drz
Well, my answer is the same—you owe the bill—unless you get really, really lucky. I have to say that I agree with you in large part. Most facilities these days have Utilization Management Departments and knowing what your insurance will and won’t cover is precisely one function of the UMD. Not to mention that their insurance department will probably have done multiple checks for general health plan benefits. Although your original post does not state the exact reason for the denial, if it is because DME is not covered at all, the hospital would likely have had that knowledge beforehand. If it is a medical necessity issue, they would not. Now, to let their UMD back off the hook, being an overnight stay, this device was likely ordered and utilized prior to the UMD having any knowledge of it. I will also take the same shot at your payer’s UMD. I am an RN working for a payer entity and our UMD specifically asks for disclosure of any equipment such as you describe prior to its utilization. It doesn’t always happen, but we ask. Lastly, and I think pretty important, most big payers—including Medicare—consider mechanical type cold therapy devices investigational / experimental and do not cover them (will vary by type of device and payer). And that is definitely something that your provider facility and physician are going to be aware of. (Physicians most definitely have good working knowledge of covered services in general as well as knowledge of devices such as this.) I feel pretty sure that the provider would have had numerous denials on these devices before. Mechanical active/passive cold / compression therapy devices have not been proven to be any more effective than standard ice packs with compression therapy and therefore, the expense is not considered medically necessary (and I’m betting the basis of the denial—you’ll lose an experimental / investigational appeal 99% of the time). If that is the case, for all the good it will do, argue it with the provider. But, there is still no obligation for them to make a prior authorization request and they can certainly require you to pay them.
Although I routinely preach being knowledgeable of health plan benefits and being a smart user, this is one time I think that the patient was a sitting duck. (Please follow cbg's advice, but health plans are rarely going to list every specific device / service or even category that is ineligible, which would probably have been necessary in an instance such as this may have been.) Again, I do not know why the payer denied, but the provider should damn well have asked for a prior authorization because of the very status of these devices in the industry. (And, had they done that, they would have learned of the ineligibility regardless of the reason.) Why would any patient lying in a hospital bed being provided a device believed to be necessary even think to question it at that point in time? Is anyone going to refuse treatment and say “wait let me call my insurance company?” Lastly, to address the issue of a $100,000.00 device—I guarantee the provider would do a prior authorization on a device of that expense since an amount that large would not be deemed collectible from the patient. This $450.00 device would be deemed an amount collectible from the patient and not worth their time to check on. If you want to take a $20.00 or $30.00 long shot, there is always the possibility that your physician ordered you an “ice pack” and through ordering error (that’s extremely common in facilities) or even perhaps personal preference of the nurse, this thing was provided to you instead. Ask the facility to provide the physician’s order page/s of your record. Ask specifically & only for those pages to keep your cost down. If an "ice pack" was ordered tell them to stuff their $450.00. If you do get those pages and find a mechanical device was ordered, try to find out which one and then research its current status from the payer’s viewpoint before making an argument to the provider.
One more thing. Physicians and any health care providers are 100% supposed to be patient advocates—and that includes the patient’s pocketbook. In a situation where a less costly alternative exists that is just as or more effective, it should be utilized. EVERY health care provider has an ABSOLUTE ETHICAL OBLIGATION to provide cost effective care. Regardless the reason for the denial of the DME, a $2.00 ice pack with a $10.00 ACE bandage was a better alternative and Standard of Care. A physician’s or provider’s lack of being a party to the specific health plan does not relieve him of that ethical obligation. Period. It’s just too bad most facilities and providers worry much more about their own pocketbooks to effectively advocate in this area. The patient cannot be expected to know or question the medical necessity of every service or anticipate what services will be utilized beforehand. That is the provider’s responsibility to explain it thoroughly and provide treatments that are Standard of Care. The providers had the knowledge here and drz’s $450.00 cost could & should have been avoided. Drz’s frustration is understandable and I daresay that unless one is a medical professional with intimate knowledge of both treatments and health insurance plans, anyone could find himself a sitting duck when providers fail their ethical responsibility.
Good luck to you, drz. lkc15507
