Insurance Companies & Their Panel Of Doctors: What's Your Take On Insurance Companies And Their Doctor Panels?

[bean]

I feel that the doctors who have to make the decisions about whether or not to approve costly medical treatment in these cases are in a no-win situation.  It would be easy to simply approve any and all treatment that are proposed.  But that would be incredibly expensive, and healthcare costs in this country are already rising at a rate that most find to be out of control.  If anything, most people would prefer that expensive treatment be denied in more of these cases, not fewer. And a sad reality is that a great many of the patients in need of these costly procedures are going to die soon anyway, whether they receive these treatments or not. For the doctors making these calls, that has to be an awfully tough spot to be in.  I couldn't imagine the stress of being faced with decisions like that every day.  I really can't. As for the particular case you asked about, a 17-year old in California was battling leukemia.  She had received a bone marrow transplant and developed a complication which resulted in kidney failure.  CIGNA originally denied the patient's request for a liver transplant.  They reversed their decision after intense publicity, but the patient died before receiving a new liver. Sure, it's easy to blast the company for being cold-hearted, but the average person knows little about the factors that had to be considered.  For one thing, the demand for livers(and other organs) far outstrips the available supply.  Approving one person for a transplant pushes other people down the waiting list, and means that someone else is sure to go without.  One factor that has to be weighed heavily is how much benefit a patient can be expected to receive if approved for a transplant.  In this particular case, the patient was given a 65% chance of surviving six months with a successful transplant. I know it sounds cold-hearted, but the patient's survival rate has to be figured into the decision.  It might be better if the organ went to another patient with better prospects for long-term survival. Sorry, but we're about dedicated physicians faced with life-changing decisions.  I have a hard time calling the choices they make "blunders."

[Frisa]

Most of the time their "panel" isn't doctors, they are nurses with a list of what is acceptable and what's not, including what diagnoses they will accept and with ones will get a claim rejected.  We had some patients that needed testing, such as a MRI or a MRA, and if we didn't put a diagnosis code that the insurance liked they would not approve the test being done.  It's very important to know your insurance.  We worked with the same hospital staff when calling and scheduling testing, and they were really good at telling us whether or not we needed to change the icd code in order to get the approval from the insurance company.  It's also important, if you are needing testing and the like, that you call your insurance company yourself, because sometimes if you are loud enough they will be more willing to do what they are supposed to do.  Insurance is a numbers game, they are betting on your not getting sick in order for them to make a profit.