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My wife broke her ankle and insurance denied the entire claim for being "not medically necessary". The "medical professional" (not doctor) who denied the claim had experience in OBGYN, not orthopedics.
100% going to win the appeal because like, we have x-rays of the shattered bones in her leg, but seriously wtf. People seriously believe this is the ideal medical system?
Cigna doctors spend an average of 1.2 seconds per case. Their whole system is to deny everything right off the bat, and then they only have to potentially pay out for patients who have the resources to appeal.
When I was in the insurance industry, for a company who administered various policies from Aetna, BCBS, Cigna, United and Medicare, that was the SOP. Deny anything that took more than a few seconds of brain power, put clients through endless rounds of appeals. The medical director was amoral AF too, because well, the insurance company exists for profit, and bonuses are dependent on paying out as little as possible. It got pretty bad, too, enough that my immediate supervisor started signing off a bunch of approvals, circumventing the medical director, where any shred of plausibility was available.
Now, there is automated software. HIPAA has it's pros and cons.
Oh, I read this John Grisham book.
I'm on appeal #3 right now with my insurance for something they told me would be 100% covered. I'm getting my doctor in on it to do a peer to peer. He sounded so fed up with everything he was like "it's probably some retired pediatrician who doesn't know anything about what you need" when talking about who he'd need to talk with. If this one doesn't work then I'm on to the "threaten to sue" stage which I'm not excited about. The whole thing is a mess and the process and money that's gone into it would have easily bankrupted or put me homeless at most previous times in my life
I'm not a lawyer, but a piece of legal advice I've seen repeated many times is "Never threaten to sue. Just sue."
As soon as you threaten to sue, you'll never be able to talk to anybody except the legal team, and they'll do nothing to help your case.
It's honestly infuriating that these companies are essentially diagnosing and treating patients without doctor-patient relationship (required by federal law). And like LITERALLY determining and dictating treatment. That's illegal if ANYONE else does it. Even if your own medical provider doesn't see you per new condition, that can be considered a violation of that law. And these insurance guys have never seen us in real life.
I also think that it's a really strangely allowed violation of HIPPA. Why should everyone at the insurance company, or ANYONE at an insurance company, have the right to my medical information? Why are they able to communicate with my doctor's office? I absolutely hate the privacy aspect of insurance so much.