appearance was to allow him and his wife to plead their case regarding their inability to pay.

They didn't show up; that is why he was put in jail.

Re: Getting prior approval is becoming meaningless

Cakers3 — Wed, 12 Feb 2020 00:13:18 GMT

@50Mickey wrote:

@quilter61 wrote:
I also saw this article on CBS News about the state of Kansas jailing people with unpaid medical bills. Here is the link:

https://www.cbsnews.com/news/coffeyville-kansas-medical-debt-county-in-rural-kansas-is-jailing-people-over-unpaid-medical-debt/

The health system really needs fixed.
I read the article. They were not jailed for owning a medical debt. They were arrested for contempt of court for failing to appear in court twice about said bill. Not a smart thing to do.

@50Mickey Exactly and had they shown up they could have presented to the judge the reasons why the debt was not being paid.

Something could have been worked out; they chose twice not to appear and he paid the price.

I feel sorry for anybody facing medical debt; but in this case the jail wasn't about the debt.