PHARMACIST STEVE

DEFINITIONS

Everyone in healthcare has a standard of care or best practices that they should adhere to:

Insurance companies:

Insurance companies have developed networks of approved healthcare professionals to provide covered services to the people that have their insurance policy. Most of these networks are based purely on the provider to agreed to a discount of “below-market” reimbursement. Often – some times never – the insurance has taken little/no assurance that the care given to its policy holder will meet or exceed best practices..

Have you ever noticed that some auto insurance companies offer a “guarantee” on the repairs to your cars.. if you use someone within their network ? Seen any such offer from health insurers ? I have heard of some pts claiming that the closest specialist in their network can be nearly 1000 miles away.

It has been stated that abt 75% of the medical directors for insurance companies education levels are GP/FP/Internist .. and yet they are responsible for making “medical decisions” on whether a the insurance company will pay for a particular procedure, on a vast number of specialties that they may not have a good knowledge of. That is why pts should appeal any denial.. BTW.. nearly all insurance companies have an  appeal process for denial.. and they have to tell you what their appeal process is and how it functions… BUT.. they only have to tell you.. IF YOU ASK !

The least expensive thing for an insurance company to do is to DENY A CLAIM… over 50% of the pts with denied claims.. will not appeal the denial.. and most pt that appeal the denial will get the product/service paid for.

A insurance company may be involved in FRAUD .. if they don’t attempt to assure that their network is observing best practices and/or even denying providing covered products/service.  So accepting premiums from the pt and not assuring that the pt is receiving covered products/services from the insurance company’s provider network could result with the insurance company complicit in committing insurance fraud.

At this point..  it would be time to file a complaint with the state insurance commissioner  and/or if Medicare Part D/Medicaid is involved then also filing a complaint with CMS

IF your have Medicare Part D

Filed under: General Problems