They will sue the doctors, claiming that if they coded the case differently or used some other form, the drug would be paid for.
When you get a drug for a patient that insurance doesn’t want to pay for, each hoop you have to jump through is smaller than the last one. That is to say, after each “no”, the next one up the line takes more time to contact, a longer explanation or more forms, until eventually (if they don’t give up) the time involved becomes unsupportable.
That’s for one patient. Two patients, three, five? Impossible.
But, the insurance company always has the out of saying, “The doctor did not follow our (impossible) procedure”.
Certainly a possibility ... but the insurance company does send out a denial letter to both the patient and the physicians office providing some documentation that would protect a physician against a lawsuit.
As a physician I have rarely felt concerned about a patient filing a lawsuit against me due to failed insurance coverage. The really critical cases I fight tooth and nail for and keep in contact with the patient every step of the way.
For the "optional" things I may not push quite as hard but still keep in touch with the patient- in general I find that most patients do not harbor fond feelings towards their insurance companies.
When you get a drug for a patient that insurance doesn’t want to pay for, each hoop you have to jump through is smaller than the last one. That is to say, after each “no”, the next one up the line takes more time to contact, a longer explanation or more forms, until eventually (if they don’t give up) the time involved becomes unsupportable.
That is certainly true. The most memorable one that I can recall was a patient of mine on Onfi for seizures where the insurance company denied the patient for refills and then referred me to the appeals division that had a 4 week turnaround. For safety reasons (concern of benzodiazepine withdrawal in a patient with medically refractory epilepsy) I had to change her over to another benzodiazepine. Clearly sub-optimal and potentially risky but discussed with the patient and came to the agreement that is was the only reasonable option under the circumstances.
That’s for one patient. Two patients, three, five? Impossible.
There does come a breaking point. Given the length of the time of appeals and the absence of enough time in the day.
But, the insurance company always has the out of saying, “The doctor did not follow our (impossible) procedure”.
Communication with patients and documentation provide some protection.