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I work on behalf of one of the largest health care providers on the planet.  I'm a front line agent for members who call in with questions about their coverage or claims. Today I had a call that floored me and believe me when I tell you, people who do what I do have "heard it all."

It isn't that one ever becomes callous. A good majority of issues I deal with are a direct result of members not taking the time to try to understand their benefits, which I readily agree are tedious and confusing in the first place. That's where I come in.  The most difficult calls are those made after the claim comes in. It is bascially too late at that point and a failure to understand about deductibles, co-pays, coinsurance, referrals and primary care physicians are the progenitor of most post service complaints. I am limited at this point.

But then there are situations such as the one that occured today. I wish I could say they are rare, that they are the exception. The industry of for-profit health care is an adversarial one. The insurance company can only increase profits in one of two ways:  adding new members or denying claims of existing members Many claims are denied routinely for errors the provider makes or for failing to get "pre authorization." Most of them stay denied. A good many are denied based on pre existing conditions and these sadly, are almost never reversed.

Mainly it is the individual member who is left with what can sometimes be a staggering amount of money he or she is legally responsible for depsite the fact that the member had nothing to do with the reason the claim denied. Today I got call from a 47 year old male member who recently recieved inpatient services for major depression and suicidal ideology. Thankfully and fortunately, this man had the fortitude to reach out and seek help. He was able to get pre approval for treatment based on his benefits and diagnosis. He doubtless was at a point in his life where, for whatever reason, desparation had so clouded his perception, that the thought of taking his own life seemed viable. I cannot imagine what it took for him to undergo the exposure he had to endure in order to satisfy the people who "pre approve" such services at my company.

But perhaps after he did so, he may have felt a spark of hope. The insurance policy he had so faithfully and diligently paid for all these years was a real "life saver." Maybe his state of mind was such that he may have felt this was one of the only "good decisions" he had made in awhile. I cannot say. But when I spoke to him this morning, his was the abject voice of defeat. The claim for the inpatient hospital stay on which he had doubltess staked his last good, hope was denied a full two weeks after he was released.

There is no law either locally or nationally which prohibits a medical care provider from "billing" any amount they desire. When an insurance carrier is involved however, a negotiated rate is paid if the claim is approved. If it isn't, many times the member has little recourse against payng the full amount. In this case, a six day inpatient stay at the hospital came to a little under $45,000.00, or just about what the median annual income would be for a family of three. He was already getting calls from the hospital.

It is necesarry here to divert the reader for a moment. Claims and insurance billing is a filed of expertise in its own right. Medical coding is a complex endeavor. The primary coding for all insurance claims is the "diagnosis code" or "ICD-9 code which Medicare usues as well as all insurance carriers and medical providers. the correct oir incorrect code means simply, approval or denial of the claim, period. 98% of insured persons have little knowledge of coding and its impact on their claims until AFTER they experience what this member did.

In 2009 with the economy teetering on disaster, the wise and forward-thinking folks from the medical coding complex, intitated a brand new diagnosis code: V 62.0. These codes are for inputting on claims for remibursment. These codes are affixed to death certificates as well. These codes are stored on every insured person in the country and are often used to deny claims based on a pre existing condition.  

ICD 9 code V62.0 is rendered as follows: diagnoses in this category are "those circumstances or fear of them, affecting the peron directly involved or others, mentioned as the reason, justified or not, for seeking or receiving medical advice or care."  The particular and distinct code of V62.0 is this: Economic. Unemployment. Poverty. Lacking means of adequate support.  This is a valid and recognizable medical diagnosis. Mainly the member never knows what diagnosis codes have, are, or will be attached to his or her name. If after reading this however, you would like to know how to find this information on yourslef, let me know.

My caller had no idea this code was attached to his pre approved inpatient hospital service. And by Federal law, I could not disclose this to him either. My company duly denied this enitre claim predicated on the inclusion of the code V62.0 as "no benefit available for service rendered."

Look if at this point, whoever you are, you have any reservations about how desparately the for-profit insurance industry in this country needs to be torn down and rebuillt, consider the example cited here. I assure you it is 100% real life. I assure you further, it is indeed a matter of life and death.  

