Anne Zieger has written a brief, very compelling piece about how a certain large teaching hospital crossed (at least technically) ethical boundaries by telling a patient she was covered, then that she wasn’t, but only after she had a procedure that was billed at $25,000.
I don’t know why the insurer didn’t cover the procedure, or why the hospital didn’t tell her it wasn’t covered, just like I’m sure the patient has no idea how she’s going to come up with $25k. It could be a breakdown in communication at MassGeneral, or it could be the patient was told and can’t remember, or perhaps there’s some other explanation.
Regardless, it certainly points out – as if we needed more evidence – exactly how screwed up our financial reimbursement ‘system’ is.
Yecch.
Jun
21
“I don’t know why the insurer didn’t cover the procedure, or why the hospital didn’t tell her it wasn’t covered, just like I’m sure the patient has no idea how she’s going to come up with $25k.”
Many reasons why insurance didn’t cover. It could be as simple as “you never asked” and this is the first volley in a back and forth between hospital and insurance
It could be we pay for a surgery for this problem but not THIS surgery.
It could be we won’t pay for this surgeon or this hospital to do that surgery.
It could be that its not covered in the benefit plan.
I assume there’s much more to come on this but it looks as if Mass General (or actually someone in the admissions process) forgot to check
In other words, as Desi used to say:
somebody has ” ‘splaining to do”
c3 –
thanks for the comment.
you are correct, that there are many reasons the insurer didn’t cover the procedure. However, in this instance the patient was informed by MassGen that the procedure was covered. Most of your other potential reasons may fit this issue yet the patient did ask; the procedure was reportedly initially approved; and it was approved at that facility with that surgeon.
This may have been due to the insurer’s internal error or a failure on the part of MassGen to communicate.
Regardless the patient is – once again – the victim of a dysfunctional health care system.
Paduda