Meeting with legislators
Jim DeWees
Description
Collection
Title:
Meeting with legislators
Creator:
Jim DeWees
Date:
8/12/2008
Text:
During a conversation last week with a couple state officials (state represenative and state senator), I was telling them about the recent event of a medical claim for a prosthetic leg and the denial from the insurance company for the precert for a new BK prosthesis. I explained that the limb was over 9 years old, and was literally in 3 pieces (the foot broken in half, and the ankle broken in half, and the socket was also too big for the patient at this point, and he was wearing 5 thick socks to fill up the socket.)
I told them how I involved the employer in the matter, and within 2 hours after contacting the Human Resources director over the benefits, she had the precertification for the new leg. Once the leg was made and delivered, the insurance did not pay for the limb because they claimed that there was no precertification on file for this limb. I again contacted the HR person and she was totally confused and upset because she had a copy of the precert in her hands (as did I) and I had faxed her the denial for payment due to this non-existent precert. Again, within a couple of hours, she had the payment approved and in the mean time, I got a call from an insurance company rep that started off telling me that it was MY fault because there was no precert on file, and that I didn't follow their rules. I informed this person that I was glad that she told me that, because I have a copy of the precert in front of me, and also the HR person has a copy of it as well, and that I was doing everything I can possibly do to show this big employer how awful it is to work with this insurance company. I told her that this HR person had a copy of the denial, and that doesn't match the fact that she also has the precert as well. I told her that hopefully I will be able to convince other providers to do the same and always contact this person at this employer and swamp her with all these problems, and to a point where she will never sign another contract with this insurance company because of these numerous issues that she has to deal with. Hopefully I will help them lose this contract. With that comment, she just hung up on me. That gave me even more fuel and another issue to share with the HR person, that the rep from the insurance (and I have her name and thanks to caller ID, I have her phone number that came in...and the HR person knows the insurance person, that is her contact person), and when I told her that she hung the phone up on me, that made her even more upset with the insurance company and she said they were going to have a meeting about all these issues....and there are more issues than just mine, obviously.
Anyway, it seems to be a common story for all of us.
I also told these legislators that I had the name and address of the doctor that did the denial in the first place. He lives in Wisconsin and works in a large hospital in Milwaukee as an oncologist. There was no reason for this doctor to deny a claim like this, and this insurance company makes it more painful and awful to have to appeal this decision and go through all those hassles just to get the precertification for this device. AND, even after going through all this, getting paid is another issue and problem.
I explained to them that this doctor that made this decision has really damaged the life of this amputee. He is a professional and has a good job with this university. I is impossible for him to go to work since his job would not be wheelchair or crutch friendly. It also took a lot of time out of my life to fight for this patient just to be able to do my job and help him get back walking and back to work. There is NO accountability for this doctor, and it is even difficult to get a name of a doctor that does these denials. It took a little work and a couple phone calls to the insurance company, but finally I was able to get his name. Legally they are required to share the name of the doctor that approves or denies any claim.
I did manage to get this doctor's name and location, and from that I was able to Google his name and find out everything about this person. I was shocked to see that he works for a hospital, even a director of his area of the hospital, and yet this hospital has major problems with this insurance company. They had no idea that this doctor was employed and worked for the insurance company, and said it was a conflict of interest in their view. They said that they would have to talk about this during their next meeting for the directors and administration.
We talked about how I was getting information from other providers on denials they are faced with, and the names of the doctors that are behind these denials.
One thing we discussed was that maybe we need some legislation that would set some standard here for these doctors, and make it so that if any doctor was found to be making denials that are unfounded or questionable, and that really harmed or damaged the patient, then they would lose their license and ability to practice medicine in this state. And, maybe it would come to a point where many doctors were faced with investigations and impact their lives by taking so much time and energy and the stress of dealing with all of these claims that they are associated with, and make them decide that they don't have time to do this work, no matter how much money they got paid. And, as soon as some of these doctors lose their licenses, maybe other doctors would decide that they either need to make careful decisions on these claims and approve the legitimate ones, OR maybe they would decide that it is just not worth working for some insurance company that has some expected quota of rejections (which can't be proven at this point, but many former employees of these insurance companies have testified about these quotas and rules and the bonus plans based on the denials).