If on the other hand, you are outraged, feel free to share and comment on this diary. Please also feel free to contact me.

8:24 PM PT: I did not mean to intentionally create a "riddle". The enitre claim was legally denied based on the fact that the inclusion of a diganosis not mutally agreed upon prior to services, was considered a contractual violation. i do not believe the provider did this intentionally. However, prevailing insurance laws give the proivder the right to puruse the member for collection


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Comment Preferences

  •  ICD 9 Code V62.0 - Are you saying that the (2+ / 0-)
    Recommended by:
    cai, glorificus

    insured patient's otherwise valid claim was denied because he was unemployed?

  •  You need to explain this better. (7+ / 0-)

    I understand that your point is that it is incredibly complex and obscure, but it is important that within the diary we understand what is going on.

    If the treatment was pre-approved, then how did it get unapproved?

    Was this a mistake on the part of the hospital in the coding, or a devious ploy by your insurance company, or what?

    •  It Was In My Opinion.... (4+ / 0-)

      A combination of both. the extra code was not pre approved which negated the enirte claim

    •  Do I understand you that (9+ / 0-)

      the original treatment was approved, but based on this code being in his file, the hospital jacked up all kinds of other not approved treatment and now the insurer can legally deny ALL the costs, even those for the approved treatment?

      This reminds me of the nonsense that was in a Wall Street Journal article today about having to "shop for benefits".  How the hell was this guy to determine if what they were doing to him was on the approved or the disapproved list?

      Un. Be. Lievable

      Go Bernie Sanders! You are what a politician should be!

      by Former Chicagoan Now Angeleno on Wed Apr 04, 2012 at 08:08:42 PM PDT

      [ Parent ]

      •  You Are Partly Correct (8+ / 0-)

        The addition of a code not previously agreed upon would potentially add other charges. In this case  the bulk of the charges were for room and board and other incidentals to an inpatinet stay, there was no deliniation by diagnosis . Yes the claim was legally denied .
        You get the point precisely when you ask how was the member suppposed to know? Unlike almost all major expenses, a serious health care event isn't something one can solict "bids" on. Most people don't even have a clue what they'll eventually be charged until after the claim comes in....

        •  So in other words, they can deny anything (7+ / 0-)

          for any reason, and make it legal.

          Say he'd gotten constipated from meds while in the hospital.  Constipation Code XYZ, not approved, throw it all out!

          Calling this "legal" only means they haven't been stopped yet.

          •  I Have Perosnally Worked on Claims (5+ / 0-)

            that were dnied because th patinet's name was misspelled under "no insured by this name." The meber has to submit a copy of either a birth certificate or government issued ID, notarized. This has to be snail malied and cannot be faxed. the member has to submit a sworn affadavit as well, Whole process can take up to two moths to clear up. Meanwhile the proivder threatens the member with a collection agency. All 100% legal

            •  Please get out of that business (1+ / 0-)
              Recommended by:
              glorificus

              Anyone with a conscience should not be polluting their lives with this kind of evil.

              •  It's a job. Diamond81 is providing a real (2+ / 0-)
                Recommended by:
                marina, antirove

                service to insured people, such as this piece here.

                We need to change the system, Diamond can't do it alone.

                I hope more diaries like this are written. As is often said, know your enemy.

                I consider insurance companies the enemy.

                If you do not believe that there is an ongoing war on women, then you aren't paying attention. h/t The Pootie Potentate

                by glorificus on Thu Apr 05, 2012 at 06:30:53 AM PDT

                [ Parent ]

                •  Agreed (2+ / 0-)
                  Recommended by:
                  Diamond81, glorificus

                  Sometimes we stay in a job for purposes such as these, as a whistleblower of sorts; and also because we worry that the next person to fill the job may not be as protective of the client or customer.

                  The "corporate ethic" is costing our society as a whole. Greed is not a good basis for a society. As far as we are forced to operate within the corporate-based system, we become complicit in their goals. And so that includes nearly all of us in one way or another.

