File this under WTF.
From our new health insurance plan description booklet:
"The [advisory board] does not determine your course of treatment or whether you receive particular health care services. The decision regarding the course of treatment and receipt of particular health care services is a matter entirely between you and your Physician. The [board's] determination of Medically Necessary care is limited to merely whether a proposed admission, continued hospitalization or other health care service is Medically Necessary under this Certificate."
Further down on the same page:
"The fact that your Physician or another health care Provider may prescribe, order, recommend, or approve a Hospital stay or other health care service or supply does not itself make such a hospitalization, services or supply Medically Necessary. Even if your Physician prescribes, orders, recommends, approves or views hospitalization or other health care services as Medically Necessary, [the insurer] will not pay for the hospitalization, services, or supplies if [the advisory board and insurer] decide they were not Medically necessary.
To see how this nonsense plays out in a real-life situation, Marrit Ingman shares this tidbit from her blog.
Hi. How are you?
You remember that uterine biopsy I had in April, was it? Yeah. I rocked that like a CHAMP. It was sort of unpleasant being scraped with a cannula, but that's what you do when you have irregular uterine bleeding for three continuous months. You say, "Wow. I'm bleeding almost constantly. Think I should ask a doctor about that?" And then you go in because "constant bleeding" is the kind of symptom you think even an HMO could get behind exploring.
The doctor was really interested when I told him I had a family history of breast cancer and my mom was currently being treated at MD Anderson. So he ordered a biopsy. It came back negative, and since we ruled out endometrial cancer as a cause of the bleeding, everyone was happy and we all went our separate ways, me still bleeding but less worried I had six months to live.
Then I got your bill for the biopsy. You won't cover it.
You people suck.
You make your own decisions about what is and is not medically necessary for me. That's my physician's prerogative, not yours. If you have a problem with that fact, I might suggest not participating with my doctor in a service arrangement and accepting my family's astronomical health-care premiums every month. They rival my mortgage. And it sure was cute of you to hike your rates just enough to absorb the "raise" AISD [Austin Independent School District] gave its teachers this year, which actually was a raise for you. You guys sure have American families over a barrel.
I curse you all with bleeding genitals.
Read more of Marrit's commentary at http://www.suite102.com/baldo/.
Tuesday, September 19, 2006
File this under WTF.