Ever wonder why so many preauthorizations are denied??

[Larra]

This little editorial doesn't pertain directly to bariatric surgery, but the salient points are

1. the people deciding on preauthorizations are employees of the insurance company and beholden to that company, and not to you, the consumer

2. they, at least some of them, are older, retired physicians who may or may not be up to the latest advances in their field (or any other field)

3. they have "guidelines" to follow, with the goal being to save the company money (i.e. increase profit) and not necessarily to provide the best treatment for consumers.

4. at least one was concerned about not receiving his bonus if he authorized expenditure of too much of the company's money. And, while this isn't said in this article, I would guess (I freely admit it just a guess, but it makes sense) that if a reviewer said yes too many times, he would no longer be a reviewer.

https://www.medpagetoday.com/blogs/revolutionandrevelation/69125

 

[Munchkin]

I agree! And of course, they hope you die while waiting for approval, self pay, or change providers!

 

[Larra]

The issue is far bigger than bariatric surgery, but yes, it's the sickest, and therefore most costly, people who are most likely to die or give up, thus most saving the insurer the most money, or really I should say maximizing its profits.

 

[Munchkin]

The issue is far bigger than bariatric surgery, but yes, it's the sickest, and therefore most costly, people who are most likely to die or give up, thus most saving the insurer the most money, or really I should say maximizing its profits.

One of the sickest most dastardly insurance plots is care for type 2 diabetes. Yes they will pay for your supplies, meds, blindness, and your amputations. But will they allow the DS to become a standard of care for the disease? Hell no!

 

[Diana S.]

It's the same as the doctors who push medications to treat symptoms instead of getting to the heart of the issue, avoiding testing, blood work, scans, etc which are all so danged expensive that it's much simpler to prescribe a pill than to actually treat the disease.

 

[southernlady]

It's the same as the doctors who push medications to treat symptoms instead of getting to the heart of the issue, avoiding testing, blood work, scans, etc which are all so danged expensive that it's much simpler to prescribe a pill than to actually treat the disease.

Yeap. I have figured out my RLS is caused either by low ferritin, low iron sat %, or varicose veins. But I have to push to have an iron panel run. The doctors would rather just throw a pill at it.

 

[Spiky Bugger]

Before I knew youze guys, I wrote my daughter's appeal letter for her VERY NEEDED (she was wearing a 36-J bra) (36-J) reduction mammoplasty. Aetna denied it because they decided she wasn't having enough tissue removed. They wanted her completely flat-chested.

When I wrote the appeal, I went to THEIR website, and without trying to hide what I was doing, I copied and pasted THEIR criteria, using one font size larger for HER stats when we used those in place of the ranges given in their criteria.

Then I wrote something along the lines of...
...I have been examined by five of Aetna's-in-network, board certified plastic surgeons who recommended [the range of tissue removal recommended]. You have denied this procedure per the review of your Dr. Whatsisname.

I will now proceed with an appeal to the Department of Managed Health Care. Please confirm for me that your Dr. Whatsisname, whom I've never met, who disagrees with the five board certified plastic surgeons who examined me is the same Dr. Whatsisname listed on the California Medical Board's wesite as a otolaryngologist.

Guess what! They called! They were sorry about the misundersanding. OF COURSE her procedure would be approved.

There are times that being unpleasant is a plus.

 

[Diana S.]

Wait. Isn't an otolaryngologist an ear nose and throat doctor?!?

 

[Spiky Bugger]

Wait. Isn't an otolaryngologist an ear nose and throat doctor?!?

Indeed. Which is why we won right there.