                  It's understandable that people can lose their better angels in this setup, so I applaud Diamond81 for keeping a clear perspective on the ethics, and having the moral courage to share this knowledge with us.

                  •  You Pretty Much Nailed it (2+ / 0-)
                    Recommended by:
                    glorificus, marina

                    as to why I stay. I actually love my job, if that makes any sense...

                    •  Sure. You are a subject matter expert in a very, (2+ / 0-)
                      Recommended by:
                      marina, Diamond81

                      very complicated field. I'd be proud, too, but I don't know if I could stand up under all the heartbreaking stories you must hear.

                      To me, it speaks well of YOU that you can see the inequities and flat out evilness of the system.

                      Maybe in a couple of years you can explain Obamacare coverage to people.

                      If you do not believe that there is an ongoing war on women, then you aren't paying attention. h/t The Pootie Potentate

                      by glorificus on Thu Apr 05, 2012 at 08:07:46 AM PDT

                      [ Parent ]

                      •  The Only Way I Can Stay (2+ / 0-)
                        Recommended by:
                        marina, glorificus

                        in this business is that I tell msyelf every hour that I work for whoever is on the other end of the phone. In fact I often tell them that.  the longer I stay and the more "tricks of the trade' I learn, the more capable I am at resolving issues like this by learning how to use the system against itself.

                        I love my jon. I loathe who I work for.

                        •  I'm concerned that insurance companies will (3+ / 0-)
                          Recommended by:
                          Diamond81, glorificus, marina

                          start combing through their ranks of claims processors looking for someone with a low rate of claims denials and higher rate of 'fixed' claims in order to identify those to include in the next round of 'downsizing' or to replace with more automation.

                          The motivation to start searching for you might be that  your actions could be cutting into the size of anticipated bonuses to top management and shareholders--don't think this impossible.  I might mention, with my IT background in health & pensions, banking and commodities, that coming up with just that sort of 'data mining' isn't that hard to do. You might not even know an IT consultant with expertise in these ares was contracted to do just this with the claims data. Depending on state of the insurance claims database and logging of claims processor actions and phone conversations, it might be just a matter of days to come up with that.

                          So, please be careful with what you write, to not reveal anything further specific to your company, or class and level of your employment, since if it ends up with you being indirectly 'outed' here, it could be even worse for you, since that could make finding future employment far harder as well as nasty legal suits.  Avoid posting here from work, as all your diary and update processing can be captured by an employer, in easily read 'clear text' format, since dailykos does not use the secure encrypted by SSL https: protocol.

                          Back in the '90s I worked for a data aggregating employer to mine the 'anonymized' claims data the insurer would provide on behalf of employers. The job ostensibly was to identify clusters of diagnoses occuring within their divisions and departments.  I ended up with the impression that this was looking like some sort of prevention effort, and perhaps tied to OSHA, or linked to making health plan improvements, perhaps by providing department specific recommendations.  After I'd done most of the coding and making a pretty clever system capable of taking into account many variables to sift, sort, isolate and locate where diagnoses and treatments occured, I eventually realized this was mostly being used to find AIDS cases and pre-AIDS patients with HIV.  It sort of became apparent when this was one of the test cases used in a live final presentation that was made where I was present in case something went awry.  It wasn't as hard as one might think to cross reference this data with other census, credit and employer data to peg which covered individuals or family members this was, at least figuring it out down to the 'department' level.  At the end, I wasn't sure of the ethicalness of applying this sort of 'cleverness' back then, and, by itself, I suppose it could have been used to help rather than hurt, to let companies know when they need to ensure their employees have a sound awareness of HIV and AIDS and how to cope if having it.  I do know a few employers were more compassionate about using it than others.  I can only imagine that rather than abandoning this sort of data mining, that employers will have sought far greater sophistication in doing this in the last decade.

                          When life gives you wingnuts, make wingnut butter!