This discussion I had was to talk about the new parity bill, which we all agreed amounts to nothing, as I have already written about here a week or 2 ago, and how the Utilization Management is the enemy to the patient and the providers, and the bill still gives this entity the power and control of the benefits. I agree that the insurance companies do need some method or manner to control the claims and the fraud that can occur, but when it comes to situations like I showed them, when it is totally obvious about what the patient needs, there is no excuse or reason why the insurance companies can play these games and cause such a problem.
So, the end of the discussion was a good one, and hopefully some ammendment will come about and fix this bill like it needs to be fixed, and also some legislation and bill that specifies that the doctors that work for insurance companies can and will be held accountable for their decisions and actions that they make when reviewing claims or authorizing the treatments.
If Indiana can come up with some bill that will help the patients in this manner, then hopefully other states will see the need to have similar bills in their states. This could really make a huge difference in the manners and methods that insurance companies operate and handle these situations.
I also had a conversation with an Analyst for one of these BIG insurance companies that is located in Indianapolis (I had my 25th class reunion and just happened to bump into my old classmate and friend, and he happens to work for this company that is a constant problem here). I told him this story, and he was shocked and embarrassed by this. He knows my reputation and my passion for my work and being an advocate for amputees. He explained to me that it is all about money to them, and if they realize that they are spending more money with these rejections and having to look at the same claims over and over, and paying people to look at them again and again, and then finally paying them, then they will change their methods of operation. But, when they keep on rejecting the claims, a lot of offices just give up and write it off, and get over it. When this happens, it shows the insurance company that there is a significant amount of savings by putting the providers through more hassles. So, as soon as the providers keep on pressing for these claims, and keep on them until they are paid, and keep on fighting, then the insurance will realize that they are not saving any money and then things will change.
Also, if the insurance companies realize that doctors are afraid to work for them to sign these claims and deny them, for fear that someone will quesion them and challenge them, and that they might lose their license just in order to make bigger profits for these insurance companies, then they will hopefully decide that they need to improve their methods and play nicer with others.
This is all just me thinking and hoping that somehow we will see some improvements in this field.
If any of you have some crazy denials like the one I mentioned, that are CLEAR examples of patients getting what they need, PLEASE follow through and find the name and location of the doctors, and then post it here if you feel like doing that. I would really love to get any names of any doctors that worked here in my area, and I would make sure that the doctor was exposed for his/her other employment, and I am sure that he/she would at that point have some accountability for what they are doing. There are easy ways to assist in this kind of publicity on these issues. If they are doing decent and honest work, then they have nothing to fear or worry about. But if they are doing things like this doctor did in Wisconsin, then they need to answer for what they did. There is nothing illegal or unethical about any of this. Just making a phone call to the local hospital or any other kind of association where the doctor works, and letting them know that doctor so-and-so is also working for insurance company X, which has a bad reputation, or has had some really bad contract negotiation lately here....there is nothing wrong or inappropriate about doing that. They will definitely research this and make sure that this is true, and then might question the doctor about his/her association with this insurance company. Again, there is nothing wrong with doing that. But, going to some newspaper and having some big story written about this, and making some statements that might be questionable....that could be a bigger problem. There is some major risk of having your business destroyed if you offend the medical community where you work. But, depending on the doctor and his/her reputation in the area, that might not matter either.
Anyway, this is just what I am looking in to at this point, and something needs to happen to stop this decline that we are seeing in customer satisfaction and the ability to help these patients and amputees that need our services. These people I was talking to really seemed interested in writing some bill, and being the author of something that would work in this situation. Most doctors are disgusted with insurance companies, and would generally support some measure like this. The only one that would fight this and not be happy with this are the big insurance companies that are located here. And even though these people that represent these insurance companies have lots of money and connections in the capitol and politics, and influence...I don't think they could really object to such a bill like this without coming across as wanting to protect these doctors and their employees that are doing things that are unethical and plain out wrong.
