Sunday, December 14, 2008

Medical Necessity

One of the precepts in getting your claim paid is the idea of medical necessity. Absent state mandates to the contrary, items covered by your health insurance policy involve treatment that is medically necessary.

Performing CPR on a heart attack victim is a medical necessity.

Having a plastic surgeon enhance your breasts is not.

Suturing a bleeding wound is a medical necessity.

Removing a tattoo is not.

But what happens when you ask your doc to induce labor so you can deliver before your insurance runs out?

Starla Darling was just days away from giving birth to her second child. The 27-year-old mother from Polk, Ohio, had a well-paying job with good health insurance at the Archway Cookie plant in nearby Ashland.

But during a visit to her parents' house, Darling received news that sent her into a panic. A neighbor, who also worked at Archway, told them the plant was closing and their health insurance was ending two days later.

Under normal situations COBRA would be an option. But the plant was filing bankruptcy and the group plan terminating. This eliminates the COBRA option.

But there could have been other HIPAA options. Perhaps Hank will enlighten us on options in Ohio.

"I flipped out," Darling said. "It was five minutes after she told me, I was on the phone with the doctor," Darling said. "I told her, 'I need to be induced.'"

A few hours later, Darling was in the hospital. The next day, she had to have an emergency C-section.

Inducing labor is sometimes done when the baby is overdue, or if the babies life, or the mothers life is in jeopardy.

Based on the information in the news article, none of these situations seem to have existed.

After the mad rush to give birth to baby Kathryn, Darling got some more bad news. A bill for nearly $18,000 arrived from the hospital. Even though Darling gave birth before she says she was told her insurance was supposed to run out, the company denied the claim.

The EOB would explain why the claim was denied. Of course it would be too easy for the reporter to do their job and enlighten us.

Instead it would appear that the claim was denied due to lack of medical necessity.

Darling applied for Medicaid while in the hospital. In many states, including Ohio, Medicaid covers medical expenses in special circumstances, such as pregnancy, if the expenses were incurred up to 90 days before the date of application and if eligibility requirements are met.

So you can apply for Medicaid and, if approved, include charges incurred up to 90 days prior. Why would anyone want to act responsibly if they can get the taxpayer to pony up and pay their bills?
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