‘Insurance’ is a word that can be loosely defined

If you ever experience something like this, call the insurance company and demand to speak to a supervisor: “I’m filing a complaint with the insurance commission and also with my congressman, and I want to make sure I have the correct details for why you’re refusing me a necessary medical test as ordered by my physician. Oh, and I want to make sure I spell your name right.”

While your state insurance commission is possibly in the pocket of the industry, they do at least investigate these cases, and the insurance companies just don’t want the hassle. It may not always work, but it’s worked for me so far for the five or six times I did it:

“I gotta tell you Kathy, I can’t keep living like this,” said Michael Fields, 46, who was experiencing tightness in his chest, numbness in an arm and light-headedness as he begged the voice at the other end of the line for help. “It’s been going on for weeks. I don’t know what else to do. I mean you know, I’m trapped here.”

“Alright, let me put you back on hold,” came the reply.

Fields, who lives with his wife and son in Elkton, Md., was not speaking with a 911 operator. He was calling a representative from his insurance provider, Blue Cross/ Blue Shield of Delaware, and he was about to find out that for the third time he was being denied a crucial test to determine if he had coronary artery disease — a nuclear cardiac stress test.

A Senate investigation released Friday found a pattern of inappropriate denials for tests like the one Fields’ doctors say he should have received from the start.

The investigation looked at 1,600 cases over a six-month period from 2009 to 2010 involving requests for nuclear cardiac stress tests in the state of Delaware. All of the cases studied were handled by MedSolutions, a company that screens test requests in the state for Blue Cross/Blue Shield of Delaware and other insurers.

According to the report, “10 to 15 (percent) of requested tests appear to have been denied inappropriately. MedSolutions and the Delaware insurers denied a significant number of medically necessary nuclear stress tests.”

“It is a huge number,” Sen. John D. Rockefeller, chairman of the Senate Commerce Committee told NBC News. “I don’t care if it is 5 to 2 percent, it is a huge percent. It follows a pattern that never stops with health insurance companies. It is always the bottom line. The more they say no, the more money they make.”

Michael Fields was one of those found to have been wrongly denied.

When Fields first complained about his symptoms over a year ago, his physician sent him to get a stress test. The request was denied by Blue Cross Blue Shield, and denied again after two appeals by the physician. Finally, his doctor sent him to the hospital, where cardiologists found that a key blood vessel to his heart was almost completely blocked.

The next day Fields had an emergency quadruple heart bypass.

6 thoughts on “‘Insurance’ is a word that can be loosely defined

  1. Yes Senator Rockefeller, it is always like this. It is always about the money, the bottom line.

    So you’ll support Medicare for all?

    Won’t you?

    We’re all waiting.

  2. Ah, yes. Serious condition which might cost a lot to correct: Time for the patient to Hurry Up and Die.

    It’s a feature, not a bug.

    Republicans are counting on it to cut Medicare and SocSec outlays. Dead people don’t need health care and don’t get SocSec checks. Win-win for the Repubs…as well as corporatist Dems.

  3. If they say “No” and they are right they save money and nothing bad happens to the patient. If they say “No” and they are wrong they save money and nothing bad happens to the insurance company.

    Either way they save money! Win, win!

  4. It’s a little more complicated than that. What the news doesn’t tell you (and what you’re not going to want to hear anyway) is that there’s a pile of fraud going on that the insurance companies are pretty interested in getting under control. I’m willing to bet this guy was basically unlucky enough to get caught up in that.

    You got better ideas on how to deal with billions in fraud each year? I’m sure they’d be happy to hear about it.

  5. What you all missed because not enough of the article is quoted is that his insurance company wanted him to do a regular stress test first. That test, which costs 1/5 of what this test costs, catches 70% of the cases. Had that test been negative, given his symptoms and history, they almost certainly would have approved the more expensive test. On the other hand, with his history of diabetes, smoking and heart disease in his family, the first test would have probably caught it.

    I am no apologist for insurance companies but cherry picking part of the story to make a case doesn’t do your argument any favors.

  6. No, we didn’t “miss” it. We read this part, which apparently didn’t sink in for you:

    Experts say the nuclear stress tests have a diagnostic accuracy in the 90 percent range. A basic stress test, in which a patient exercises on a treadmill while connected to electrocardiogram (or ECG) equipment, is accurate 70 percent of the time. According to data from the American Medical Association, nuclear stress tests can cost up to five times as much as an ECG test.

    His doctor felt his symptoms warranted the more accurate test. In fact, he requested it three times. Do you believe the insurance company should make that call instead?

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