Denial, stuck in the middle

[cnyman]

What is the name of your state (only U.S. law)? New York

In May of 2013 my neurologist ordered a SPECT/DaT scan for purposes of a differential diagnosis for Parkinson's, as my symptoms had not progressed in two years. The scan results showed fairly normal dopamine production cells, not typical of Parkinson's, and my symptoms have still not progressed, which was a great relief to me.

What has stressed me instead is that the insurance company denied the claim and the hospital that performed the scan is billing me for over $6000. The claim was denied to SPECT being "investigational and not medically necessary." The insurance company said that a PET scan should have been performed instead.

I have spoken to the office admin in the neurologist's office, who told me she called the carrier and was told that no pre-approval was required. I originally thought that mean the procedure was approved for the purpose intended, so I asked the Dr's office to provide the proof to the carrier that they had indeed called. I have since found out from the carrier is that all "no pre-approval required" means is that they can't deny it later for not getting pre-approval. Essentially that statement meant nothing as far as assurance that they would cover the procedure.

I appealed the decision again and asked the provider to forward their notes and rationale to the carrier, but was again rejected. The 2nd rejection said SPECT was not approved for non-vascular issues (even though a DaT SPECT scan is different than one for vascular diagnosis) and listed the only reason for the scan being done as "hand-tremor." I had some other minor symptoms, and the reason was to rule out Parkinson's, not diagnose it. In fact DaT scans are specifically FDA approved for that purpose.

I will be picking up everything the Dr. provided to the carrier so that I can make sure my final appeal is handled properly, but I don't understand how the provider and the carrier can have procedures in place that put the patient's finances in jeopardy. Neither seems to be able to explain how such a problem can be avoided.

I'm not sure how to best approach the appeal, and don't know how to hold the Dr. responsible if my final appeal is denied, as I see no reason that I should be on the hook for the cost of the scan, but it's not the Dr. billing me but rather the hospital.

My plan so far is as follows:

- Review the Dr's. notes, especially as to the purpose listed for the scan
- Confirm again why the Dr. ordered a SPECT rather than PET scan - not clear on this yet.
- If for some reason a PET scan could not have been used for a differential diagnosis, request a separate letter from the Dr. to the carrier specifying the reasons.
-Request a reduction in the fee (I know, good luck) as I will be forced to start making payments to avoid it going to collection.
- If the final appeal is denied and I can do so I am perfectly willing to take the Dr. to small claims court (or the insurance carrier?) but don't know if I have a case. To me it seems one or the other needs to have some responsibility.

 

[cbg]

At what point did YOU pick up the phone and call the insurance company to ask how, or if, it would be covered?

 

[lkc15507]

It is ALWAYS the responsibility of the plan member to be aware of health plan benefits. "No pre-approval required" does not equate to "it's covered". If one were familiar with Plan requirements and / or inquire of the health plan, this mistake could not be made. I'm sorry, but you should always, always, always clarify these things by reading your Plan and / or calling the payer. Providers make these calls routinely and the person calling has no responsibility to you to be sure you understand your plan ie as in "No pre-approval required". Also, when calling a payer, be specific. I'll guarantee the provider simply asked if a SPECT needed pre-approval and the answer was "No"--correctly, but that is not the question you personally would have wanted answered. It is your responsibility to ask that specific question.

SPECT is experimental / investigational in virtually any health plan I encounter for the given diagnosis. There has been an explosion of using SPECT in mental/nervous and neurological conditions. There simply are no evidence based studies available to demonstrate their superiority or even equality to more standard tests for those types of diagnoses. As far as FDA approval for a test or procedure? Many people make this mistake. The FDA is approving a device for use in a test or procedure. They approve primarily based on safety and that it meets a minimum requirement of doing what it is intended to do. The FDA approval does not require a level of equality or superiority for a device. Payers typically will not cover these types of new devices (test or procedure) until time and evidence establish superiority to other current methods.

You will most surely lose your appeals with the payer. External review should be available. External review historically is about as(slightly less) favorable to the claimant as to the plan in ultimate decisions. I suspect external appeal will lose as well. My opinion is that if anyone should at least discuss it with you, it's the provider. My opinion is that in the climate I've described, he likely knew eligibility of SPECT for the given diagnosis was questionable. I suspect he didn't care.

Good luck.

 

[cbg]

Well, no, not quite always. Plans do exist where the doctor has responsibility for determining if prior approval is required. However, in those plans, the policy will expressly and in so many words state that the responsibility is on the doctor. It is not enough that it doesn't say, The patient has the responsibility. The patient has that responsibility UNLESS the plan specifically places it on someone else.

But...the patient should be aware of whose responsibility it is, and not assume that it belongs to the doctor.

If the OP wants to come back and let us know whether or not he ever made that call, what was said if he did, whether his specific plan specifically puts the onus on the doctor, and what type of plan he has (HMO, PPO, POS etc.), we can then go through the next steps.

 

[cnyman]

At what point did YOU pick up the phone and call the insurance company to ask how, or if, it would be covered?

I have called my carrier in the past to determine if I needed a referral, and I have am very familiar with my coverage information - I've probably read far more of it than most people ever do. In fact my carrier does cover SPECT scans, but not for this particular purpose, and there is nowhere in the plan documents that provides such specificity. It would not occur to me to check on a specific item like that when ordered by my physician. In the 15 years that I have been covered by health insurance I have never had this problem. I had nerve studies, MRI's etc. performed before with no problems, and I had very excellent high-end coverage (I did not even owe co-pays for those procedures) so I simply did not know I would need to check on this.

