Another Denial: The Good Fight Update

I received word from my mom yesterday that the insurance company denied her request for pre-approval again, so no surgery this week. Perhaps most infuriating is that they claim there isn’t an appeal process for pre-approval—that she should go ahead and have the surgery and appeal their decision afterwards. My issues are as follows:

Item, the first: It is difficult to believe in the nonexistence of an appeal process. If pre-approval is required for non-urgent procedures, I think they are obligated to provide a process for appealing unfavorable decisions. Then again, that assumes a large measure of reason and fairness, which seem inapplicable to the insurance game.

Item, the second: This entire experience highlights the ways in which our healthcare system is lacking in integrity. Things would be just swell if everyone had the same assets and access, but falls short in our present, dingy little reality. The suggestion that she go ahead with the surgery and appeal later is laughable—this is a $40,000 procedure. If she had assets such that it didn’t really matter whether it was covered or not, the appeal probably wouldn’t matter as much. It would still be a lot of money to pay out of pocket, but not prohibitively so.

Item, the third—a continuation of the second: It’s sad that she’s probably going to end up paying a tidy sum in legal fees to prove that she’s in the right. Again, a system lacking in integrity (please hold any and all jeers at my chosen profession until the question and answer period at the end of the sermon, thankyouverymuch). You have to pay to play, and there’s no playing on your own. This simply isn’t a problem that can be solved with a little diligence and phone work (though even if it were, she’d have a tough time with the phone part). It seems pretty clear that nothing positive is going to happen without a little (big?) push to compel such action—probably in the form of little white papers wrapped in blue. Oy.

Item, the fourth: I’m uncomfortable with the fact that my mom essentially needs to prove why she deserves better hearing. People, she’s damn near deaf and she’s a professor….isn’t this pretty plainly clear? Am I just biased because it’s my moma? I think not.

This whole thing is making me think very, very seriously about patient advocacy law.