                          by antirove on Thu Apr 05, 2012 at 11:17:48 AM PDT

                          [ Parent ]

                          •  Thank You Very Much For... (3+ / 0-)
                            Recommended by:
                            glorificus, marina, antirove

                            your concern and head's up. You are correct that if "outed" I would be fired and probably sued and maybe even prosecuted. I am fortunate that I enjoy a wide lattitude within the purview of my "position."

                            I will say that every syllable I utter over the phone is recorded. Every movment I make is video recorded as well. I had to sign a waiver that every key stroke I make on my work computer is subject to scrutiny. Part of this is industry security protocol due to the senitivity of the information I deal with and part of it is simply a menas of geeting more "production" form me (and my coworkers) as we are evlauted LESS on the actual correct information we give than we are on how long we took to complete the call.

                            I do not however operate unilaterally but I am becoming proficient in the art of "schmoozing" with other employees who have the means and the method and the authority to override certain thngs, so I can get results for my caller. This does not imply anythng unethical, just greasoing the wheels so to speak . You are also correct about a target per centage of negative claim results, But as long as the entirte department stays within the poarameters, it isn't hard to fly under the radar and maybe get a "neutral" claim processed in favor of the consumer, particularly if it is an admin type or error- entry type denial. These are just the realitites........ I admire and appreciate you expertise in the area of IT

              •  I am Pleased You Had Such a Strong (1+ / 0-)
                Recommended by:
                marina

                revlusion toward my post. It is normal to want a face to put on something lke this.

          •  And this is the reality into which Republicans (8+ / 0-)

            want to force senior citizens.  How many eighty year olds with serious medical issues do you know that could negotiate this swamp?

            “when Democrats don’t vote, Democrats don’t win.” Alan Grayson

            by ahumbleopinion on Wed Apr 04, 2012 at 09:00:59 PM PDT

            [ Parent ]

            •  I Could Not Agree More And In Fact.... (5+ / 0-)

              Since Medicare is mandatory primary for ANY group coverage with less than 20 employees, many seniors believe their group sitll covers them until their claims get dened by the company who does not inform them of this until after the fact. One cannot cancel oup coverag until the open enrollment period or a qualifying event such as sepration from the comapny. They pat maybe an enitire years' worth of wasted premium and then, have to fightwith meducare to get a "late enrollment" to get meeicare at all after this,. Tragic.

              I this was in any way confusing to you, that is precisel the poit Thanks for illustraing

            •  So true, I am one of those seniors, (2+ / 0-)
              Recommended by:
              basquebob, glorificus

              and I am totally confused, and I don't confuse easily.

        •  it means can't afford a lawyer (2+ / 0-)
          Recommended by:
          glorificus, Diamond81

          so screw him, it can't bite us back.

          fact does not require fiction for balance (proudly a DFH)

          by mollyd on Wed Apr 04, 2012 at 11:22:58 PM PDT

          [ Parent ]

    •  see blow comment (0+ / 0-)

      thanks

  •  I fail to understand how (8+ / 0-)
    The particular and distinct code of V62.0 is this: Economic. Unemployment. Poverty. Lacking means of adequate support.  This is a valid and recognizable medical diagnosis.
    could be a valid medical diagnosis.

    "Lacking means of adequate support" is a disease? Or found in some accepted encyclopedia of medical diagnoses?

  •  Very interesting but also confusing (6+ / 0-)

    I think technical talk with some follow-up in 6th grader speak will really help get the message understood. I appreciate your effort I just want to be sure I understand correctly.

    Does the gentlemen in question have any recourse from here forward?

  •  Truly (7+ / 0-)

    We have gone through the looking-glass.

    As an aside - There's no hospital bed in the world worth $7,000+ a day. The system is broken. Irreparably.

    It's time to start over from scratch.

  •  Ok, here's what I get from this (for those (9+ / 0-)

    who say they are confused).

    Guy gets pre-approval to be hospitalized for major depression and suicidal ideation.  (Suicidal ideology would be something else.)

    Problem is, along with the code for those two things, somebody at the hospital billed for a third thing -- being worried about his economic situation.

    A sensible person would think that this might be a contributing factor to the depression and suicidal ideation, and not a separate thing at all.

