Sister Needs Wheelchair Medicaid won't pay

[Irishmom2]

But the decisions are still going to be “evidence-based” and follow rules created by the government (HHS/CMS)

Not necessarily. Insurance decisions are often made by non-medical employees and doctors have to get on the phone at times and argue with the insurance company so their patients can even get certain prescriptions or procedures. In actuality, that is not their job. They are not paid to spend a half hour on hold and then have to argue with someone that is not a doctor about what is best for their patient.

 

[Cricket2]

Not necessarily. Insurance decisions are often made by non-medical employees and doctors have to get on the phone at times and argue with the insurance company so their patients can even get certain prescriptions or procedures. In actuality, that is not their job. They are not paid to spend a half hour on hold and then have to argue with someone that is not a doctor about what is best for their patient.

You are so right. People might be surprised to know that a lot of the representatives they are talking to at the insurance company have nothing more than a GED or HS Diploma. How do I know? Cuz that is the kind of job my cousins daughter had. All they do is look in a chart and see if you fall into the right category. Talk about stupid.

The ONLY one that should be determining care for a patient is the doctor. The ONLY thing insurance companies should be doing is paying out what people have paid for: coverage for those needs. And if they want to work against fraud, track the doctors only, not every patient. If “Doctor Killdare” is suddenly issuing hundreds of wheel chairs go check out why. Oh…he works with spinal injury folks no big deal but if he is in some other specialty check him out further.

Monitor the companies that make and distribute chairs a little more as well, but leave the patients alone, as most of us have no desire to requesting any of this stuff anyway. There is nothing fun about any of it and most of the fraud is not going to come from the sick, it is and does come from the insurance companies, medicaid and medicare with all their bottom line maintenance procedures.

It would take less tracking to do it this way and cost less money. I suspect there is more spent on “preventing fraud” than the amount of fraud that is actually occurring. I know they don’t check in the right places. The should start at the top of their own companies and then go out from there.

 

[maryjk]

It would take less tracking to do it this way and cost less money. I suspect there is more spent on “preventing fraud” than the amount of fraud that is actually occurring. I know they don’t check in the right places. The should start at the top of their own companies and then go out from there.

The problem is, there are people out there that are trying to defraud the government. Patients, the ones you say would never request a wheel chair if they didn’t need it, are part of the problem. Because, yes, they would do exactly what you claim they won’t do.

Two doctors practicing near me were just charged with fraud. One, if convicted, owes hundreds of thousands of dollars in restitution. The other one owes a little less, but both are charged with falsifying medical records.

Fraud needs to be attacked from all sides. And I for one am glad that at least one government program is at least trying to stop flow of unnecessary spending.

 

[Orogeny]

The ONLY one that should be determining care for a patient is the doctor. The ONLY thing insurance companies should be doing is paying out what people have paid for: coverage for those needs.

Well, every insurance policy has things that they don’t cover. If you pay for a policy that doesn’t cover X and your doctor prescribes X, you are likely out of luck, but you are getting what you paid for. Medicaid is no different than private insurance companies in that regard.

My wife is a nurse in a doctor’s office and every day I hear stories about problems with Medicaid. Recently, she had a hard time getting Medicaid to approve diabetes testing equipment for a pregnant woman with gestational diabetes. That was a typical problem that her office has to deal with.

I am glad to read that your sister got the help she needs.

Peace

Tim