Sterile Water Irrigation Denied By Insurance. Patient Not Sterile Enough.

I feel bad for our patients.   Insurance economic algorithms are defining  the patient and doctor experience regardless of situations unique to the patient experience.  If our recommendations as physicians or your needs as a patient do not comply with your insurance company's economic algorithms, you and your  physician will likely get denial of care letters.  That means hours of headaches and delayed therapy for you and hours of headaches and uncompensated expenses for your physician's office in communication with your insurance company.  It is no wonder many offices have started charging patients for their busy work. 

That denial of care can come in the way of preauthorization headaches.   I experienced that tragedy while trying to authorize a lidoderm patch for a patient of mine that was getting  great pain relief in the hospital.   That patient was denied coverage for the patch as an outpatient.   We too have experienced the frustration.  Mrs Happy was recently at Walmart.  She learned  our Blue Cross Blue Shield  insurance would not authorize coverage   on her medication refill required for our 9 week baby pregnancy related care last week because she was two days early to pick up the prescription..   That's right folks.  BCBS algorithms are denying care to our unborn baby because Mrs Happy is too compliant with her therapy.

CMS would be thrilled at Mrs Happy's actions!    They actually have a program in place to track how compliant you are with your medication adherence.  You think big brother isn't watching?  Think again.  This information will be used against you when the time is right.  Follow this link for the crazy details. 

If you need outpatient radiology imaging such as MRI or CT or ultrasound, more than likely your insurance company will require your physician's office  to obtain preauthorization.  Every insurance company is different.  One algorithm may allow the scan while another may deny it.  That formula will change from year to year and from company to company.    Some medications will be covered, some will not.  It changes from year to year and from company to company.

Medicare wants hospitals to  make our patients happy.  They care so much about our patient's hospital experience that they are withholding money from  hospitals that don't win the patient satisfaction game.  We could spend hundreds of thousands of dollars a year training staff to be nice, but if a physician writes an order for that Lidoderm patch and the patient can't fill it, they aren't going to care about being AIDETized.

Then there's this patient below.  They  most certainly aren't going to give my hospital glowing patient satisfaction scores after experiencing a devastating denial of payment on their sterile water irrigation solution script.  The insurance company said it wasn't on their formulary.  More likely, I suspect the algorithm denied payment because the patient wasn't sterile enough to benefit from sterile irrigation. 

The same insurance company that will pay $100,000 for seven smoking related COPD readmissions  has decided to deny their patient insurance benefits to sterile water. In fact, I guarantee if this patient came to the ER saying they needed to be admitted because they couldn't get access to sterile water, I would bring them in under observation care just for spite.  At least then they could get their sterile water irrigation flushes with a diagnosis of rule out lack of access to sterile water irrigation flushes and they will pay  $3000 a day for the right to do so and I will get paid form my highly complex level 3 observation history and physical. 

Denying sterile water irrigation flushes.  This is what our life as doctors and patients have become.  And it's only going to get worse from here. America has spoken.  They are getting what they asked for.  Algorithms rule our health care decisions.  More and more decisions are going to be made based on computer models and actuaries.  ObamaCare says we can't deny care based on preexisting conditions.  From where I'm sitting, there's plenty of denying going on.   One solution is to stay healthy, exercise, don't smoke and hopefully you can live a long and happy life away from this madness.  For the rest of you, you had better plan on saving lots of money to pay your physicians extra.   It's only a matter of time before patients who can afford to pay extra do and those that can't  will be denied.



This post is for entertainment purposes only and likely contains humor only understood by those in a health care profession. Read at your own risk.

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