A while back, I wrote a diary about some of the dirty tricks I have been seeing health insurers pull in order to avoid paying for patients’ needed procedures. I wear a lot of hats at my job–one of which is obtaining pre-authorizations for outpatient medical procedures. I have been noticing some trends over the last few months that are making it even more difficult for patients to get the care they need.

Many insurance companies use third party entities such as Availity, Evicore, or Carelon to process prior authorization requests. A lot of companies have started using AI to make the determinations, which has been causing a lot of patients to have their procedures denied, even when they meet medical necessity guidelines. This especially seems to be happening when we have to submit clinical documentation such as office visit notes, imaging reports, or medication lists. Apparently, the AI is conveniently unable to read these notes unless they are worded and formatted a specific way–which of course, the insurance company won’t tell you.

Then, we are left with the option of scheduling a peer to peer discussion with the insurance company’s doctor (and often only have a few days to do it), filing an appeal (which can take anywhere from 30 to 60 days) or in the case of Medicare plans, waiting at least 65 days from the date of denial before we can resubmit. Unless you have a UMR commercial plan–then for certain procedures you may have to wait as long as 180 days before we can resubmit.

On a side note–if you are denied on appeal and the processor is the one who denies your procedure, you can still appeal directly to the insurance company. Of course, this delays things for the patient even more–which is the point from the insurance company’s perspective. They want the patients and providers to give up.

Another thing I have been seeing is that some insurance companies (like Aetna) are now asking for patients with no documented history of smoking to have a nicotine test before they can be approved for surgery.

In addition, pain patients who have ever reported that they consume alcohol or have ever in their lives used any sort of drugs, no matter how long ago, have to now prove they are clean before they can have any sort of pain related surgery. I saw a terminal cancer patient get denied for a pain pump once–this person was in horrible pain, but was made to suffer because they admitted they had smoked pot in the recent past.

For musculoskeletal procedures, such as guided steroid injections or rhizotomies, Medicaid plans are now all but requiring at least 6-8 weeks of formal physical therapy before they will approve the patients for any kind of procedure. They used to accept physician supervised home exercise programs, but I have been seeing more and more patients get denied if they have not had any formal PT. This is especially difficult for patients who work and can’t take time to go to PT, or who live a long way from a physical therapist who accepts Medicaid, or who just don’t have transportation. Again, this is way to wear patients down and have an excuse to deny them the care they need.

It is harder for patients to get approved for sacroiliac joint injections–many insurance companies are requiring at least one “diagnostic” injection, in which the patient gets an injection with just anesthetic only to allegedly test to see if the correct area is being targeted, and only if they get temporary relief are they allowed to get an injection that as steroids in it. This means the patient has to pay the copay on two procedures instead of one. Many patients struggle to come up with the money for the copay on even one outpatient procedure. Again, this is a way of getting the patient to give up. (Did I mention that sacroiliac joint pain is much more common in women? Funny how health problems affecting us ladies are more likely to get brushed aside.)

I also saw a patient whose spinal cord stimulator was denied because the insurance company (BCBS of Texas) approved the procedure, but did not approve the add-on codes which would cover the device itself. So of course, the surgery center would not do her procedure, and may even have to stop accepting most Anthem plans for certain kinds of impants if they won’t cover the cost of the device.

The whole system is designed to wear patients and providers down with increasingly unreasonable demands so they will simply give up on getting the care they need.

Life has been pretty crazy lately, between work, taking care of my sister, my sister in law, my daughter and all of my housing issues, so I have not had a lot of time to participate on the site lately. This is my first attempt at writing a diary on the new Daily Kos–I hope I didn’t mangle it too badly!

So what kind of health insurance horror stories do you guys have to share?

We’ll get straight to the point: The financial hardships that Daily Kos is facing this year are tough.

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