Insurance & Medical Coverage

[terpkristin]

In the "My Daughter Suffers a Concussion" thread, EF27 said:

Originally Posted by EF27

If she was my daughter and she vomited any more or deteriorated in any way, I'd be asking for a repeat CT scan of the head.

This is actually something I've "wondered" about. With all the talk of insurance stuff, even if a patient or the parent of a patient were to ask for a repeat CT, would the hospital do it? If the doc feels it's unnecessary, would insurance cover it if they did? Would it be different if Dr. EF27 asked than if Ms. tk asked (on this matter, I bet it would--my mom's sister and parents spent a lot of time in hospitals before the ends of their lives. My aunt in particular, the hospital was inclined to think she was "just another drunk" and kind of treated here that way....until my mom casually dropped her business card at the nurse's station saying that's where she could be reached...her business card that says she is Dr. tk's mom who works at NIH. Amazingly, after that, quality of care improved.).

/tk

[RainMaker]

I think it's a factor of a lot of things. I went into the ER a little while back with this raging pain in the back of my neck and head. Literally could barely stand and it would take the knees out from under me. I had been to the doctor earlier in the day and he said it was a bad neck strain. But at night, it just kept getting worse and I had this fear it was something more.

So I went in with my insurance card and they gave me a CAT scan and MRI. Had a neurologist and spine guy look at me and a bunch of other stuff. They found some bad ligament damage in my neck and put me in a neck brace for a month.

Now go back 7 years when I was in a small car accident. Woke up the next morning and couldn't move my neck. Just locked and in tons of pain. It was a Sunday so went to the ER. I didn't have insurance at this time (I was a stupid 22 year old who just graduated college). I got a once over by the ER doctor, told to take it easy for a couple days and sent home.

Now maybe they were completely different circumstances. Maybe one doctor was just more cautious than the other. But I wondered after my last trip if it had something to do with insurance. I have good insurance now and the guy had no problem running $6,000 worth of tests on my head and neck over this. He had no problem calling in a neurologist and neck/spine guy to look at me. I was thankful for the thoroughness but wonder if I had no insurance would I have gotten those tests?

[RainMaker]

More to the question.

I think a doctor objected to it, you'd have a hard time getting the hospital to do it. You'd probably be stuck finding another doctor who would or going the private route.

Insurance company is a total crapshoot though. I'd imagine they'd question why the second one was done just days later. Probably be a flip of the coin whether they fought it or not. As someone who has had to fight the insurance company for my Mom on many occasions, it seems like a spin of the roulette wheel trying to figure out what they will and won't cover. The stuff I think they won't they do and the stuff I think they would have to they fight.

For instance she had surgery on her ankle that required a skin graft. She's on some auto-immune drugs that increase her risk of infection so the doctors wanted her to stay an extra two days to make sure the wound was constantly kept clean and monitored. The insurance company fought this real hard and stood firm. But then when she got out, they told her they'd pay for her to have a physical therapist come by her home for rehab (which she didn't really need). I life threatening infection being prevented was a big no but getting some rehab on her ankle was. I'm guessing some nerdy MIT grad figured out the profit risk/reward for the scenarios, but it's kind of sad that profits play such a bigger role than whether you could die or lose a leg.

Epilogue to that story is that my Mom wanted go home early because she didn't want to get stuck with the huge bill for 2 more days. When her surgeon found out later on, he called the insurance company personally and literally threatened them with bad press. He is one of the top foot surgeons in the world (does all the surgeries for major athletes in Chicago) and has a massive reputation.

[M GO BLUE!!!]

Many times they still try to fight it when the doctor approves.

When I had my big accident in 2002, the insurance tried to deny my ambulance transport for both times (I was released, then couldn't get out of bed the next morning.) It took me arguing that I had a fractured vertebrae that was overlooked in not just the first ER visit, but both. I could have made it on my own? I couldn't even sit up the second time until they gave me a shot of valium and a second (bigger) shot of percoset.

And the argument that your job will switch to a government plan to save money rather than stick with the superior coverage you have now... My job switches about every two years to the cheapest plan they can get. My dentist is now out of network because he told me that the new insurance only covers about $25-$50 over the lab costs. And they take about $50 out of each of my paychecks for the privilage of having such insurance.

[BishopMVP]

From what I've heard, if you push hard enough or go around to different doctors you can get a second CT approved. Whether the insurance will cover it or not I have no idea, and I'm not sure they do on anything other than a case by case basis.

