SquirrelWithATophat
49759
2170
52
Dec 13, 2024 3:05 PM
SquirrelWithATophat
49759
2170
52
digitalbac0n
Doot cause favorites broked
euphoricopportunity
Meanwhile I get denials because of "we couldn't find the supporting documentation that you got the prerequisite procedure "
Daarst
Tactic I saw that worked was a GP had to call the insurance company to clear a test that had been denied. When he talked to the insurance's doctor he said "I'll need your name and license number, so when my patient dies you'll be at the malpractice court case with me."
ddashizzle
"We need less regulation in this country..." ... right...
DrKonrad
"No way to prevent this", says only western country without Universal healthcare
Revicus
Avoiding being asked this sort of thing is one of the many reasons for the web of hapless, powerless middlemen in insurance. I'm not saying this is bad advice, but my question to all of this is, "Ask who, exactly?"
SirenBrick
That is one of the largest tricks they use. 10 layers of management, 15 departments that have no direct access to one another, multiple 3rd party providers and call centres. No matter what, it is ALWAYS someone elses responsibility to help you. The legally required service is there, just inaccessible.
JackieTreehornProductions
wildly successful? LMAO no it's not. They won't provide any of this.
chunkym0nkeyyy
If the doctor asks they often grudgingly have to. Source: I have done it, and it has occasionally actually worked.
CyanideBreathMint
Another trick I learnt from the webs is to demand any test/labs you asked for and the doc denies to be noted in your medical file for this appointment.
sgnight13
The fact that any of this is necessary is justification to burn the system down with the C-Suite still inside.
scootwhoman
Health insurance companies convince us to give them money to pay for things that they get to choose whether or not to do.
slinkydust
I shouldn't have to be a doctor or insurance specialist to get proper fucking healthcare!
DJOldguy
Wow... we've been lucky, since my wife's cancer has gone into remission, and stayed there, we have not had any major medical issues, what medications we do need we are getting without a problem- so far. But if something does come up, this could be really good advice, gonna save this one.. Thanks for bringing the tips here @OP...
ToSisPoS
They can also just do that Delay thing. No company will be obliged to reply to your request in a timely manner.
“Due to higher than usual call volume, we fired our in- house customer service department and now contract out to an AI call centre.”
chunkym0nkeyyy
Some states have laws requiring responses to prior authorizations within a certain timeframe. Mine is 7 days for a regular PA, 48 hours for expedited.
ToSisPoS
And how stiff are the reprimands and expediency of enforcement?
SirenBrick
I believe they are tens of dollars in fines /s
ToSisPoS
Gods. My wrist stings in sympathy from such severity.
ZaphodBbx
Sound advice.
SewerRanger
No, it's pretty much 100% bullshit advice - none of it is actually true
SquirrelWithATophat
I can assure you from plenty of first hand experience that it is very real. I've done this with my insurance company FOUR times just this year.
/gallery/Slq0LOL/comment/2433010355
fractalsphere
I hope insurance companies get absolutely slammed with these requests.
BellsTheorem
This is great advice. However it does not solve the problem of the "Delay" tactic with these corporate vampires. They will drag their feet on this until you die from whatever it is you are seeking treatment for.
CobainsSarcoma
haha joke's on you op, i can't afford insurance
(actually i have kaiser - it costs a shitload and doesn't really do anything, just like Real Insurance ©®™)
ScootyPuffSr
Fwd: Fwd: Re: Fwd: Re: Re: Fwd: Re: Totally legit trick for dealing with insurance companies for real
SquirrelWithATophat
Having done this FOUR times just this year, I can say with certainty that this trick really does work with insurance companies. Looking at the other comments it appears I am not the only one here who has had to deal with this.
Zephrman
Yeah okay, bit imagine a world where you didn't have to do that? One where you go "doc I accidently cut myself" and the adhesive bandage didn't cost $100. One where your physician comes back to you with positive cancer results and news of full coverage because that's what you paid for every month up to this moment.
Zephrman
I will forever reiterate my point: AI should never make a final decision without human oversight. 1. AI makes mistakes - and quite frequently at that as well. Always design to have a human have the final say. 2. Corporation decisions don't care about you as a person, but they DO care about your money. If they suspect you don't have any more to give, they won't rule in your favor.