Thanks for taking the time to read this. If you have any thoughts or ideas on something like this, feel free to let me know. I will keep everything confidential here.
Jim DeWees, CP
_________________________________________________________________
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I told them how I involved the employer in the matter, and within 2 hours after contacting the Human Resources director over the benefits, she had the precertification for the new leg. Once the leg was made and delivered, the insurance did not pay for the limb because they claimed that there was no precertification on file for this limb. I again contacted the HR person and she was totally confused and upset because she had a copy of the precert in her hands (as did I) and I had faxed her the denial for payment due to this non-existent precert. Again, within a couple of hours, she had the payment approved and in the mean time, I got a call from an insurance company rep that started off telling me that it was MY fault because there was no precert on file, and that I didn't follow their rules. I informed this person that I was glad that she told me that, because I have a copy of the precert in front of me, and also the HR person has a copy of it as well, and that I was doing everything I can possibly do to show this big employer how awful it is to work with this insurance company. I told her that this HR person had a copy of the denial, and that doesn't match the fact that she also has the precert as well. I told her that hopefully I will be able to convince other providers to do the same and always contact this person at this employer and swamp her with all these problems, and to a point where she will never sign another contract with this insurance company because of these numerous issues that she has to deal with. Hopefully I will help them lose this contract. With that comment, she just hung up on me. That gave me even more fuel and another issue to share with the HR person, that the rep from the insurance (and I have her name and thanks to caller ID, I have her phone number that came in...and the HR person knows the insurance person, that is her contact person), and when I told her that she hung the phone up on me, that made her even more upset with the insurance company and she said they were going to have a meeting about all these issues....and there are more issues than just mine, obviously.
Anyway, it seems to be a common story for all of us.
I also told these legislators that I had the name and address of the doctor that did the denial in the first place. He lives in Wisconsin and works in a large hospital in Milwaukee as an oncologist. There was no reason for this doctor to deny a claim like this, and this insurance company makes it more painful and awful to have to appeal this decision and go through all those hassles just to get the precertification for this device. AND, even after going through all this, getting paid is another issue and problem.
I explained to them that this doctor that made this decision has really damaged the life of this amputee. He is a professional and has a good job with this university. I is impossible for him to go to work since his job would not be wheelchair or crutch friendly. It also took a lot of time out of my life to fight for this patient just to be able to do my job and help him get back walking and back to work. There is NO accountability for this doctor, and it is even difficult to get a name of a doctor that does these denials. It took a little work and a couple phone calls to the insurance company, but finally I was able to get his name. Legally they are required to share the name of the doctor that approves or denies any claim.
I did manage to get this doctor's name and location, and from that I was able to Google his name and find out everything about this person. I was shocked to see that he works for a hospital, even a director of his area of the hospital, and yet this hospital has major problems with this insurance company. They had no idea that this doctor was employed and worked for the insurance company, and said it was a conflict of interest in their view. They said that they would have to talk about this during their next meeting for the directors and administration.
We talked about how I was getting information from other providers on denials they are faced with, and the names of the doctors that are behind these denials.
One thing we discussed was that maybe we need some legislation that would set some standard here for these doctors, and make it so that if any doctor was found to be making denials that are unfounded or questionable, and that really harmed or damaged the patient, then they would lose their license and ability to practice medicine in this state. And, maybe it would come to a point where many doctors were faced with investigations and impact their lives by taking so much time and energy and the stress of dealing with all of these claims that they are associated with, and make them decide that they don't have time to do this work, no matter how much money they got paid. And, as soon as some of these doctors lose their licenses, maybe other doctors would decide that they either need to make careful decisions on these claims and approve the legitimate ones, OR maybe they would decide that it is just not worth working for some insurance company that has some expected quota of rejections (which can't be proven at this point, but many former employees of these insurance companies have testified about these quotas and rules and the bonus plans based on the denials).
