Paciente evita la enfermedad de Lyme, pero recibe una factura sorpresa

At the end of the week in April, Leah Kovitch planted invasive plants in a garden near her house while a garrapata was caught on the beach.

No notice of the little insect until the moon, when he felt pain in the pantorrilla muscle. This is how I got a virtual quote from a doctor —recommended for your health plan—, who received a 10-day treatment with doxicline to prevent Lyme disease, and he insisted that he also be consulted personally. Then, later that same day, it was, without prior citation, a clinic near your home in Brunswick, Maine, evaluating him and taking a single, highest dose of that same drug.

I made a good decision because the clinic staff encountered another garrapata in Leah’s body during this visit. Additionally, after sending an insect to a testing lab, the test result came back positive for Lyme.

“I can seriously lock myself in,” Kovitch said.

But Kovitch’s insurer asked to go to the clinic. Is that the reason? You have not obtained a diversion from your doctor to see a specialist or prior authorization. “Our plan is not this type of attention, so we rechazamos this cargo,” explains a document.

Health insurers have argued over the years that prior authorization helps reduce fraud, unnecessary spending to protect patients. And if these people are looking for associations with expensive treatments, such as cancer, Kovitch’s little victim must be like the companies that also use this policy to avoid paying for services of any type, including when they are considered economic and pharmaceutical. necessary.

Promises of change

President Donald Trump’s administration announced that private security doctors have agreed to make significant changes to the prior authorization process.

The promise includes completely eliminating licensing requirements for certain medical services. It also allows a grace period for patients who change medical plans, so as not to run afoul of new rules that interrupt their current treatments.

Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services (CMS), announced at a press conference in June that some of the changes were taking effect in January.

But today the federal government offered few details on which diagnosis codes — used for medical billing purposes — must provide prior authorizations, or how private insurers should plan their new rules. It’s not clear that in some cases, like Kovitch’s Lyme disease case, he’s carrying out his activities.

Chris Bond, head of AHIP, the medical security industry’s leading trade group, confirmed that insurers were committed to implementing some changes by January 1. Other changes will be made later. For example, companies have agreed to respond to 80% of authorization requests in “real time”, but this will not happen until 2027.

Andrew Nixon, head of the U.S. Department of Health and Human Services (HHS), told KFF Health News that changes promised by insurers could “reduce bureaucracy, speed up medical care decisions and promote transparency,” an announcement that requires time to register an impact. complete.

Meanwhile, some health policy experts must be skeptical about whether the companies actually deliver on their promises. This is not the first time that major insurance companies have announced a reform of the prior authorization process.

Bobby Mukkamala, president of the American Medical Association (AMA), wrote in July that the promises made by insurers in June are “parallel” to the security industry yesterday in 2018.

“I think it’s one thing,” said Neal Shah, author of the book Insured for Edith: How Health Insurance Is Failing Americans — and How We’re Taking It Back (“Asegurados hasta la mort: cómo el seguro de salud perjudica a los estadounidenses y cómo podemos recuperarlo”).

According to Shah, insurers have confirmed the impetus of public pressure. Collective outrage against insurance companies grew after the death of United Healthcare executive director Brian Thompson in December. Oz said the insurers’ compromise was a response to “violence in the streets.”

“Cada vez rechazan más reclamos,” said Shah, who is one of the founders of Counterforce Health, a company that uses artificial intelligence to help patients eliminate the negative aspects of safety. “Nadie is responsible.”

Solve the case

The truth that Kovitch received his quote in the clinic was $238 and you paid for your bag as you undertook your insurance, Anthem, without purchasing a cent. The first intention was to make the decision. This included a retroactive discount from your primary care doctor that addressed the need for the visit.

No function. Anthem volvió a negar la cobertura. Kovitch said that when he called to find out why, the representative couldn’t explain it.

“It was like we couldn’t hear him,” Kovitch said. “All that was repeated, over and over again, was that you did not have prior authorization.”

After that, Jim Turner, the lead singer of Anthem, blamed the security attorney for a “billing error” made by Maine Health, the health system that operated Kovitch’s clinic was expected. According to Turner, the error caused the request to be treated as a visit to a specialist, instead of a walk-in or emergency visit.

Turner did not provide documentation showing how the error occurs. The medical records Kovitch entered stated that Maine Health coded his visit as “mordida de garrapata en la parte inferior izquierda de la Pierna, primer encuentro,” and it’s unclear why Anthem interpreted it as a visit to a specialist.

After KFF Health News contacted Anthem to verify Kovitch’s bill, Turner said the company “must have identified the billing error early in the process and told us the inconvenience it caused Senora Kovitch.”

Caroline Cornish, a spokeswoman for Maine Health, said this isn’t the first time Anthem hasn’t covered patients who send it without their prior citation. It has been reported that Anthem’s procedural rules have been applied incorrectly to this type of visit on multiple occasions, resulting in “inappropriate requests.”

Confirmed that these visits should not require prior authorization and that Kovitch’s case illustrates how insurers should use administrative requests as an initial response.

“Maine Health believes that insurers should provide the attention their associates need, instead of creating barriers that track coverage and can discourage patients from receiving attention,” he said. “The system, with an overwhelming frequency, is against people who are supposed to serve,” he added.

Finally, in October, Anthem sent Kovitch an update to its earnings resume, and it indicated that a combination of insurance payments and expenses covered the total cost of the consultation. Kovitch said a company representative called for him to be exonerated. Basically in November I received the refund of $238.

But it has just entered that, according to new rules established for Anthem, its annual town with the ofthalmologist now requires a diversion from its primary attention doctor.

“It’s the same,” he said. “But now I know better how to act.”