    The insurance company, however, thinks it is a separate thing, and because it was not pre-approved (who knew "worries about money" was a diagnosis that needed to be pre-approved?), denied the entire claim for the hospital stay.

    Just to contemplate the evil of this for a moment... simply being able to jump through the hoops to get pre-approval when one is in a mental health crisis is an enormous accomplishment.  And think for a second, how was the patient supposed to give the insurance company a diagnosis for his own problem, if nobody medical had ever given it to him?  Even depression and suicidal ideation are things medical people diagnose.

    This is evil, pure and simple.

    •  We Have A Winner..... (8+ / 0-)

      Now for a second, imagine yourself after enduring what this man did. No one called him. No one gave him any warning. He went to his mailbox and there was the explanation of benefits from the insurance company stating the entire claim was denied. Formal. Cold. Impersonal.  Very much akin to the manner in which survivors were infomred during WWII of the death of their loved one. There is a number he is advised to call with any questions.

      I answer the phone and tell him basically the same thing (minus the editorialzing) I have stated here except for the actual diagnoisis code themselves. Talk about confusion. His new meds haven't even had time to kick in yet.

      •  No one calls the doctor to question the codes used (1+ / 0-)
        Recommended by:
        Diamond81

        and asks if that's what was meant before denying the claim?  No chance to correct or appeal 'coding errors'?  Or to fix 'transcription errors' in medical records?  This seems to make private insurance behave more like a lottery--you win only if you can guess the right sequence of code numbers for diagnoses and treatments.  That can't possibly be what is meant when politicians and lobbyists claim America has the best health care in the world.

        Are there provisions in health plans under which V62 would actually qualify patients for any other services or benefits?  If not, why should any clinicians bother entering this code on behalf of anyone since all it seems to do is give insurers reasons to not pay them what they're due?

        This is what's so broken about private medical insurance.  Each insurer makes such a complex matrix of rules, plus bizarre exception logic, so that a claim filer must get all the pieces exactly right, within the right sequence of diagnoses and treatments, or else everyone actually involved in delivering the health services and the patient all loses out; well, except for the insurance company, which gets to hand out the accured mountain denied benefit monies as bonuses to top management and shareholder dividends.  And this 'business behavior' is not taken as a sign of gross mismanagement or corruption--that so much denied benefit monies acrues in the first place?  (ok, that ACA 80%/85% claims paid per premiums received rule is starting to have some impact...but there's still a lot of room for this problem.) And each plan still can have it's own byzantine labyrinth of rules and exeptions that defy comprehension, even by people with medical degrees, let alone patients--whom it's all supposed to be 'for'.

        Is there perhaps a different ICD-9 code for a patient who is bankrupted due to crappy insurance, and to be denied any further treatment? Or is that simply covered by V62 too?  Is V62 really perhaps just ALEC/GOP code for just hurry up and die already if you're sick and too poor?  

        This seems to clearly show our uniquely American private insurance isn't about giving Americans the best medical care in the world.  But it sure can be highly effective at giving sick Americans the most bankrupting medical debt in the world, due to denial of claims, along with crushing our credit bureau records & 'scores', and of course 'death by spreadsheet'.  Does a V62 score prevent one from getting jobs these days as credit bureaus are adding our health and medical compliance data?  Can't we get HIPPA updated to prevent even that?

        Does anyone know if anywhere in the 2700 pages of the ACA legislation this byzantine plan benefits problem is addressed as omething that will be reformed?  At one point, there was serious discussion, as ACA was being written, of simplifying all this byzantine malarky into three plans with national definitions, to be labeled as Bronze, Silver or Gold plans, with only differences in deductibles, co-pays and premium prices. And this would enable real competition on comparable pricing and service quality at a level consumers could understand, since other plan features would be 'equal'.  I presume the insurance companies managed to crush this sort of efficiency in plan design concept before the ACA law was finally codified.  So we can't have single-payer, and we can't even have nationally defined benefit plans?  Yeah, I know, we can't even get federal laws that apply to automobiles or building ordinances without states using their rights to insist on state and local differences.