Sorry to hear that Rainmaker. Neck injuries suck - it's the most debilitating thing I've ever experienced. Broken foot, separated shoulder, even back injuries I could adjust to and complete some tasks. I couldn't sit still, couldn't lie down, couldn't read a book, watch TV, go on the internet without massive pain and feeling like I was making it worse. I pray I'll never have that sort of an injury again.

[RainMaker]

Yeah, it's amazing how much if screws you up. The first thing the neck guy said to me was that neck injuries are completely disproportionate to what you actually did to it. Mine was from sleeping on the couch for a night. If someone had taken a baseball bat and hit me 5 times in the neck, it would have hurt less than this. I've broken bones, dislocated a knee and had injuries from various sports I played in my life. Nothing even comes close to this pain.

The weird thing is that the pain went away real quick. I had it bad for like a few more days and then it almost went away overnight. Had to wear the neck brace to be safe still but it was just odd how I could go from excruciating, mind boggling pain for a few days to pain free the next morning.

[flere-imsaho]

I'm not a doctor, nor a health insurance expert, but ever since my wife got pregnant (and continuing through having a baby), I've spent a lot of quality time dealing with my insurance company and doing paperwork....

Originally Posted by terpkristin

even if a patient or the parent of a patient were to ask for a repeat CT, would the hospital do it?

Generally-speaking I'd suspect so, mostly because of the litigation risk if they don't. I suppose they might not if it seems little is wrong with the patient and the parents of the patient have nothing to say except "do another CT".

The only thing we've been through that's remotely similar to this situation was the weekend little Sam went to the ER twice due to being dehydrated from stomach flu. In both cases after the ER staff failed on two limbs in a row to get the IV going I said "OK, that's enough, get the pediatric nurse" and they complied. The pediatric nurse got the IV going in one go, both times.

The pediatric nurse's time was itemized at a higher cost (of course), but insurance paid it anyway.

If the doc feels it's unnecessary, would insurance cover it if they did?

LOL no. In the almost two years since my wife first got pregnant I can't tell you how many routine medical charges my insurance company has tried to deny. I've estimated I spent anywhere about 10 hours a month on "routine" paperwork and another 10 to 20 hours a month on paperwork specifically fighting the insurance company.

Here's the kicker: I have good insurance. I have a PPO plan with Blue Cross and Blue Shield of Illinois. Almost all of our doctors are in-network. Aside from little Sam being born and the ER visits we haven't had any truly out of the ordinary (I think) medical issues. And we go to good and very reputable hospitals and doctors (OB/GYN, pediatrician, etc...).

Anyway, back to the question: based on the legitimate and doctor-approved procedures my insurance has tried to deny in the past two years (and, eventually, failed), I can only imagine how far one would get trying to get them to pay for something the doctor didn't think was necessary.

[SportsDino]

Just think though, your getting your care denied so much faster than you would in Canada or Europe! And only paying twice the amount... now thats service!

[sterlingice]

Originally Posted by SportsDino

Just think though, your getting your care denied so much faster than you would in Canada or Europe! And only paying twice the amount... now thats service!

Spoiler

(Since it's snark, I thought it would be best to put it in a spoiler tag rather than threadjack)

Now if only you could bus in people to manufacture outrage in town halls, you'd be gold!

SI

[terpkristin]

Originally Posted by flere-imsaho

LOL no. In the almost two years since my wife first got pregnant I can't tell you how many routine medical charges my insurance company has tried to deny.

Oddly enough, my company hasn't tried to deny me much of anything except my orthotics, which I got them to go back on owing to medical necessity.

They have, however, asked me on a monthly basis if there's anybody else who could be paying for this, like Workman's Comp or coverage from an auto accident. I almost feel bad just saying, "Um, no, this is just part of covering me."

/tk

[flere-imsaho]

You realize that in every other insurance company in the nation there's a picture of you on the sales floor with a sign that says: "Never sell insurance to this person", right?

[terpkristin]

Originally Posted by flere-imsaho

You realize that in every other insurance company in the nation there's a picture of you on the sales floor with a sign that says: "Never sell insurance to this person", right?

Can I say how much I hope the "no denials because of pre-existing conditions" thing goes through? Being officially diagnosed with that silly genetic disorder may come back to haunt me...

/tk