Monday, January 25, 2010

Insurance Companies - Don't Believe Everything You Hear

The plan for healthcare reform is to villify the insurance companies and tell all kinds of horror stories about the insurance companies' bad behavior, but you can't believe everything you hear.

If unconscionable behavior is really the issue, there is already a Department of Insurance in most, if not all, states to file a complaint.  It's one of these complaints I'm going to use as an example.  This is a true story.

A surgeon files a claim with the department of insurance stating that the insurance company denied his surgical consult as not covered when it should have been paid.  He was called in to the emergency room, he said, to determine if surgery was needed.  He decided that it was not and therefore, his claim for payment of the consult was perfectly acceptable and reasonable and the insurance company's refusal to pay was grounds for official complaint.

This sounds terrible, doesn't it.  You pull in a surgeon to see if a procedure is necessary and the insurance company won't pay for it just because the surgery wasn't performed.  Those awful, nasty, rotten and unethical insurance companies.

Unfortunately for the doctor, I dug a little deeper into this issue and found something really interesting.  On the same day, the doctor had filed a claim for a surgical procedure and been paid for it.  The consult fee is included in the payment for the procedure itself.  What was really interesting is that the surgeon was saying he deemed the procedure not necessary and that was why he should be paid for the consult.  Why then did he bill for the performance of the procedure he deemed unnecessary?

But I'm sure it was all the insurance companie's fault.


  1. People are catching on to the polarization game. Who will be Obama's boogie men next week?

  2. You nailed it!

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  3. Simply Alinsky: there's gotta be a villain to demonize, otherwise it's hard to mobilize the proles.

    And I'm a bit confused: the doctor's billing in your story - this billing for surgery w/consult the same day he consulted without surgery (and billed), was this for the same patient, or two different patients?

  4. Interesting article. The story that you have posted is quite surprising but also confusing too. I am not able to understand who is at fault either the surgeon for charging consultancy fee two times or the insurance company.
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