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  • Writer's pictureKathryn Bruns, CPA

Medically necessary? Depends on who you ask.

Oh, the healthcare system we have here in the U.S. (sigh). I generally remain pretty passive about many things that others enjoy debating and arguing about, but being forced to navigate our healthcare system is just something that I cannot avoid, and it pushes ALL OF MY BUTTONS.

I have recently spent hours sorting through another healthcare mess with respect to my daughter, but I am not going to write about the specifics today. I just want to make others aware of my opinion on what you need to be aware of to protect yourself. This is important because it impacts your health and your family's health. Life or death stuff in some cases.

Our healthcare system involves a lot of different parties, all who have competing priorities, so the whole thing becomes a power struggle and a game of chess. Here are the priorities of three of the parties:

Insurance Company: Primary Goal: Money in their pocket.

Secondary Goal: None

Service Provider: Primary Goal: Earning what they believe is the market value for what they do. Secondary Goal: Helping others get and stay healthy

Patient: Primary Goal: Getting and staying healthy

Secondary Goal: Getting Insurance Company to pay as much as possible and/or the Service Provider to accept as little pay as possible

As you can see, if I am correct in my assessment of things, the system is a big mess. Every time I, or my daughter, has to undergo a procedure or get some kind of healthcare service that is beyond the routine checkups, I cringe, because if I don't play this game correctly, I will lose.

Here is a typical example of how this plays out...

Patient is experiencing an issue that is negatively impacting her health. If she ignores the problem, the issue can likely fester into a bigger problem down the road. Patient tries to do the responsible thing and nip the problem in the bud. Patient sees a specialist on the matter ("Service Provider") and the Service Provider believes Procedure X would fix the problem. Service Provider knows that if the Patient pays for Procedure X out-of-pocket, they can get more money than what the Insurance Company will pay them to do Procedure X.

Service Provider, as a first pass, tells the Patient that the Insurance Company will not cover Procedure X because it is not going to be deemed "medically necessary". Patient has a brain, and therefore knows the dictionary definition of "medically necessary". Service Provider tells the Patient that the Insurance Company does not define "medically necessary" the way normal human beings do (to be fair, the Service Provider does not say this literally, but may as well have). The Insurance Company's version of "medically necessary" is instead something akin to "never necessary". The Patient tells the Service Provider that they intend to fight with the Insurance Company if needed, to get Procedure X covered. Patient wishes that the Service Provider was motivated to help the Patient convince the Insurance Company that Procedure X is "medically necessary". Service Provider is not motivated. Patient is annoyed. Service Provider is annoyed. Insurance Company would be enjoying this so far if they were a fly on the wall.

As a second pass, Service Provider tells the Patient that Procedure X must be done "right away", that there is no time to jerk around with the Insurance Company for what could be weeks or months in appeal. Patient points out that the Service Provider's urgency is indicative of "medically necessary". Service Provider says "no it isn't". Patient scratches her head. Patient and Service Provider are beginning to go beyond mere annoyance, and Patient walks out, telling Service Provider she must think about what to do next. Meanwhile, Patient must balance a health issue possibly festering, with trying to move forward in meeting her Primary and Secondary Goals. At the end of a day, Patient puts together a strategy to ensure she gets Procedure X done with as little out-of-pocket cost as legally dictated in her contract with the Insurance Company. The strategy must also consider if Service Provider has been alienated to the degree that it may make sense to have Procedure X done elsewhere. Insurance Company is now annoyed at the "difficult" patient that is trying to thwart their Primary Goal. EVERYONE IS PISSED OFF !

Personal Affairs Stewardship is VERY GOOD at this game. Owner Kathy Bruns CPA can make sure you, as the Patient, pay as little out of pocket as possible under your health insurance contract while getting your healthcare needs met. Don't let the Insurance Company's attempt to meet THEIR Primary Goal come at YOUR expense !!

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