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When Insurance Companies Say No

NPR, the Kaiser Family Foundation, and the Harvard School of Public Health recently published the results of a telephone survey on the health care delivery system in the U.S.

Among the questions asked was whether a patient had their doctor's recommended treatment denied by their insurance company.

In the past year, has a doctor ever recommended a treatment or prescription drug for you, but you found out your insurance company wouldn't pay for it, or hasn't this happened?

The graphic below shows the distribution of responses.

40% of those who had the recommended treatment declined went without treatment or had to pay for it themselves.

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In an abcnews.com story Cynthia Toussaint recounts how her insurance company said no to the prescribed drugs that were working at the time:

"Eighteen years ago, my insurance company switched me from Axid, which I was using to treat CRPS in my vocal cords, to a cheaper medication," she recalled. "As a result, I couldn't speak and even experienced pain when whispering. I was forced to 'fail' on two cheaper medications before getting the medication my physician originally prescribed."

Toussaint said that she had a similarly negative experience when her insurance company switched her off her brand name Klonopin -- a pain and anxiety drug -- to a cheaper alternative that left her in pain and experiencing hallucinations.

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NYTimes.com tells of a husband and wife who have been looking for insurance for their 21-year-old son with metastic testicular cancer. Although he has been cance-free for a year the cost of regular monitoring is making finding insurance a tough road. Because the family owns their home the federal government says no to any federal subsidized insurance plan.

Neither of the Walkers has been able to land a job with the kind of large group coverage that would disregard Jake’s health status. His cancer history effectively makes him uninsurable on the individual market. He is too old to qualify for Medicaid as a child, and it is virtually impossible in Texas to qualify as an able-bodied adult.

Posted by: Staff on April 23, 2009
Category: Cancer; Health Disparities; Health Equity; Healthcare Costs; Universal Health Care; health insurance

The problem of 'balanced billing'

Star-Telegram.com has a lengthy article on the problem of 'balanced billing' and how it can lead to unexpected hospital bills.

[Balanced billing] happens when anesthesiologists, pathologists, radiologists and emergency-room physicians at a hospital on a health plan’s network aren’t on the network.

Those out-of-network doctors, who don’t have an agreement with the insurer for discounted fees, can demand full price.

Then, insurers can determine what portion of the bill they’re willing to pay. And the physicians can collect the remainder of the tab from patients.

In this case, a patient who was having a cardiac procedure checked to be sure his hospital and doctor were in his health insurer's network.

While they were, the anesthesiologist was not. The anesthesiologist billed the insurance company $2020 for his services and they opted to pay only $1015. The anesthesiologist billed the patient for the difference.

Several states are taking insurance companies to court over the issue of balanced billing. New York, Texas, and California have all had recent rulings or settlements in their favor.

The Health Blog has a post on balanced billing along with a spirited discussion in the comment section.

Posted by: Staff on February 17, 2009
Category: Health Care; Healthcare; balanced billing; coverage; health insurance; sick care