Yesterday’s post about Mass General’s mishandling (to be kind) of a woman’s procedure and reimbursement thereof elicited a thoughtful email from the former CEO of a major work comp insurer.
Here’s what he said (identifying details removed to protect the source).
I got in trouble early on with (the payer’s) UR staff and attorneys because (after giving them multiple direct orders to clean up pre-auth letters) I began directing them to pay for procedures they approved but later wanted to deny. They would simply say that the procedure was appropriate for the injury but NEVER check the claim to see if it was part of the approved injury. For instance, they would approve a shoulder surgery as medically appropriate but the injury was for a knee. Had they checked the claim they would have seen the shoulder was not covered. Regardless, the UR folks approved it in pre-auth and the surgery was done.
Only afterwards, when the bill came in and the claims rep denied it did UR look at the claim more closely and support the adjuster. UR’s excuse was that in very small lettering at the bottom of the page it said that we (the payer) may not be liable if blah blah blah. I told them that was execrable and to clean up the process and language. For too long, the UR department did not and so I made them pay the claims and docked them in their evaluations.
If the doc and the patient did everything they were supposed to and got an OK in writing I felt it was the carrier’s ethical and moral responsibility to pay regardless of what the lawyers said.
Hear hear.
I’m of the opinion that this happens more frequently than one might surmise, but these types of determinations are kept quiet so as to not motivate more requests for treatment on non-covered body parts/conditions.
I’d also surmise that many non-approved treatments get paid due to the lack of an automated electronic connection between UR and bill review/claims. This is also an ethical issue of high importance, as it is a failure to act as a responsible fiduciary.
What does this mean for you?
How does your company handle these issues, and how do you feel about that?