For someone to order an expensive procedure when they are not positive of coverage my view is that they either need to advise me to check my coverage or make sure that they ask the appropriate questions or get any required approval. That is what I would do in that circumstance.

I know the bill is ultimately my responsibility, but so did the provider. It does appear from the copies of the Dr's records that they did not fully explain that the purpose was a differential diagnosis, and I'm also waiting to see what their response in to my inquiry as to why a PET scan was not done instead.

 

[cnyman]

My coverage was through Verizon group policy, Anthem BC-BS, and I believe it was a PPO. I did not even need referrals in most circumstances, unless the specialist required it.

 

[cbg]

Did you call the carrier FOR THIS PROCEDURE? The fact that you did so in the past does not relieve you of responsibility this time.

 

[cnyman]

Did you call the carrier FOR THIS PROCEDURE? The fact that you did so in the past does not relieve you of responsibility this time.

No need to shout - I did not call for this procedure. The only time I have called before was to check on the need for a referral or to determine coverage for certain types of care. As I noted above, there has never been a problem with coverage for any procedure ordered by a provider. All were in-network and presumably familiar with the carrier's policies. I do understand I should have checked, but I had no previous experience that would have led me to do so. Given some of the poor info and communication experiences I have had with the carrier I'm not sure I would have received the correct answer anyway.

 

[Zigner]

Have you asked the provider to better explain their rationale and their opinion of the medical necessity of the procedure (to the carrier)?

 

[cnyman]

Have you asked the provider to better explain their rationale and their opinion of the medical necessity of the procedure (to the carrier)?

Yes, that will be part of the appeal, as I noted above I don't feel the Dr's office did a proper explanation previously. I believe this may hinge on whether the SPECT scan provides a more accurate result for the purpose intended. I'm not optimistic if that's so, because it appears that PET scans done with tracer may provide the same info.

 

[lkc15507]

Well, no, not quite always. Plans do exist where the doctor has responsibility for determining if prior approval is required. However, in those plans, the policy will expressly and in so many words state that the responsibility is on the doctor. It is not enough that it doesn't say, The patient has the responsibility. The patient has that responsibility UNLESS the plan specifically places it on someone else.

But...the patient should be aware of whose responsibility it is, and not assume that it belongs to the doctor.

If the OP wants to come back and let us know whether or not he ever made that call, what was said if he did, whether his specific plan specifically puts the onus on the doctor, and what type of plan he has (HMO, PPO, POS etc.), we can then go through the next steps.

I think the misunderstanding is that I stated that it is always the responsibility of the plan member “to be aware of plan benefits” vs. being the one to actually be required to submit any documentation / make the calls. I understand a plan may have provider requirements. Using this poster’s example, if the plan requires that the provider obtain all necessary pre-authorizations, the provider accomplished this by calling the payer and learning that no pre-authorization is required for the test in question. However, the plan member is still likely to lose the appeals because he was not aware of his plan benefits as it was denied for a medical necessity issue vs. a procedural issue. Even if a provider is required to fulfill certain aspects of a plan—and does so—it will not necessarily negate denial of coverage on other grounds. That is the point I was trying to make. So I stand by the fact that it is ALWAYS the responsibility of the plan member to "be aware of plan benefits". At least if they want their claims paid. Sorry if it wasn’t clear.

For the poster, certainly continue your appeal with the payer, but I truly don’t hold out much hope for success in that area. Going forward, you can always ask your payer if they will conduct a pre-determination of benefits for a specific situation. Ask your provider to provide you / the payer with documentation prior to the procedure being done if there is any question at all.

 

[cbg]

So I stand by the fact that it is ALWAYS the responsibility of the plan member to "be aware of plan benefits".

Gotcha. I certainly agree with this, and I rarely disagree with you on the major issues anyway. Thanks.

 

[cnyman]

So I stand by the fact that it is ALWAYS the responsibility of the plan member to "be aware of plan benefits".

Gotcha. I certainly agree with this, and I rarely disagree with you on the major issues anyway. Thanks.

OK, I have had further time to think about this and am back to my original conclusion that it is the provider and insurance company who are remiss more than am I. I know that I am responsible to know the terms of my insurance coverage, but it is of course impossible for me to know the coverage for a certain procedure in a particular context. So, those here would say that means I need to call to confirm coverage - presumably for every procedure or test.

But let's say I had made the same call as the physician’s office - I would presumably have received the same answer - that no pre-approval is required. Until recently I thought that meant the procedure would be covered. Without knowing the correct questions to ask I cannot be assured I would have received an accurate, relevant answer. For example, if I had asked a call center person at the carrier if SPECT scans were covered the answer could easily have been "yes," as there is no assurance that the person would go far enough to differentiate between coverage for a particular purpose.

In all the time I had coverage through my employer there was not one procedure that was not paid, including other scans and nerve studies, a heart ablation, etc. In fact I never paid more than $25 myself, so had no reason to question the physician’s or insurer's procedures.

As far as I am concerned those ordering procedures to be done on my behalf need to advise me if the insurance coverage I have may not cover the cost at all, and the insurer has the responsibility to have procedures in place that protect their customer. I would expect the physician's office to inquire as to coverage for both the procedure and purpose, and the insurer to either be able to give a definitive answer or advise that it may not be covered, and request the provider to have the insured call for clarification.

I hold the physician and the insurer responsible for the liability related to this procedure.

 

[cbg]

Fine, then. You go ahead and expect whatever you like.

 

[ecmst12]

You undoubtedly signed paperwork for the doctor accepting responsibility for any costs not covered by your insurance.