Tuesday, October 2, 2012

Crazy Stupid Things about Insurance Coverage

          1. Until recently, Medicaid and Blue Cross said they covered IUD's, but paid half the purchase price of the IUD device, and made it illegal for the patient to cover the additional cost.   The cost of pregnancy, is fully covered by Medicaid, and so is a tubal ligation--which usually involves surgery under anesthesia.  IUD's are probably the best birth control available, and are least expensive in the long run.
          2.  Insurance companies like Blue Cross and Medicaid cover Viagra but, until a few years ago, would not cover  birth control pills.
          3.  Medicare denies payment for B-12 shots, saying:  "It's not medically necessary."  Cost:  $0.43.
          3.  Blue Cross didn't cover the recommended screening colonoscopy for its policyholders, until  forced by the government.
          4.  Medicare does not cover psychological counseling.
          5.  Insurance companies don't cover compounded medications--only those one-size-fits all drugs manufactured by major pharmaceutical companies.  Despite the long history of compounding medicines--a process by which a pharmacists mixes up ingredients according to a doctor's recipe--Medicare, Medicaid, and most other insurance companies won't cover the cost of these prescriptions.
          6.  Medicare denies payments for  EKG's, with a form that says, "Not medically necessary."  Office notes with a description of a patient's chest pain come back with a second payment denial. But if the same patient goes the the ER complaining of chest discomfort, Medicare will pay for a hospital stay and tests running upward of $30,000 or more--all covered.
          7.  Medicaid has a new rule:  Patients can't have more than two doctor visits per month, and four ER visits,  no matter what the patient's state of health.
          8.  Medicare doesn't cover the cost of urine drug testing in the office:  $13.  But it will cover the cost when the test is sent to the lab:  >$100.
          9.  Medicaid doesn't pay for urinalysis.  Doctors are told to do the test at no charge.
        10.  My office has not been paid for the 500 flu shots we administered to Medicare patients last year.  No reason was given, and our appeals have been ignored.
        11.  Medicaid covers the cost of skin testing for allergies, but won't cover the cost of medicine formulated for treating allergies.
        12.  Medicaid covers the cost of testing for vestibular abnormalities, but won't cover the treatment--which is 9 session--to correct dizziness and prevent falls.  It covers hip replacement surgery fully.
        13.  Medicaid doesn't cover house calls by doctors, but it pays for long-term care in nursing homes.
        14.  Medicaid doesn't pay for home health nurses and aides, who help patients stay in the comfort of their homes, rather than being moved to nursing homes.
       15.  Insurance companies change their medication coverage every six months.  A medicine that was covered at the beginning of the year may not be covered at the end.
       16.  We can't ask a pharmacist to tell us if a certain medication will be covered by a patient's insurance--the prescription has to be called in, processed, and a fax notice sent before we know the medicine isn't covered.  This takes so long the patient isn't in the office any more, and needs a second visit.
       17.  HIV medications costing up to $80,000 per year are covered by insurance companies, but not condoms for us to distribute to patients.
       18.  Medicaid and other insurance companies will pay for me to apply a leg cast for a broken bone, but not for me to supply crutches so the patient can walk out of the office.
       19.  Every Blue Cross patient has different coverage guidelines.  Doctors have to do research or call for information on what will and won't be covered every month for every patient.  One full-time employee is required for the job of  "insurance verification."
       20.  If the an employee calls Blue Cross twice about the same patient, within the same hour, two different sets of information about what is covered and what is not, will be given by the Blue Cross reps who answer the calls.


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