Bad Medicine is What I Don't Need
June 26, 2018 8:52 AM   Subscribe

My specialist physician has the chance to modify my diagnosis so insurance will cover my treatment. Initially, he did not modify it. What are the realistic possible consequences of having a claim denied? How will it impact future treatment?

I need IV infusion of a medication to treat x, which is caused by y. If Y didn't exist, X wouldn't either. Insurance covers the procedure, but the medication itself is only approved for FDA-approved treatments. FDA approved using it for Y, but not for X.

Doctor was given a chance by business office to add a note to my chart. He said the diagnosis is x, not y. Two social workers have told him he needs to change it or complete the paperwork to request specialty coverage from the provider of the medication. (it was either $2500 out of pocket or $25,000 out of pocket otherwise).

My concern is this. If the clinic requests insurance to cover treatment for x and they deny it, will that not increase the chance of future denials even if a doctor in the future lists Y as the primary or principal diagnosis?

My condition just exacerbated by stress. I'm really angry with the doctor. According to my research, changing the diagnosis to the condition that, upon further study, prompted treatment, is appropriate and ethical. You treat x by treating the underlying cause.

So basically I sent the doctor a message and said, if he is not interested in modifying the diagnosis based on further review of my file and the relationship between x and y conditions, then I need to wait for treatment until I get a second opinion. I haven't heard back.

Is there anything else I can do to advocate for myself? I was already planning to leave this doctor because he doesn't review my chart, walks in late after laughing with colleagues, and took a call from Comcast on his personal phone during my appointment, and didn't bother to tell me the upcoming iv treatment takes six hours. So I'm angry and ready to go, but was trying to get these treatments first, because my condition is pretty severe and needs to be treated.

What else can I do? Would complaining to the hospital customer service people help? They send complaints to the doctor and the doctor's bosses, and the complaints are used for performance evaluations. I don't think what I am asking for is unreasonable but I just don't know what else to do, and this condition is already going to require ongoing treatments so the last thing I need is for the process to get any hiccups in billing that could be used against me later. That is a thing, isn't it? I've always been healthy so I admit I don't really know whether health insurance denies and makes you fight harder for treatment in cases like this (where the initial introduction of the recommended treatment was linked to a diagnosis that doesn't have that protocol approved by the FDA) or not.
posted by crunchy potato to Health & Fitness (3 answers total) 1 user marked this as a favorite
These billing issues are common place and most likely won't be used against you in any real way, but that being said insurance companies are assholes by definition, and if he doesn't do the paperwork correctly, you won't get what you need.

Go ahead and schedule with another specialist and fight this out until you've seen the new doctor.

Then leave a grievance. Be detailed. Names of the Social Workers who intervened, times and dates. No one should have delayed treatment because the doctor won't correct the paperwork. It is patient harm and you are suffering due to his delay.

Call the office staff daily. It is OK, it's your health. If he did what needs to be done, you will leave them alone.
posted by AlexiaSky at 9:52 AM on June 26, 2018 [4 favorites]

To not abuse the edit function , you can do a grievance whenever you are comfortable doing so. My conflict resolution style is to leave and then complain, but if you have the tolerance to do the offical complaint (written, using hospital approved form ect) and then interacting with the office, do it.
posted by AlexiaSky at 9:57 AM on June 26, 2018 [2 favorites]

Update. The doctor modified the diagnosis. He's still terrible, but at least I can get these treatments before I start with a new specialist. I will be leaving a grievance after I go. He doesn't respect me enough to care so there's no point making things awakward before I leave but maybe it will light a fire under his butt to treat other patients better.
posted by crunchy potato at 5:00 AM on June 27, 2018

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