        When life gives you wingnuts, make wingnut butter!

        by antirove on Thu Apr 05, 2012 at 10:37:32 AM PDT

        [ Parent ]

        •  Most Insightful Non- Industry Post I've Seen..... (2+ / 0-)
          Recommended by:
          glorificus, antirove

          Kudos antirove. Nohing I admire more than consumer activism. Your grasp of the issues is laudible, In response to some of the points and questions you raised, I will say that  NO ONE CALLS. Claims are generally submitted electronically then scanned electronically using various industry "software".  

          Claims can and genrally are processed and adjudicated by a computer that scans the varying codes (there are actually six different sets of codes: HCPC, ICD -9, CPT and varying location or type of service codes. The computer keys these off the member's unique ID number which then plots/reads/decides the claim based on the member's unique plan. I am not an IT person so forigve my pedestrain terminology but you get the point. The porcesing of claims, upto and including an auto generated mailing to the member can be done 100% without no human interaction. Yes, it really is that impersonal. if no one objects, there will BE no human interaction either.  Payments are then automatically made through EDI to the provider (where applicable)  using the proivders national provider index and financial acct numbers.

          V62 diagnosis codes are not really a "score" per se and I am unware of any integration between dtata bases other than helath related ones. I do know that your health information "follows" you wherever you go and all HIPPA does in protect your rights to privcacy for other non entitlted entitites to access it without your consent. I am an entitled entity.

          I know more about your heath than you do,since it is rare for this info to be shared with you by your provider (s).  I know when you contracted a minor STD though you are married. I know when your spouse infilicted a blow to your person.  I know your psyhcological history if you ever sought treatment, I know what drugs you take and how much you pay for them I also have all your personal ID information up to and including your checking account info if you pay my company with this method. I know where you work, how long you've been there and the names of all your children.  I know what brand name birth control your daughter usues. I have your home, cell and work phone numbers. I know exactly where you live, how long you've been there and who resides with you. I know if you are in a domestic partner relationship (in states where this is the law).

          In fact, if you are a member of my company's extensive data base of "insureds" I can find you anywhere. I can do this without supervision, permission or just cause.
           

          •  Head's Up: The Above Reply Ought To Scare (1+ / 0-)
            Recommended by:
            glorificus

            the bejesus out of you and everyone else.....An insurance corporation's data base  might be the most exhaustive and comprehensive collection of personal information in the US.  Hypothetically, if yoou have been with the company you work for say, 10 years and they have always used my company, I will absolutley be able to know more about you than you know.....

    •  Evil, pure and simple. (8+ / 0-)

      Insurance co. runs the table, marks the cards and calls winners & losers at will.  No other party is allowed adequate information to cover their bets and asses.  

      Whoops!  a little incongruency on a form and a poor (sick) sucker is out $45,000.

      The clinicians are running around caring for pts.  Precerts. are onerous time-suckers at best.  Techs. are filling out form after form.  No one is probably aware that so much money and angst are at stake.

      By the time this huge shit storm hits the pt., time's moved on, game's over.

      What a disgusting, unnecessary scam.

      Diamond 81, hope you do an on-going series of dairies on the ramifications of these codes and the pitfalls of the precert process.

      Information is power and we can all use some to counter these fuckers.    

      •  Oops. "dairies' fine. "Diaries" better. NT (1+ / 0-)
        Recommended by:
        cai
        •  I love ice cream. (2+ / 0-)
          Recommended by:
          dotdash2u, cai

          If you do not believe that there is an ongoing war on women, then you aren't paying attention. h/t The Pootie Potentate

          by glorificus on Thu Apr 05, 2012 at 06:35:45 AM PDT

          [ Parent ]

          •  You found the best side to pint-sized dairy errs! (3+ / 0-)
            Recommended by:
            Diamond81, glorificus, dotdash2u

            And given these dairies were to be aired in series, you'll get graze all your choices of toppings to boot!  You see where optimism and seeing the best in others can get you, folks?  Rising like cream to the top!  And, hey, Dotdsh2u, don't apologize for taking a strong dairy stand! It goes well with apple-pie too!

