I’ve observed the incessant complaints on various cancer blogs and discussion boards about BC/BS "denial of coverage" on the backs of injured and diseased human beings during their fight with the great crab.
In one case, the patient was denied a CT scan. As the poster said, "because BC/BS is practicing medicine and deciding that such a thing is not medically necessary." Without the CT scan, there was no way for the doctor to definitively tell if a swollen leg is cancer related or a blood clot. The physician couldn’t make a diagnosis based on the best available technique to make that diagnosis.
Another poster presented the case that BC/BS used to cover Pet Scans. Unfortunately, some study came out stating that Pet Scans aren’t more effective than CT Scans to find colon cancer. With that one study, BC/BS had decided not to cover the Pet Scan, even against the physician protest.
And one more described their situation while fighting prostate cancer that had metastasized to the hip bones, and a clinical trial using hormone therapy and Helical Tomo Therapy was looking to be the best opportunity to fight the cancer. The studies showed that is was really helping people with bone cancer, as it is very precise treatment that does much less damage to surrounding tissues. However, BC/BS had denied covering the Helical Tomo Therapy treatment. They said it was just too expensive and the hormone therapy should be enough for the patient.
These are just a few of the numerous complaints happening across the United States. I thought this was only a problem with reimbursement for cell culture assay tests. But it seems to be happening across the whole spectrum of diagnostic and lab tests.
One poster goes on to say, "It would appear to me that we in the USA are rapidly closing in on having all of the drawbacks of socialized medicine, with none of the purported benefits. It is partly privately financed, but the controls are given over to remote bureaucrats who determine who shall live and who just isn’t worth it."
In 1994, Blue Cross of California supported tumor cell drug resistance testing. It can improve results when the tests are used. California Blue Cross used to cover it when California Blue Cross was non-profit. Then they were taken over by Wellpoint, turned into a "for-profit" and abruptly without explanation stopped paying for it. I guess they had to show some kind of profit maximization for their corporate executives and shareholders by denying some coverages. However, numerous people have appealed their cases in small claims court and won (even one in superior court).
The Blue Shield of California Medical Policy Committee on Quality and Technology, in a meeting on March 2, 1994, unanimously accepted the validity of cell culture drug resistance testing. The official Blue Shield of California conclusion was drug resistance testing in oncology was accurate and reliable. The information can affect clinical decision making and can lead to the avoidance of ineffective and potentially harmful chemotherapeutic agents. There was sufficient published data to determine their safety, clinical utility, and impact on clinical decision making.
As Medicare contractor National Heritage Insurance Company (NHIC) found out in 2006, cell culture drug sensitivity testing was merely a point a little farther along on the very same continuum upon which resistance testing resides. This was one of their reasons for reimbursing coverage for both drug "resistance" and drug "sensitivity" testing beginning February 28, 2007. They (and the previous Medicare contractor) were paying for drug "resistance" testing since December 2000.
At injuryboard.com, editor Brent Adams said, "in recent years, insurance companies have become more and more involved in the practice of medicine by trying to dictate to doctors the procedures they should give to their sick patients and the fees for those services. Doctors complain that they cannot practice medicine independently and are hampered by insurance companies who look over their shoulders and dictate how they should practice medicine."
A group of Miami, Florida doctors sued twenty-three Blue Cross and Blue Shield Plans, as well as the Blue Cross and Blue Shield Association, because they alleged they had been systematically cheated by these insurance companies when the doctors filed claims for medical services.
It’s an interesting thing about outside of Medicare. Are BC/BS and the other private insurers practicing medicine? I thought that’s what physicians were for?
Reference to the injuryboard.com:
Reference to the discussion board postings: