4 ms·

I have great insurance through my employer. Last week my spouse was suppose to go in for a surgery that multiple doctors made it clear she needed. We were on

I have great insurance through my employer. Last week my spouse was suppose to go in for a surgery that multiple doctors made it clear she needed. We were on the books for months for the surgery. Insurance denied it the day before, throwing all our plans up into the air. The surgeon suggested getting a different surgery that wouldn't fix the problem. The idea is that when it didn't work it would act as evidence to convince insurance to pay for the original one. We have a terrible, stupid, inefficient system. It's drowning in its own chaos and bureaucracy.

theragra 3y ago
Insane ;(
tomrod 3y ago
Get the surgery, get notarized items from multiple docs, talk to a lawyer. Healthcare insurance doesn't get to dictate your healthcare directly. They aren't doctors, and open themselves up to liability if we don't push back.
- grecy 3y ago
  .. and if that doesn't work out, go bankrupt.
  - tomrod 3y ago
    Nah, you have rights in this situation[0] [0] https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ https://www.healthcare.gov/appeal-insurance-company-decision...
    - grecy 3y ago
      ... and if that doesn't work, spend years in a stressful and time consuming legal battle.
      - tomrod 3y ago
        Perhaps, at a pessimistic extreme. Exercise of rights is important. It's worth consulting a lawyer for assistance. Organizations occasionally need to be compelled to do the right thing. Life isn't always easy or fair, but standing up for yourself is important as you are your best advocate.
- stusmall 3y ago
  Woooofftt. That's bad advice and in an even worse order. There are a bunch of steps in between getting denied and just YOLOing it out of pocket. It looks like going through the insurance company's peer to peer process is probably going to work out. It is still a bit up in the air but its looking positive. We'd already started down the route of getting connected to lawyers in case it doesn't. I don't think "do it out of pocket and try and claw the money out of them after the fact" was ever on our list of options. I wouldn't consider that unless the lawyers suggested it. We were looking into going overseas to have to done, which honestly its another big indictment of this system. The point still stands about how insanely inefficient this whole system is at the macro level. The fact that lawyers are getting involved in routine medical procedures or doctors are suggesting what they know is incorrect treatment is a sign of deep inefficiencies. We aren't an outlier either. It is profitable for the insurance companies to jerk you around, fight you, try and sneak past denials were they can.
  - tomrod 3y ago
    Have yall looked into external review? https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ https://www.healthcare.gov/appeal-insurance-company-decision...
    - stusmall 3y ago
      No offense, I appreciate the idea, but I'm not looking for suggestions. I only posted this here as an example of how the system is failing even for people with high quality insurance.
      - tomrod 3y ago
        And I appreciate your story and empathize, which is why I am ensuring both you and others reading your story remember that folks finding themselves in your situation have rights that are less commonly exercised. But I appreciate that it's a tough topic and not engage further. Good luck with it.
- nitwit005 3y ago
  > Healthcare insurance doesn't get to dictate your healthcare directly. They aren't supposed to, but in reality, of course they do. They just have an on staff doctor who rubber stamps the decision. With expensive procedures, they have a financial incentive to find a way to say no.

theragra 3y ago

Insane ;(

tomrod 3y ago

Get the surgery, get notarized items from multiple docs, talk to a lawyer. Healthcare insurance doesn't get to dictate your healthcare directly. They aren't doctors, and open themselves up to liability if we don't push back.

grecy 3y ago
.. and if that doesn't work out, go bankrupt.
- tomrod 3y ago
  Nah, you have rights in this situation[0] [0] https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ https://www.healthcare.gov/appeal-insurance-company-decision...
  - grecy 3y ago
    ... and if that doesn't work, spend years in a stressful and time consuming legal battle.
    - tomrod 3y ago
      Perhaps, at a pessimistic extreme. Exercise of rights is important. It's worth consulting a lawyer for assistance. Organizations occasionally need to be compelled to do the right thing. Life isn't always easy or fair, but standing up for yourself is important as you are your best advocate.
stusmall 3y ago
Woooofftt. That's bad advice and in an even worse order. There are a bunch of steps in between getting denied and just YOLOing it out of pocket. It looks like going through the insurance company's peer to peer process is probably going to work out. It is still a bit up in the air but its looking positive. We'd already started down the route of getting connected to lawyers in case it doesn't. I don't think "do it out of pocket and try and claw the money out of them after the fact" was ever on our list of options. I wouldn't consider that unless the lawyers suggested it. We were looking into going overseas to have to done, which honestly its another big indictment of this system. The point still stands about how insanely inefficient this whole system is at the macro level. The fact that lawyers are getting involved in routine medical procedures or doctors are suggesting what they know is incorrect treatment is a sign of deep inefficiencies. We aren't an outlier either. It is profitable for the insurance companies to jerk you around, fight you, try and sneak past denials were they can.
- tomrod 3y ago
  Have yall looked into external review? https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ https://www.healthcare.gov/appeal-insurance-company-decision...
  - stusmall 3y ago
    No offense, I appreciate the idea, but I'm not looking for suggestions. I only posted this here as an example of how the system is failing even for people with high quality insurance.
    - tomrod 3y ago
      And I appreciate your story and empathize, which is why I am ensuring both you and others reading your story remember that folks finding themselves in your situation have rights that are less commonly exercised. But I appreciate that it's a tough topic and not engage further. Good luck with it.
nitwit005 3y ago
> Healthcare insurance doesn't get to dictate your healthcare directly. They aren't supposed to, but in reality, of course they do. They just have an on staff doctor who rubber stamps the decision. With expensive procedures, they have a financial incentive to find a way to say no.