            Maybe if we encourage dotdash2u, butter him up a bit, we can milk his errs until dotdash2u's great scoops can muck the custard, er, cut the mustard, sorry,   Mphnmmhph ...with udderly perfect sentences that are semantically grade A mphmmm...and syntacticly full of sugar...  It's...Mmnph...kind of hard for me to talk Mmnph...with all this hot fudge ..Mmmnhphchk... & carmel & nuts getting shtuck to the roobpf ob my mouth.  MMmph...needs more bananas... mmmmPhslurp... and strawberries. [wipe/wipe] Just don't give me the raspberries for pointing this out.  They're too good to waste on that.  

            Wait...does this mean I'd have to get my tonsils out in order for insurance to cover my 3 scoop sundae boat, with or without a cherry on top?  Here's where dotdash2u's expertise could help!  Just what diagnoses and ICD-9 codes could qualify me for ice cream?  Or Sherbert?  Italian Ice? Theoretically speaking, if lots of dark chocolate is used, maybe with some some bupropion sprinkles, could depression qualify me for this treatment?  I am sure Dr. Oz would approve this, if fresh pineapple & avocado were used.  Gonna need way more raspberries now.

            When life gives you wingnuts, make wingnut butter!

            by antirove on Thu Apr 05, 2012 at 09:53:17 AM PDT

            [ Parent ]

      •  You Are Indeed (5+ / 0-)
        Recommended by:
        marina, glorificus, dotdash2u, cai, antirove

        On the right track. The average health insurance claim is less than $100.00 bucks. When a claim like this comes in, any reason at all to nibble away at it is sought. If no one fights back or manages to win, more money for the Insurance company. if it takes 3-4 months to settle an appeal, it could be simply a lat negotiaion of how much the hospital will accept. if that is the case, the money was held without having to pay it for that many more months it accrued interest in escrow

  •  Unfortunately, I don't see how the SCOTUS decision (3+ / 0-)

    can do anything for this man.  He already has insurance, and if the insurance company's action are "legal" as you claim, he'd be equally SOL in 2014.

    •  Under the PPACA (3+ / 0-)
      Recommended by:
      Diamond81, cai, glorificus

      some big, bad bureaucrats will get together to decide what is medically necessary.

      These bureaucrats will use words instead of diagnostic codes.

      The coding system does point the finger at the right thing, the man's (and society's) unemployment and poverty problems.

      SingleVoter can get and has gotten very depressed over money problems. Very depressed.

      After a few months of then expensive Prozac and Zoloft, SingleVoter decided to simply give himself a happiness budget equal to the cost of the pills instead.

      Money as medicine.

      •  Single Voter Gets It (1+ / 0-)
        Recommended by:
        glorificus

        that even having a medical code for a situation a vast majority of Americans are in as a contrbuting cause to health issues, speaks volumes in and of itself.

        Think of the profit that could be made by the health care proivders if this new code could one day be 100% billable.

  •  This really is literally sickening. (6+ / 0-)

    And to dream this up is evil and getting it accepted and passed is even more evil.

  •  shocking and and thoroughly depressing...oops (3+ / 0-)
    Recommended by:
    Diamond81, marina, glorificus

    I shouldn't have said that. I have instinctively stopped talking to medical professionals about anything at all. I am also becoming very, very suspicious when they ask questions about family history I bet you all can guess what I am seeing and imagining here. I refuse to participate in the now mandatory depression screening in my "healthcare plan".

    In the future if I have the misfortune to, for example break my leg with a compound fracture I will just point at it with a frown on my face. Silence. Maybe I shouldn't frown either?

    I really feel for this guy.  I know how bad it can get. What I am saying is in no way meant to discourage others from seeking mental health treatment.
    Thank you for this simply horrifying diary.

    •  Wendy You Should See What Is Already (3+ / 0-)
      Recommended by:
      marina, glorificus, dotdash2u

      In your private insurance file. Believe it or not, you cannot get access to your own insurance files without submitting a wirtten and signed resuest and then, the decison is "subject to review".  No FOIA covers confidential medical information, even your own.