This discussion I had was to talk about the new parity bill, which we all agreed amounts to nothing, as I have already written about here a week or 2 ago, and how the Utilization Management is the enemy to the patient and the providers, and the bill still gives this entity the power and control of the benefits. I agree that the insurance companies do need some method or manner to control the claims and the fraud that can occur, but when it comes to situations like I showed them, when it is totally obvious about what the patient needs, there is no excuse or reason why the insurance companies can play these games and cause such a problem.
So, the end of the discussion was a good one, and hopefully some ammendment will come about and fix this bill like it needs to be fixed, and also some legislation and bill that specifies that the doctors that work for insurance companies can and will be held accountable for their decisions and actions that they make when reviewing claims or authorizing the treatments.
If Indiana can come up with some bill that will help the patients in this manner, then hopefully other states will see the need to have similar bills in their states. This could really make a huge difference in the manners and methods that insurance companies operate and handle these situations.
I also had a conversation with an Analyst for one of these BIG insurance companies that is located in Indianapolis (I had my 25th class reunion and just happened to bump into my old classmate and friend, and he happens to work for this company that is a constant problem here). I told him this story, and he was shocked and embarrassed by this. He knows my reputation and my passion for my work and being an advocate for amputees. He explained to me that it is all about money to them, and if they realize that they are spending more money with these rejections and having to look at the same claims over and over, and paying people to look at them again and again, and then finally paying them, then they will change their methods of operation. But, when they keep on rejecting the claims, a lot of offices just give up and write it off, and get over it. When this happens, it shows the insurance company that there is a significant amount of savings by putting the providers through more hassles. So, as soon as the providers keep on pressing for these claims, and keep on them until they are paid, and keep on fighting, then the insurance will realize that they are not saving any money and then things will change.
Also, if the insurance companies realize that doctors are afraid to work for them to sign these claims and deny them, for fear that someone will quesion them and challenge them, and that they might lose their license just in order to make bigger profits for these insurance companies, then they will hopefully decide that they need to improve their methods and play nicer with others.
This is all just me thinking and hoping that somehow we will see some improvements in this field.
If any of you have some crazy denials like the one I mentioned, that are CLEAR examples of patients getting what they need, PLEASE follow through and find the name and location of the doctors, and then post it here if you feel like doing that. I would really love to get any names of any doctors that worked here in my area, and I would make sure that the doctor was exposed for his/her other employment, and I am sure that he/she would at that point have some accountability for what they are doing. There are easy ways to assist in this kind of publicity on these issues. If they are doing decent and honest work, then they have nothing to fear or worry about. But if they are doing things like this doctor did in Wisconsin, then they need to answer for what they did. There is nothing illegal or unethical about any of this. Just making a phone call to the local hospital or any other kind of association where the doctor works, and letting them know that doctor so-and-so is also working for insurance company X, which has a bad reputation, or has had some really bad contract negotiation lately here....there is nothing wrong or inappropriate about doing that. They will definitely research this and make sure that this is true, and then might question the doctor about his/her association with this insurance company. Again, there is nothing wrong with doing that. But, going to some newspaper and having some big story written about this, and making some statements that might be questionable....that could be a bigger problem. There is some major risk of having your business destroyed if you offend the medical community where you work. But, depending on the doctor and his/her reputation in the area, that might not matter either.
Anyway, this is just what I am looking in to at this point, and something needs to happen to stop this decline that we are seeing in customer satisfaction and the ability to help these patients and amputees that need our services. These people I was talking to really seemed interested in writing some bill, and being the author of something that would work in this situation. Most doctors are disgusted with insurance companies, and would generally support some measure like this. The only one that would fight this and not be happy with this are the big insurance companies that are located here. And even though these people that represent these insurance companies have lots of money and connections in the capitol and politics, and influence...I don't think they could really object to such a bill like this without coming across as wanting to protect these doctors and their employees that are doing things that are unethical and plain out wrong.
Thanks for taking the time to read this. If you have any thoughts or ideas on something like this, feel free to let me know. I will keep everything confidential here.
Jim DeWees, CP
_________________________________________________________________
Reveal your inner athlete and share it with friends on Windows Live.
<URL Redacted>
Citation
Jim DeWees, “Meeting with legislators,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/229742.
