Hindsight is a beautiful thing. If you had not admited that patient and carried out the appropriate investigations then something much more sinister might have been missed. That would then put you at a liability as you were the one who did not pick up on the early warning signs (seizures).

I'm a 4th year medical student in the UK and I'm glad that this kind of situation is not one I am going to have to deal with.

What can you/your hospital do if the insurance company decides not to pay for the expenses?

By the way this is really interesting as I myself am looking to get into the medical field (currently an undergrad).

Dopa, I don't know how you put up with this stuff day after day. My hat is off to you sir. It's bad enough being a patient on the receiving end of much of this bafoonery from the insurance companies. I can't imagine what you doctors go through...

Wow. That's all I can say. So, if you hadn't treated the patient, then you would be negligent. Since you treated the patient, and found the root cause through tests, but it didn't fit what the insurance company was looking for, they don't have to pay? Are you (doctors) supposed to read the future or something? I wish I could work out a scam like the insurance companies...pay us a ton of money, or else, but we won't pay in the end. Awesome.

Interested to hear how you deal with it.

8k for two days. 4k a day. W T F

I'm glad people seem interested in this. It's a good constructive way for me to vent.

So far some great points, but there are still many more (in my opinion).

Of course they don't want to pay, they're for profit, their profitability is based on paying out as little and collecting as much as possible. A for profit model for health insurance is unintuitive and hurtful to say the least.

Dopa, it sucks that your hospital can't get paid for doing one of the most important jobs out there.

In addition to the points everyone else has made, I find it interesting that they're only now disputing a claim that occurred in February, but then again, that's corporate bureaucracy for you.

Out of curiosity, why was he transferred to your hospital from the original emergency room? Is that common? (Sorry if this is something that's common knowledge. I've never been to a hospital, save for my birth...)

"after reviewing the medical record and the resulting diagnosis, we feel that the patient's care could have been managed as an outpatient and did not require hospitalization and therefore we are withholding payment for these services."

That's got to be one of the most insulting statements I've come across.

They're conclusion is that those test shouldn't have been performed because of the diagnosis that those test confirmed?

Am I missing something here, or is that just a blatant slap in the face and piss poor excuse to not pay?

@twiceborn The patients 2 day stay wasn't warranted in what could have been done in a couple hours. Given the patients medical record which is all clear from my understanding in that statement and that the MRI and EEG turned up nothing from the brain. The patient was probably under a lot of stress and deptression as dopa said and like many of us are. Your body can only handle so much.

"After reviewing your communication regarding the medical records and the resulting diagnosis of patient X, we feel that the patient's care was managed appropriately based on the information at hand. Therefore we are requesting payment in full for services rendered.

If you believe that the testing conducted by our properly schooled, trained and certified staff members was inappropriate, we invite you to treat the next patient within your own medical facilities with the medical professionals you obviously have on premises."


I thought it would be most fun to simply reword their original.

I'm a 3rd year medical student, so take my perspective with a grain of salt. I've had it pounded into me over and over and over again, from a liability and insurance perspective that the bottom line in this situation is whether or not your testing met the standard of care in this situation. Beyond that, the insurance company won't (and really shouldn't) reimburse the hospital for the services. If the MRI and EEG monitoring should have been completed without admitting the patient for two days / the diagnosis should have been reached earlier, the insurance company shouldn't pay. I realize that this seems cold to those who have to deal with insurance companies, but that's what keeps hospitals honest. Otherwise, they can order any test/procedure under the sun without justification and drive up the cost of insurance coverage for everyone.

This may actually be a violation of HIPAA. IANAL and I don't know if this extends to insurance payments to hospitals or not, so I'd have a lawyer double check it, but it seems suspect to me, since a diagnosis was necessary, based upon symptoms which were the result of a medical condition (depression).

http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html

From the link:
Can my health plan deny benefits for an injury based on how I got it?

Maybe. A plan can deny benefits based on an injury's source, unless an injury is the result of a medical condition or an act of domestic violence.
Therefore, a plan cannot exclude coverage for self-inflicted wounds, including those resulting from attempted suicide, if they are otherwise covered by the plan and result from a medical condition (such as depression).
However, a plan may exclude coverage for injuries that do not result from a medical condition or from domestic violence. For example, a plan generally can exclude coverage for injuries in connection with an activity like bungee jumping. While the bungee jumper may have to pay for treatment for those injuries, her plan cannot exclude her from coverage for the plan’s other benefits.

1. This has less than nothing to do with HIPAA. This isn't about violating privacy laws.

2. The letter from the insurance company doesn't say they were denying based on the cause of the symptoms they were denying based on the fact that the management should have been handled differently (independent of the cause of the symptoms) OP just framed the story so it sounds that way.

3. My intuition would be that the insurance company paid for some of the care, not all. As scary as it is, the scenario that the OP described should cost more than $8K. I'll bet that the $8K was the part that the insurance company found to be out of line with the standard of care.

4. It's a crazy-ass world where I am defending insurance companies. I have plenty of butting heads stories with them myself.

After having read that, I am glad I live in Canada and not risk having to deal with the denial of an insurance company like that. How can they make their own medical assumptions about something? They're not doctors! You are! It's the Doctor's call to make sure the patient is not risking any further health issues or in some cases, DEATH. In that case, why does a patient need to go see a doctor when all they need to do is go to the insurance company because they decide what you are and are not covered for. WTF is this world coming to?!

"after reviewing the medical record and the resulting diagnosis, we feel that the patient's care could have been managed as an outpatient and did not require hospitalization and therefore we are withholding payment for these services."

the words "resulting diagnosis" is whats gonna let them go themselves.

Quote: the words "resulting diagnosis" is whats gonna let them go themselves.

not really. If he reached that diagnosis in the first 8 hours of dealing with the patient, for example, the insurance company is right. In that case, they are absolutely right to deny the claim because the OP wouldn't be following the standard of care. There would be no need to admit the patient for 2 days at great expense to everyone. You are over-reading into the quote from the insurance company based on how the OP presented all of this.

Quote: How can they make their own medical assumptions about something? They're not doctors! You are! It's the Doctor's call to make sure the patient is not risking any further health issues or in some cases, DEATH.

All that is true, but you need perspective. First, the insurance companies don't come up with their policies arbitrarily. They cover what is the normally and widely accepted procedure ie. standard care. They utilized MDs when they came up with the policy and they utilize MDs in their daily business.

I think the insurance company's position in this case, would be something along the lines of once you established that the symptoms were psychiactric and non-life threatening, why did you admit the patient for 2 days? It is unnecessary and expensive and most doctors wouldn't do that.

Think of it this way, what if the patient had presented with a sore throat? After routine physical and exam the doctor establishes it is most likely a simple viral infection where you send them home for bed rest. Should the doctor be allowed to run every test under the sun, costing 10s of thousands of dollars or admit the patient to the hospital costing thousands more per day when it is someone else footing the bill? Doctors don't work in a vacuum, we are supposed to consider what is reasonable/affordable/etc. and not just order every last test because we can.

What is happening with the OP's situation is just flavor of that exact situation, it just sounds a little more dramatic because of the presenting symptoms.

Hi guys, because the follow-up for this post is taking longer than I thought, I'll post it tomorrow. Thanks for all the great comments so far! There is an end to this story.....