Community Chat

[cherry]

Who make the final descision in these cases? Is it a Dr or just a bean counter?

http://www.dailymail.co.uk/news/article-5769813/Anorexia-patient-weighs-58lbs-prepares-early-death.h...?

[CrazyDaisy]

I would ask what is different about the program in NY and why are her current doctors not using that protocol.  There are a lot of experimental programs/drugs/therapies out there that are not covered by insurance.

[Vivian]

This heartless treatment harkens back to the 19th century, when mental illness was considered a character defect. The insurance company has a he££ of a nerve calling anorexia a luxury. Getting away with it is sinful.

[phoenixbrd]

@cherry  Bean counter.

[Marp]

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@Vivian wrote:

This heartless treatment harkens back to the 19th century, when mental illness was considered a character defect. The insurance company has a he££ of a nerve calling anorexia a luxury. Getting away with it is sinful.

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This thread title is misleading.  As explained in the linked article It is not anorexia that the insurance company is calling a luxury it is the program offered by Columbia University in NY, at a cost of "tens of thousands of dollars" the program charges, that is the "luxury".

[cherry]

I altered the title. It wasn't done purposely to mislead anyone

[Marp]

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@cherry wrote:

I altered the title. It wasn't done purposely to mislead anyone

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@cherry, it never even crossed my mind that you purposely tried to mislead anyone.

Title phrasing is sometimes tricky when trying to give enough information but not too much.

[chrystaltree]

They didn't describe the program so it's impossible for the reader to know what went the reason for denial is.  However, I am 100% positive that no one is denying that girl treatment.  They just won't pay for $$$$$$$$$ care at some facility that might not even be what the patient really needs.  There are a lot of $$$$$$$ eating disorder programs out there, it's big business now.  I think I read that this patient is on Medicaid.  So, yes "the bean counters" have duty to protect the taxpayers and keep the program solvent.  Yes, she's ill.  Anorexia Nervosa is a mental illness. The physical part are always covered by all insurers, everywhere.  If she has cardiac problems or orthopedic or whatever....that will be treated.   But those long term $$$$$$$ inpatient programs that supposedly treat the psychiatric issue often aren't covered by insurers for host of reasons.  Some don't have qualified clinicians, some don't have medical staff,  some don't provide standard of care therapies, some don't meet state licensing requirements.  Also some simply don't work.  Like with every other insurance denial, that final decision about coverage is made by a team of outside physicians (meaning they aren't employed by the insurer) who are experienced and specialists in the field.  I think they said something about "single case agreement" in the story and that would only come into play if the insurer had APPROVED the admission.  The insurer and the facility negotiate the charge based on that particular patient's condition and they sign the SCA.  It seems to me the owner of that clinic wanted more money than the insurer was willing to pay and after negotiation (or he just wouldn't negotiate payment); there was no SCA.  Those for profit centers usually cost $25,0000 to $50,000 a month and the patients stay for many months and even the best of them aren't doing anything that can't be done in other approved and less expensive programs.  

[chrystaltree]

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@Marp wrote:

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@Vivian wrote:

This heartless treatment harkens back to the 19th century, when mental illness was considered a character defect. The insurance company has a he££ of a nerve calling anorexia a luxury. Getting away with it is sinful.

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This thread title is misleading.  As explained in the linked article It is not anorexia that the insurance company is calling a luxury it is the program offered by Columbia University in NY, at a cost of "tens of thousands of dollars" the program charges, that is the "luxury".

Yes, but they spent all those paragraphs document the patient's history and the article was intended soley to bash and trash the insurer.  Also, I doubt that anyone ever said that the Columia program was a "luxury".  I'm sure the actual denial said that the program did not meet the insurer's standard of care and that the patient can receive necessary and appropriate care elsewhere.  Which is true.  Either an approved inpatient program and specially designed outpatient program.  

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[Stray]

The thing that makes  the Columbia program very unique is that it's free if you agree to be part of their research program.  I think what some may think of as "luxury" is that you stay as long as it takes because they are not constrained by insurance companies and limited inpatient hospital stays.  

It puzzles me that her physician did not contact the program director unless the young woman does not want to be a part of research or maybe she can't get to the mandatory start weight of 65 lbs?