SquirrelWithATophat
My last reloadable credit card company got fined $44 million because their AI/algorithm kept randomly closing people's accounts with them (many of which were used as banking accounts for benefits payments to disabled people) and refused to allow anyone to access the money. The company swore that they fixed the problem, but two months later it happened to me as well. I had to switch to a new company while they drained some of the remaining money I couldn't spend out with recurring fees. 1/2
SquirrelWithATophat
I contacted their customer support and they flat out told me, "yeah I don't see any reason listed for closing your account, but our system will not allow it to be reopened and you are now banned from creating any new accounts with us. So too bad." 2/2
grosscol
.
generalprotectionfault
This post is astroturfing supporting the healthcare oligarchs
Huor
Hard to picture any of this actually working.
SquirrelWithATophat
It works if you do the legwork to prepare your initial argument in the appeal. I've had to do it several times just this year.
Splosions
Me: I would like A,B,C, and D.
Insurance: Lol no.
TrueNorthernLights
Yeah. Do all that, and then have your letter ignored.
SquirrelWithATophat
Depends on how you present your case. Their business model is built around victimizing people they believe are less likely or less able to fight against them. If the victim shows that they have everything necessary to make a case against them a sure win for any lawyer and/or make it a PR nightmare for the insurance company they often change their tune pretty quick.
badbmc
Me and my 70 cent dollar are laughing in Canadian.
SquirrelWithATophat
It's pretty detestable to mock or laugh at people being hurt and/or killed by a system that was forced upon them by the ruling elite with no alternatives.
bloodbloodbloodblood
Got any room up there? 'Bout 77 million of us need a place to stay.
HelikaformerNubisKnight9
You could also look for a place in the EU if you're willing to learn a new language. Some states here are in dire need of skilled workers.
cookies87
Any interest in becoming our 11th province? I'm sure Trump would be happy to be the Premier of the great province of America 😉
TemporarilyEmbarrassedThousandaire
There is also the "irate customer" escalation for pursuing an administrative override
StarshipSuperTrooper
My sister goes full karen on the hospital billing as a starting point. Her child is blind. She used to feel bad about it. Finding out that that's literally the only way her stuff gets pushed through she feels less bad about it.
TemporarilyEmbarrassedThousandaire
I'd do the same tbh, there are some categories of reps that you can afford to be civil to until they prove themselves to be incompetent, but civil does not mean not cold-blooded
StarshipSuperTrooper
My sister. Isn't angry. She doesn't view them as incompetent. Harbors no ill will against the person she's talking to. They have a quota of denials, she's reached her denial limit.
The only thing that moves the needle is being irate.
LespritDeLescalier22
Yup. Keep going up the chain. Don’t stop at the first manager you get to. Go to the second or third up. Give the details about your call to the first manager you speak to, but refuse to give it out again until you get another manager or two positions up. I had to do this with jannsen regarding their registration to pay $5 for a $13,000 PER SHOT medication. They kept fucking it up, and I went right up the food chain. Resolved immediately.
MrHorseManBaby
Yep. Just try your best not to do what this poor lady did and lose your cool, because they are chomping a the bit to make examples of us.
SavageDrums
Champing*. (also, this Florida woman did nothing wrong!)
MrHorseManBaby
Webster's dictionary indicates that "chomping" is a valid alternative ;)
420supercoolusername69
Also: if you ask a doctor for a specific treatment/therapy and they refuse, ask them to CHART YOUR REQUEST AND THEIR DENIAL.
chunkym0nkeyyy
What does this accomplish? Is it to avoid step therapy? Patient refusal of a therapy typically doesn't invalidate it as a requirement, unfortunately.
CardboardStomach
I imagine the thinking is you're implying you're gonna ask for a copy of your records either to show to a malpractice lawyer or to show to a medical board. The implication being that you think your doctor is not practicing a good standard of medicine or isn't appropriately justifying their actions and is instead brushing you off because they're too busy or being lazy.
chunkym0nkeyyy
I thought the context here was about fighting for prior authorization. or maybe this was just a different topic. but sure, yeah, note that it was discussed and provide your logic for why it was not appropriate in this case/at this time.
[deleted]
[deleted]
chunkym0nkeyyy
The problem arises when they demand you do an appeal though...
