When will the BS end?

[mmglobal]

(Should I ask when will this BC/BS end?)

A client of mine is scheduled for surgery in the US tomorrow. After 2 failed fusion surgeries, he needs a revision with an artificial disc on top at a now-degenerated adjacent level.

Everything was authorized by insurance company.

They evaluated their options and made their choice based on a copious amount of research.

They flew across the country, arriving in the surgery city on Sunday, and are expecting to have surgery tomorrow.

This afternoon... less than 24 hours before surgery, after they are already here at great expense and heartache.... they are told that the ADR portion of the surgery is not approved.

They can have a 3-level fusion.

They may be able to pay way too much for the disc portion of the surgery, but we are uncertain if that is even an option.

They can go home, out many thousands of dollars and many extra weeks of suffering and start again evaluating their options.

This is devastating.

I'm hoping to speak at the BC/BS meeting on Wednesday and I was wondering what I was going to say. Now I know.

When will this bullshit end? I've heard this story way too many times over the past few years. I thought we were nearing the end, now more than 2 years after Charite' approval and 5 months after ProDisc approval.

This is horrible. They may be forced into an inappropriate solution based on this incredible nonsense.

When will this end?

Mark

[Poncho]

Mark,

This is bullshit! I agree!!!

Sometimes, I wonder if the practices of BCBS are right up there with insurance fraud.

[annapurna]

Go get 'em Mark! Perhaps battling unethical insurance denials may be your true calling as a patient advocate. What is being done to these people would probably be looked upon as a criminal act if it were performed by anyone other than an insurance company.

Hopefully the outcome of all this will be good, albeit delayed.

Best to All!

[dshobbies]

They say that Californians are sue happy... maybe because of all the fraud we have to put up with.

All kidding aside, I believe the insurance company acted negligently and caused untold pain and suffering. Complaining has done no good as I've been (almost) in those shoes, having my surgery cancelled 1 week before I was scheduled. The mental preperation that goes into a surgery of this caliber or any surgery is well known within the medical community. The insurance company could have acted weeks, if not months, earlier. They've done this too many times because there has not been any challenge to set a precedent. I believe this one may be a turning point if your client gets an attorney. I don't think bad faith is relevent anymore but negligence and pain and suffering is.

This is completely inexcusable!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!

Dale

[Maria]

That's *&^$%ed up!!!!!!!! I can't believe that these stupid insurance companies don't realize what kind of pain and suffering they inflict on people who are already on their last emotional nerve let alone all the other kind of hardship and suffering persons like this go thru~

I feel so badly for your client Mark. I've had the door shut on me re WC as everyone knows and it took nearly 2 years to get nearly back what they had promised me in terms of surgery~ but at least I didn't plan the surgery to the date, have family members make adjustments and was sitting on the hospital doorstep literally the day before surgery~ that is just an outrage that insurance companies can not only change what they authorize but do it so very suddenly right before a surgery...

Please go get 'em Mark, and if there is anyway that community involvement could be helpful, please let us know

[ans]

Thanks Mark for speaking up. This is a horrible situation.

Gee I'm glad that I have BC/BS.

[sahuaro]

It is truly wonderful that Mark and Dr. Delamarter will be speaking about these issues and the value of ADR, but, from my experiences as a "provider," (a term invented by insurance companies to minimize my professional training), patient and victim of insurance companies, I am viewing the situation more helplessly and cynically. The expectation/hope that insurance companies will consider patients' feelings and the harmful effects of their decisions is just unrealistic; their decisions are based solely on financial considerations and minimizing their losses. The only way to influence their decisions is through financial impact and/or political impact but the insurance lobby is considerable and powerful. One example is State Farm's denial of Katrina claims and then after a considerable judgment again them, their decision to no longer insure homeowners in Mississippi.
Mark: Unless it involves information that is too personal, could you let us know on what basis the insurance company reversed its decision? Because "forewarned is forearmed," this information is potentially helpful to those of us who may be facing this situation. Thanks.

[ans]

Barbara, you nailed it. My sense is that ADRs will not be subsidized unless a cogent case can be made that it's cost-effective. In this regard, I think that the jury is out if ADRs do not promote the domino-effect - the bane of fusion. My very best and thanks again.

[mmglobal]

Surgery happened.... pt. got ADR.

I'll leave it up to them to patient and his family to write details.

This is an incredibly frustrating process. Many of us experienced it first hand in the early years of ADR in the US. Who would have thought that more than 2 years after Charite' approval and with ProDisc approved for more than 6 months, that we'd still be in this situation.

I did get to speak at the tech assessment forum yesterday and got to spend some time with Dr. Delamarter. I'll write more later.

Mark

[dshobbies]

Wow, that's great news about the surgery and adr. The question still remains as to who paid for it?

Sahuaro,
While I agree that the ins co cares little about the paitient, cancelling the surgery 1 day prior is unconscionable. Not covering adr's is one thing, not acting with due consideration is negligent and I believe actionable. However, there still must be a test case to set precedent.

Dale

[sahuaro]

Of course the insurance company's 11th hour cancellation is unconscionable--but insurance companies do not have consciences. Even after they've paid for services, they have the right (or claim to have the right) to re-review and demand that payment be returned. This in fact happened a couple of years ago with an HMO declaring an audit of psychologists' records after having already paid the claims, to determine "medical necessity," and if the psychologists' records were judged by the HMO as not meeting their standard of demonstrating "medical necessity," they demanded their money back. Fortunately, the American Psychological Association and other professional organizations got involved and they backed off somewhat--but the threat is there. Here again, to push back against the almighty insurance companies, the individual psychologists needed the clout and money of the professional organizations. Unbelievable, I know, but unfortunately, true.