Monday, February 19, 2007

The Denial-of-Payment Game

“Hello, Ms. Nicestpersonintheentireworld.”

“Hi.”

“How are you feeling after your ablation?”

“Tired. You know I was in the hospital for pneumonia?"

“No, I’m sorry, I wasn’t aware that you were admitted.”

“Yeah, they thought my CT looked bad, so they put me on antibiotics for a while, so I’m recovering from that. And you know what else?”

Gulping and concerned what would come next, “No, what?”

“The insurer won’t pay for my ablation.”

“What??? You mean they won’t pay for a person with documented supraventricular tachycardia (SVT) at 180 b/min that occurred in the hospital while you were receiving treatment for your breast cancer that was very symptomatic? The same SVT that was refractory to medical therapy and required several doses of adenosine to correct?”

“That’s right. They’re denying payment saying I didn’t need the ablation – they said you should have called the insurer first and that I should have been treated with drugs first.”

“But you were in the hospital... So even though you’ve got lung disease and use inhalers, they want me to use drugs first and even though this flies in the face of established guidelines?.”

“I guess so.”

It’s all a big game, this denial of payment thing. Here’s the score as I see it:

* * * S C O R E B O A R D * * *
ROUND 1:
Patient: 0, Insurance Company: 1

Now we have 14 more rounds to go to get this settled, if we're lucky. And meanwhile, Ms. Nicestpersonintheentireworld not only gets to deal with all the aspects of her cancer care, she gets to worry about whether she gets to pay for the ablation, too.

-Wes

1 comment:

radioactive girl said...

This is what was the hardest for me to understand. I had cancer almost two years ago, and am still trying to figure out which things I should just pay to make them go away, and which things I should fight because they should have been covered. It's not enough to be sick, but now I get to deal with all the paperwork and try to pay all the bills and also try to get back to normal. There should really be a better system!