JustDumbCommentsAndCorrections
I assure you that my list of priorities has "Receiving medical care that improves my quality of life" far, far above "Being liked". And honestly you shouldn't WANT a patient who cares about your feelings. That's the kind of patient who will lie because they're ashamed of the stupid thing they've done that has directly led to their medical problem. Yours is a difficult job, and I respect that, but if a patient self-advocating annoys you, take it up with your therapist
chunkym0nkeyyy
I respect that it is part of advocating for yourself. I would rather a patient obnoxiously advocate for themselves than not. But, there are ways to approach this in a collaborative way that can help move your care forward (and there are ways to be a big dick). Same for the doc--they should always be able to explain their logic (they shouldn't just say "NO because I said so"). If they decline a treatment and give a reason, just ask if they can include it in the note so you can read it later.
chunkym0nkeyyy
And I agree with you, the onus is on the physician to not take perceived aggression/rudeness/obnoxiousness personally, but doctors are also only human. I always try to remind myself that this is possibly the worst day of someone's life, or the worst thing they have ever experienced, and to keep in mind that any lashing out is not personal. That having been said, I have ABSOLUTELY NO patience for people who are rude to staff who are just doing their job or are becoming physical/violent.
CardboardStomach
If asking for complete charting or an explanation for your choices is all it takes to be obnoxious to you then maybe you should reflect on that. Like I work in veterinary medicine and a basic communication log detailing client requests and my responses is a pretty basic "CYA" industry standard.
mothermushroom
Fuck you. You and every doctor that treats patients differently depending on whether or not you "like" them, or how hard they advocate for themselves in this horrendous system you clearly gleefully take part in. Fuck. You.
420supercoolusername69
I was gonna launch right into what a fuckin asshole a physician must be to “hate” patients they consider “obnoxious.” But this is a learning moment.
TL; DR family member had post-surgery complications that docs ignored. Docs were wrong and family member sued and got fuckin paid.
Over six years ago, my family member had a bladder sling implanted. FM started getting infections regulalry post-op. Docs prescribed antibiotics but infections were persistent. A week here. A few days there. After six-
420supercoolusername69
months, FM saw a commericsl for a class action lawsuit commerical for the bladder sling. It was causing problem in other patients so she mentions this and asks docs if they’ll check it out. They dismiss her and keep prescribing antibiotics. Another 6 months go by. By now, FM is a frequent flyer at the local ERs and urgent cares, where the docs also dismiss her requests to have the bladder sling scanned/investigated as possible causes of the infections. More antibiotics and pain killers. FM is-
420supercoolusername69
in and out of the hospital so regularly for this that the docs isolate her because of issues w/ c. diff. They’re also worried she’s developing resistance to antibiotics. Again, she asks them to check out the bladder sling. Again, they deny her.
This went on for almost two years. She called an attorney who confirmed her symptoms were similar to other patients in their suit. The attorney told her to keep asking the docs for alternatives to whatever they thought they were treating, and have them-
420supercoolusername69
chart every denial. FM follows attorney’s advice, and for the next six months, has docs chart denials.
The attorney finally recommended a doctor who could help. But guess what? There’s only two in the US, so it takes her four months from that point to see him. All the while, infections keep happening and docs refuse her request to check out the bladder sling.
By the time she sees the specialist, it’s been two-ish years. FM has no quality of life for almost the entire time. Bed ridden. Doped.
Chicagorooftop
As a vascular expert doctor I always had to talk to a dope who barely graduated med school. too lazy to practice. I learned to 1. Demand a supervisor immediately. 2. Demand review by a Board Certified vascular expert. 3. Advise the patient to contact the consumer satisfaction division of the company and complain persistantly to them. THEY are a different branch of the corporation, their goal is to prevent damaging public embarassment. They want problems to go away, so
chunkym0nkeyyy
I often have good results requesting "review by a physician board certified in [my field] with up-to-date/current clinical experience in managing [xyz] with novel therapies." Also I have asked for the "name, NPI number, board certification, and medical license number of the denying physician" and occasionally been sent an approval in response. A lot of the specialty-specific professional groups have templated letters for specific drugs with the citations already included.
Chicagorooftop
Hit 'em with data, like other companies cover a treatment, or it's covered in men but not women, etc. Unequal care is immoral but $$$. 4. Your state insurance comission will review complaints (hopefully), and if you join a disease centered group online they can flood similar complaints to the board. 5. Search other sufferers for connections to local MEDIA to try to inflict embarassment on the insurance company (they really hate that exposure). 6. Finally, we made form letters for patients.
Chicagorooftop
I also had identified the vascular experts names and directly sent them articles and supporting stats. Don't try that at home, but organized groups can marshall an effort.
Unfortunate500
I believe this is almost entirely false because I have been unable to find any reliably documented cases where it worked. Nor can I find any legal requirements that back up any of the assertions about claims handling.
My current insurer outsourced the denial process to the point where they don't even have this data. I would have to call the 3rd party company. They send a letter with the doctor's name and specialty and details about why it was denied.
It's useless to call them.