      Dont believe this? Call your insurance company and simply ask them to send them to you....

    •  Shouldn't blame fall on Ins. co. for leveraging a (2+ / 0-)
      Recommended by:
      Diamond81, glorificus

      loophole to forgo paying their fair share of this pt's expenses.

      It sounds like:  The pt. was in good standing and had a proper expectation that the expenses would be paid.  Also the provider diligently precertified the hosp. admission with the Ins. co.  

      The situation went awry when some time along the way an extra code was added to the paperwork by persons unknown and the Ins. co. used this admin. mistake to go after the weakest party in play, the pt.  At least this is my understanding of the situation.  Diamond81 please correct me if i am wrong.

      The hosp and clinic/provider wrestle and fight with multiple Ins. cos. every day and usually have legal backup.  The pt. is vulnerable, weak, ignorant of these ins. ploys and often alone. ("Fresh fish" as they used to say at Andersonville.)

      My point:  Please don't mistrust your medical provider unless they deserve it medically.  They often count on detailed info. about you and your situation to diagnose problems and work out management plans.  But  you have a right to any and all medical info. about you (I take home a copy of each visit and all tests).    Ask if a procedure needs precert. and have the provider give you all the codes and diagnoses to be used for this.  Then check that the precert went thru. Keep documentation of everything.  At least, if the sh*t hits the fan you have a core of material to work with.

  •  insane. (3+ / 0-)
    Recommended by:
    semiot, glorificus, Diamond81

    I swear, Insurance companies need to be weeded out. With a guillotine.

  •  In ordinary English (3+ / 0-)
    Recommended by:
    glorificus, Diamond81, dotdash2u

    Man gets very depressed because of bad economic circumstances such as
    long-term unemployment.

    Man seeks help because he feels like killing himself.

    Man seeks professional help.

    Hospital says it will try to help.

    Insurer says it will pay for hospital to try to help.

    Help given by hospital. Man doesn't feel like ending it all now.

    A massive $45,000 bill sent by hospital.

    Insurer naturally doesn't want to pay the bill because it would take $45,000 away from its profits and insurer welches out of its promise to pay.

    Man has an unpaid $45,000 hospital bill to add to his other financial problems.

    Man feels really bad again.

    [It probably would have been cheaper to extend unemployment benefits or to pay them on more than the 30% of claims where unemployment insurance actually pays out.]

  •  I should add that grinding people (2+ / 0-)
    Recommended by:
    dotdash2u, glorificus

    down economically can make them physically and mentally sick.

  •  There needs to be a simpler (0+ / 0-)

    and sounder system.

    A number of government-set questions should have been asked by the insurer.

    If truthful answers were given, the insurer should be required to pay.

  •  Please keep posting diaries Diamond81, (1+ / 0-)
    Recommended by:
    Diamond81

    on this and related topics.  I am "hearting" you and look forward to reading more.

    Perhaps pointers on how to appeal a rejected claim and barriers and pitfalls to expect.

    Also what to expect with Medicare as Primary and private Ins. co. as Secondary, both with pt. continuing to work and after retiring.

    Thanks again ......

    •  Thanks for The Vote of Confidence and.... (1+ / 0-)
      Recommended by:
      dotdash2u

      I will do just that. I didn't know how a post on this topic would be recieved. It has been my experience that many otherwise diligent and educated individuals get "taken" by not becoming aware of health care coverage.

      Incidentally, I do volunteer my "knowledge" on Saturdays. The community I live in is almost exclusively a retirement community and the Seniors are always eager to gather with each other even over something as boring as this..)

      •  A situation that can whack you back $45,000 (1+ / 0-)
        Recommended by:
        Diamond81

        in one blow for 5 days care that you were precertified to receive is by definition not boring.  Especially when the ins. co. hangs their disallowance on such a flimsy reason as a paperwork error that they, then hide from the poor, shocked, befuddled client.  It is so cold and deceitful.

        The more we can learn about the MO of these slimy bastards the more possibility we have to protect ourselves and those we love.

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