Home Forums Discussions General Discussion New Insurance Scam

The insurance companies have a new scam.

One of our patients had their claim rejected because of a previous medical condition. I'm talking about routine things like a physical, f/u appt., etc.

This person's previous medical condition is---tobacco use disorder

Yep, just because they smoke, they are being denied coverage for 6 months.

Interesting find!

I think a lot of us would agree that smoking is not exactly a DISEASE but rather a lifestyle choice. However some would argue (as in alcoholism or drug addiction) that tobacco addiction is not different than a disease. As a non-smoker, my preference is to characterize it as a lifestyle choice.

That being said, tobacco use disorder has an ICD-9 code: 305.1, and I'm certain that would be their argument is that it's a defined disease entity even though it's not commonly thought of as a disease or "pre-existing condition."

Really though, what will they think of next to deny claims or even deny coverage? The insurance industry has hit yet another moral low.

So following this flawed logic???, if the patient and the doc both agreed to try and help him quit smoking would they deny claims for smoking cessation, for the duration of the pre-existing condition clause in the contract??? I gather they will deny meds for that assistance too then.

So now his and your outcomes are certainly going to be negatively impacted by their lack of finacial support in your attempts to help him quit or at least monitor his condition and general health. So, now let's talk about P4P while we're at it too. If we continue on this twisted path could they, would they try to hold his lack of quitting against you in your numbers under a P4P type situation??? So they won't pay for helping him quit, nor will they probably pay for any tests to keep an eye on him, like chest x-rays, spirometry, ECG's all because they are sort of tied to this disorder and Dx code. Meanwhile he may have a small attackable tumor growing in his chest, the beginings of emphazema and the like, which if gotten early could have much better outcomes but now now we'll all wait the duration of this clause in his contract with his employer. All while using his negative outcome data against the treating (can we call not treating because of denies treatment?) doc. Just great.

This just proves my point that carriers don't give a rat's behind about outcomes when they push P4P, seeing how they all swap employer groups back and forth every year anyway. P4P is but another trick to use, to find a way to not pay hard working docs in certainly specialties like PCP's, Cardio, Endo and the like who will have data to pick and choose from to use to their advantage. Does anyone here really think that they didn't do the math on each and every measure they propose before they roll these stupid things out??? The larger groups who "represent" you guys need to get a clue and finally see these SOB's for what they really are.... SOB's; carpet baggers and robber barons, plain and simple.

Question: Was your claim for assisting him with quitting or for some condition tied to his smoking, or was it one of those the issue simply came up in taking his history and so it was on a laundry list of other Dx's with the claim? I would love to have you share all of this with us as it moves thru their system. Did you say which carrier did this to you and your patient? Have you reported it to AG Cuomo or the state insurance dept???

Yes this industry has hit another real low. "You're momma is so low she can crawl under a pregnant ant"

Good Night and Good Luck,
Paul

BTW Wayne,
We sort of have that parody of coverage law here in NYS so the condition itself should be properly covered even if they care to call is Psych instead of a "regular" physical health issue. But that being said, this is still based on pre-existing condition contract terms and not the type of condition it is. Just an out loud brain fart thought.....

I hadn't heard of that expression before. Funny...

Pre-existing conditions, another business BS-based policy of the insurance companies which means: we will not cover your medical needs for the next 6 months; thus, for that period of time, you are on your own. They don't even make it clear to their clients; thus, in many cases, we get the headaches of explaining this to our patients and the hassle of collecting from them.
I will stop writing now, I just don't want to ruin my saturday.
Have a nice weekend folks.

Romel,
Only in America. As I like to say; "A pre-existing condition should be nothing more than a note in your chart". These SOB's are just unreal.

I have an old patient who moved out of town and so left the practive calling us for weeks now because her old BC/BS won't pay a lab from back when she first started with us in Sept of '05! And it seems that I delt with it back then, as their request was off base, based on the fact that they were requesting notes from before her first visit here and NYS prompt pay laws say they only get one chance to ask and that we don't have to supply anything from before her starting here. Now they are asking again (wrong) and now they are asking for her notes from her first visit which is different from their first request (also wrong).

And the kicker of it all is, she is all pissed off thinking they just want these notes to dot an "I" or cross a "T" before they pay! BULLCCHIT! They are just looking for that nail to hang their hat on so as to be able to deny her claim and now they will have part of her PHI to share with any and all other carriers to hold against her for the rest of her medical life in this crazy American insurance system.

These SOB's are Carpet Baggers and Robber Barons and we need to put a shotgun in the small of their back and insist upon escorting them off of our land for their abuse of our trust placed in their hands....

Good Night and Good Luck,
Paul