JustDaShoemaker
Of course they’ll say sorry we don’t have that info
SquirrelWithATophat
I can tell you from first hand, personal experience that this is very real. I've had to deal with it FOUR times just this year. As soon as I confront the insurance company with all the data, reference numbers, etc showing they are wrong to an extreme extent that could cost them big if the matter were to be taken to court they always back down pretty quick. Looking at the other comments I can see I'm not the only one here who has had to deal with this.
Snooj
There's another one of these that is mostly debunked.
SquirrelWithATophat
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keraos
Correct. I worked in a medical insurance call center for several years (it was hell). You're welcome to ask any of these questions, you will probably never get an answer to any of them. We were told that information isn't released for the safety of the doctors (retaliation for denied PAs and care).
I got multiple calls like this, none of them resulted in a change in the denials.
Just to be clear, I was in CS, I did everything I could to help, but that's still basically nothing. Burn it all.
travishawkins2199
I have a Dr that really spent some time making a case for me to get medication that had been denied. I mean, the medication isn't working, but he tried really hard to get it for me
RomanSnow
Yeah, when I got one of mine denied I tried reaching out and they refused to tell me just about everything.
OhOhOwen
I dealt with an American Insurance company for a surgical procedure once. The Dr showed me an AMA book that literally listed the prices of procedures (it was the 90’s). Insurance denied me a certain portion. When I explained the Dr had shown me his reference book and asked if they could tell me where they got their prices from they just said “no”.
RomanSnow
Yep! I had an MRI get denied, and I called and I asked to get the names and qualifications of the individuals who made the decision. And they said they couldn't give me that information, just that they were qualified and trained. When I said I wanted to make sure they were trained in relevant fields to make that decision they said that's an excellent point to put in a written appeal. So I asked again for their information and they said they were trained and qualified and refused to budge.
Knifesmith
You can legally compel insurance companies to provide this information by filing a complaint with your state's Dept. of Insurance, which surprisingly is really a consumer protection agency, and is fairly antagonistic to insurance companies.
ScootyPuffSr
It’s the same kind of fake-legal chain email nonsense that makes people think they’re sovereign citizens if they handwrite a disclaimer on their birth certificate or whatever magical thinking they’re spewing these days.
SquirrelWithATophat
/gallery/Slq0LOL/comment/2433010355
Just because you haven't experienced this personally doesn't mean that NOBODY has. I've done this several times just this year, so I can say from experience that it does in fact work.
AbelardSnazz
My dad always used to call them ‘barrack room lawyers’ from his national service days because every barracks would have one, all talk about their rights until they’re face to face with the sergeant
Unfortunate500
The denials for me are always because they want to see something specific in my history and the doctor failed to provide it. Specialists and surgeons can't do the one-on-one that insurers demand because it is impossible to schedule. These kinds of doctors have 6 month waiting lists...you miss an appointment and you are SOL until the next one. They can't sit around for a couple hours a day waiting for a call from the insurance company.
It's part of the "Delay" phase.
ceakay
Because this post is missing the most important part: reporting the person you spoke with to law enforcement for practicing medicine without a license. As far as you know, the person you spoke with is the person who rejected you. Then it's on the company and it's employees to figure out who needs to be arrested, not you.
Beanholio
The police will do absolutely nothing in that instance as they will deem it a civil matter.
ceakay
Nah, fuck the police, law enforcement is about lawyers. You just need the report to someone, so you can take it to the College to verify that insurance agent isn't a practising doctor, for the sharks to get started. Plenty of those ambulance chasers will take this easy win on contingency.
Unfortunate500
They know I am in severe pain and they know that their initial denials bought them 3 months. By requesting a one on one with a surgeon, they get 3-6 more months.
The pain and resulting lack of sleep cost me my job.
I finally gave up and paid for the CT scan out of pocket.
Ball fragmented. Socket full of crushed bone pieces. Lots of torn things.
Surgeon needs MRI to plan surgery. Denied because the doctor did not send a copy of the CT result and they won't accept the copy I have.
WolfPacker
My unsolicited advice, report this to your state insurance commissioner/board/secretary. It may have no effect, but there’s always a chance it will make an impact.
Unfortunate500
The moral of the story is that HIPAA has a massive perverse incentive baked into it.
Your insurer does not have a right to access your records. This means that for each and every little item they are asked to pay for, a prescribing doctor must provide 100% of the history and treatment. If they fail to report something *no-matter-how-obvious*, it is a reason for denial.
TomBrokaw
Can I interest you in a 3D printer and some monopoly money?