I recently performed a breast reconstruction on an unfortunate woman who was diagnosed with breast cancer and had to have bilateral mastectomies (both breasts removed). Thankfully, breast reconstruction is now covered by health insurance which, prior to a federal law mandating coverage in 1996, wasn’t always the case.
Despite it being illegal for insurance companies to deny coverage for the reconstruction, they still do it regularly.
"Deny, deny, deny" is the corporate slogan of health insurance companies these days. I wouldn’t be surprised if the CEOs of these companies specifically discuss this strategy in their board meetings. How on Earth can they break a federal law and get away with it? Creative loopholes. As health care providers, we have to jump through a huge number of hoops that the insurance companies set up in order for us to receive payment for provided services.
In the case with my patient’s recent breast reconstruction, a clerical coding error in getting the surgery pre-approved (That’s right. We have to have the insurance company pre-approve the surgery that they legally have to approve and cover anyway. That's Hoop No. 1) led them to deny payment for the surgery even after we discovered the error and notified them. We even appealed the denial (Hoop No. 2) and it was rejected again.
I personally called the health insurance physician reviewer for a "peer-to-peer" review (Hoop No. 3) to discuss the problem and get an explanation for the denial and, you guessed it, he hasn’t returned my phone calls.
"Delay, delay, delay, if you can’t implement the corporate slogan," the CEOs must say. The longer insurance companies delay payments to providers, the longer they keep the money which then earns them additional interest. I’m talking huge interest if you add up all the denials and delays across the country.
If you haven’t figured it out yet, health insurance companies don’t care about your health. They are businesses that exist solely for the profit of their shareholders at the expense of people's health. It’s a great racket if you’re in insurance, but it’s borderline criminal in my book.
You see, they get to take everyone’s money with their monthly premiums that rise every year and not pay for some of the medically-necessary treatments they promise you when you sign up with them, even when mandated by federal law. As providers, we sign onto their plans but have to accept whatever they want to pay us for the services provided, and oftentimes they won’t even let us know how much that is before we sign up.
What happened to American capitalism and free markets? It doesn’t exist in today’s medicine. Insurance companies control who you see when you're sick, which treatments you can receive, how much money you pay, and how much your doctor gets paid.
Actually, there is one area of medicine that is wholly a free market, cosmetic surgery, and this is why you see so many doctors trying to enter cosmetic surgery market, much to the chagrin of us plastic surgeons and to the detriment of patients and their safety.
Gregory H. Pastrick, M.D., is certified by the American Board of Plastic Surgery. He practices at The Plastic Surgery Center, located at 1 Sheridan Square, Suite 200, Kingsport, Tenn. Check out all of his services at www.theplasticscenter.com or call 423-392-4884.