United Healthcare denies claim of woman in coma
The patient's doctor criticized the insurance company, saying that the treatment was necessary to prevent her from dying.
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At the risk of you all putting a literal hit out on me, I'm going to proclaim the hot take that this is not the best example of insurance company abuse. I am in complete agreement that insurance greed and frankly insurance company power over the entire US Healthcare system is way out of balance. I argue the walls need to come down and things need to be rebuilt in aore socialized model. But as far as refusing claims go, be it socialized or the insurance Co mess we have now, Healthcare resources are inevitably limited. Someone with a brain hemorrhage, in a coma, ventilated, in heart failure is going to be massively expensive to support and will have a low likelihood of functional outcome. Rather than denying dozens of chemotherapy meds, or MRIs for suspected brain lesions, I could see the ugly job of denying this claim as justifiable.
The reason for denial given was that the doctor didn’t prove the treatment was medically necessary, not that it costs too much.
That's nitpicking. Is it medically necessary to support someone in a coma that likely won't have a good outcome? It's always about the money with insurance. That has to be assumed.
It’s not nitpicking, it was the literal denial reason. You are explaining why you think it was okay for them to do, but that’s not the reason given for a denial. They need to be able to defend what their denial actually says, not what you think it means, in the event of a lawsuit or appeal.
“Medically necessary” has a legal meaning, and it’s not dependent on whether you consider them a ‘useless eater.’
Medically unnecessary = we don't support the decision making and don't want to pay for it. It's the only language they will ever use. This is just the wording insurance companies use to deny claims.
Medically necessarily to have a chance to live, YES. You are confusing medically necessary with profitable, which is the whole point behind the outrage and the reason why the insurance "industry" is monstrous and dispicable.
I get what you're saying. Every denial reason is just a code for this is too expensive. The reason itself might be grounds to argue, but they are just going to try to deny it again with a different reason code.
To your original point, I agree that we should ask ourselves if it's worth hundreds of thousands of dollars just to keep a vegetable breathing for a few more days. Frankly if I were in that shape, I know death would be a kindness.
But I will say it seems immoral to leave the decision in the hands of the profit-makers.
I’ll go with the opinion of the patient’s doctor, rather than some internet rando, thank you very much
The patient's doctor isn't the one that denied it. I'm not really sure what you're saying. I think you just agreed with me.
I agree with the insurance company too and most doctors would. I'm not sure who this doctor is but most people in healthcare industry that actually work ICU will agree. I also challenge commenters here to speak to your (hospital) healthcare friends about it too, especially if they work ICU.
ICU beds are very limited and honestly not designed to house pts who are intubated or comatose indefinitely. They are designed to be short term with active treatment. Otherwise, if they need to live somewhere as a comatose pt, they need to go to a subacute facility, forever on a vent. That's the real reason why United Healthcare denied. "Not medically necessary" ('for hospitals' is what they left out).
If hospitals kept every uninduced comatose pt, they wouldn't be able to treat anyone else (think stroke, cardiac, trauma, severe pulmonary, etc). Pts with TBI for example, 50% will never have consciousness returned and just have to live in this vegetative state. . Not only that but hospital staff isn't trained to provide long term care. They aren't educated or specialized in doing so. Some hospitals only have let's say 20 ICU beds. Larger ones maybe 40. But even without people living in them, they are near 100% capacity every day.
Subacute facilities are also really difficult. They have trouble staying afloat because the care they provide is so expensive and most are reimbursed at a loss (Medi-Cal).
Theres lots of things wrong with the healthcare system but like this poster said, its not a good example. There are honestly literally millions of other examples that are absolutely egregious.
Y’all are making a lot of assumptions about this person’s life, as if you yourself were on the death panel. Maybe it’s, true, maybe it’s not, but the doctor knows more about the case and the patients prognosis than any of us
I know in the 10 years ive worked in a hospital ive never had a patient denied care in ICU unless the reason listed above. I also know A LOT about insurance, much more than most healthcare professionals. I also connect my doctors to insurance when we do need to appeal decisions and ask for a peer to peer.
Im not saying insurance never denies care. They do. Anecdotally though, never had incorrect denial with ICU. Its too easy to prove insurance definition of "medical necessity' there. I am still very doubtful of this specific example. Downvote all you want but the scanario I gave above is almost 100% probably what happened. I'm just explaining the process and likely what happened. Its okay if I'm not believed. I know what's true and how healthcare works. Its bittersweet that I have my job because I know how to navigate the healthcare system and get my patients what they need for their healthcare goals.
The fact that you have to be there and know the tricks to getting care is part of the problem. We have people who paid a crap load for medical insurance and doctors taking care of their treatment: why does there also need to be someone to deal with getting paid?
100% agree. Our healthcare sucks and I won't deny that. It would be so much cheaper and more efficient to have single-payer/universal healthcare. Studies and data consistently show that Americans pay the most and have worse healthcare outcomes (especially comparing mortality rates: overall, maternal, infant, etc). People are paying into it with high premiums and still having copays, out of pocket costs, etc. Single payer is the way to go for sure.
My job still exists in other countries like Australia, Japan, etc. But yes they dont have to worry about the healthcare services patients get being paid for or covered as much.
I'm not sure who this doctor is
This doctor is someone who knows a hell of a lot more about the situation than you do or the friends that I might ask that are in healthcare. Maybe, just maybe, he knows some information where it makes sense to continue treatment. You seem to be under the assumption that he did not share that information with the insurance.
I know in the 10 years ive worked in a hospital ive never had a patient denied care in ICU unless the reason listed above. I also know A LOT about insurance, much more than most healthcare professionals. I also connect my doctors to insurance when we do need to appeal decisions and ask for a peer to peer.
Im not saying insurance never denies care. They do. Anecdotally though, never had incorrect denial with ICU. Its too easy to prove insurance definition of "medical necessity' there. I am still very doubtful of this specific example. Downvote all you want but the scanario I gave above is almost 100% probably what happened. I'm just explaining the process and likely what happened. Its okay if I'm not believed. I know what's true and how healthcare works. Its bittersweet that I have my job because I know how to navigate the healthcare system and get my patients what they need for their healthcare goals.
Edit: Also, with the scanario above, almost 100% of ICU professionals would agree with insurance for the reasons listed above. We know how it feels to want to bring someone up from the ED but can't because we have beds already full... There are a very few select patients occasionally that want to live in the hospital. I'm aware we are encountering some people at their most vulnerable, traumatic times. It sucks. But they can't live there.
The only other reason I can think for denial is if treatment is experimental. Otherwise, its really easy to appeal and get the care approved in ICU.
