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

[Birtel]

how do you feel about these insurance companies and their panel of "quacks" deciding if we live or die.... or how we should live the rest of our lives according to their versions of disability...heaven forbid if the shoe was on the other foot.... why is it we don't get to decide if these individuals should lose their jobs for faulty and deadly decision making?what's your take on the precendent setting "CIGNA" lawsuit in California where a liver transplant approval came too late?this is just one example.... i'm sure there are many horror stories as this one...where do these people come from?did they strike out in the "private practice" industry as nuisances and this is where they can continue practicing without being held accountable for their blunders or being sued for malpractice?what gives?

[Wiellaford]

Some insurance companies are better than others, but I suspect there is higher pattern of avoiding payment for insurers that are publicly traded vs. not-for-profit companies. As someone who's worked with both clinics and insurance companies as an business/IT consultant, I think it's safe to say that there's some fraud all around.  There are cases of doctors being busted for fraudulent Medicare claims.  There are cases(as you noted) where insurance companies irresponsibly denied a claim. In fairness, there are good doctors and decent insurance companies, and I think that assessment extends to doctors who work for insurance companies.  Not all of them are bad, and I suspect some are present there because they were unable to make enough in primary care practice(it's not the best paying M.D. track).

[Forrester]

I agree with you! Good grief - the first time I was truly affected by the insurance companies was when they were more than willing to pay for my MIL's quadruple by-pass, however, they would not pay for any smoking cessation materials - huh????  I remember looking at my DH and saying "let me get this straight, they'll pay the $80,000 hospital bill but they won't pay $40 for the patch."    Alot the reasoning doesn't make sense . . . and the people that call themselves "doctors" working for the insurance companies, well, whatever.  A doctor supposedly takes an oath to help people, I think the insurance company doctors take an oath to help themselves . . . to your premiums.     Sources: My opinion cruzin2paradise 73 months ago Please sign in to give a compliment. Please verify your account to give a compliment. Please sign in to send a message. Please verify your account to send a message.

[Berto]

I used to work in a doctor's office, and... 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.  spoiledbeth 73 months ago Please sign in to give a compliment. Please verify your account to give a compliment. Please sign in to send a message. Please verify your account to send a message.

[Sakeri]

I think it depends on the insurance company... Some insurance companies are better than others, but I suspect there is higher pattern of avoiding payment for insurers that are publicly traded vs. not-for-profit companies. As someone who's worked with both clinics and insurance companies as an business/IT consultant, I think it's safe to say that there's some fraud all around.  There are cases of doctors being busted for fraudulent Medicare claims.  There are cases(as you noted) where insurance companies irresponsibly denied a claim. In fairness, there are good doctors and decent insurance companies, and I think that assessment extends to doctors who work for insurance companies.  Not all of them are bad, and I suspect some are present there because they were unable to make enough in primary care practice(it's not the best paying M.D. track). Pete_Lee 73 months ago Please sign in to give a compliment. Please verify your account to give a compliment. Please sign in to send a message. Please verify your account to send a message.

[Phillip]

This type of thing is built into the system. The lawmakers who created HMO?s thought that the major problem with health care was that prospective lawsuits made it difficult for doctors to treat people well and make money. They limited most lawsuits to the value of the denied care, so that the legal expenses of these new health care organizations that they were creating would be more reasonable. What has happened is that they created a system where Doctors make more money NOT treating illness and allowing some patients to die then they make by offering the best care they can possibly give. In order to receive good care now, you must be proactive on your own behalf. You must advocate for your own best treatment. It used to be the Doctor?s job to do that against the Insurance companies. dejapooh 73 months ago Please sign in to give a compliment. Please verify your account to give a compliment. Please sign in to send a message. Please verify your account to send a message.

[caspar99]

Mine might not be a popular answer, but I have a hard time faulting insurance companies in this area. 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." BarnacleJake 73 months ago Please sign in to give a compliment. Please verify your account to give a compliment. Please sign in to send a message. Please verify your account to send a message.

[Montrel]

The lawmakers who created HMO?s thought that the major problem with health care was that prospective lawsuits made it difficult for doctors to treat people well and make money. They limited most lawsuits to the value of the denied care, so that the legal expenses of these new health care organizations that they were creating would be more reasonable. What has happened is that they created a system where Doctors make more money NOT treating illness and allowing some patients to die then they make by offering the best care they can possibly give. In order to receive good care now, you must be proactive on your own behalf. You must advocate for your own best treatment. It used to be the Doctor?s job to do that against the Insurance companies.

[Curtice]

Good grief - the first time I was truly affected by the insurance companies was when they were more than willing to pay for my MIL's quadruple by-pass, however, they would not pay for any smoking cessation materials - huh????  I remember looking at my DH and saying "let me get this straight, they'll pay the $80,000 hospital bill but they won't pay $40 for the patch."    Alot the reasoning doesn't make sense . . . and the people that call themselves "doctors" working for the insurance companies, well, whatever.  A doctor supposedly takes an oath to help people, I think the insurance company doctors take an oath to help themselves . . . to your premiums.    

[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."