Dr. Denial and Dr. Decline

Recently, 60 minutes did a special on a topic that seems to get little attention—insurance company coverage denials. 60 minutes focused on patients with mental health issues who have the potential of hurt themselves or others and been admitted to long-term care facilities.  The story uncovers the decision making process insurance companies go through in determining the level of care a patient needs and whether they will approve the payment.

Generally, a patient who is admitted to a long-term care facility will be evaluated by their primary doctor who will determine the level of care and course of treatment a patient requires. That determination is then submitted to the patient’s insurance company for approval. Shortly thereafter, the primary care doctor is contacted by another doctor—who is employed by the insurance company—to evaluate the recommended course of treatment and determine whether the planned treatment will be covered.

According the 60 minutes, some of these “evaluation” doctors have denial rates of 95 to 100 percent and most of these denials come with strong objections from the primary treating doctor citing the safety and well-being of the patent or society. Essentially, these “evaluation” doctors can overrule the primary doctor even though they have never evaluated the patient themselves.

Although the special focused primarily on the mental health aspect of this issue, long term care insurance denial affects a broad area especially when any type of litigation is involved. The attorney’s at Wooten Kimbrough are familiar with these “evaluation” doctors and have extensive experience dealing with them in trial.