When health insurers play games, patients lose
A doctor jumps through numerous hoops to get UnitedHealthcare to pay for a patient's breast reduction — only to finally be told the surgery wasn't covered by her policy.
April 17, 2014, 4:50 p.m.
Dr. Theodore Corwin, a plastic surgeon in Thousand Oaks for the last 30 years, has had run-ins with insurers before, but never one so aggravating — and pointless — as this.
A 26-year-old woman recently came to his office complaining of back, neck and shoulder pain, as well as numbness in her hands and arms, resulting from her unusually ample bust. She's 5-foot-6, not overweight, Corwin said. She wanted a breast reduction.
"There seemed to be no question that her pain and numbness was caused by her carrying this excessive weight," Corwin told me. "It seemed like a straightforward diagnosis."
It wasn't, at least in the eyes of the young woman's insurer, UnitedHealthcare. Its response to both a policyholder and her doctor speaks volumes about the seeming priorities of our for-profit healthcare system.
"It's clear that there are some types of claims that are routinely denied," said Shana Alex Lavarreda, director of health insurance studies at the UCLA Center for Health Policy Research. "They might not even look at the policy until the doctor follows up."
Corwin said he contacted UnitedHealthcare after his patient's visit to receive authorization for the operation.
He heard back about a week later: The treatment wouldn't be covered.
Corwin said UnitedHealthcare wasn't convinced that the woman's condition impaired her ability to function normally. It wanted more evidence that her symptoms were related to her figure.
So Corwin drafted an appeal describing how the woman was unable to fully lift her arms, which affected her performance at work, and how she had difficulty carrying things because of the tingling in her hands.
He also included the results of an MRI showing a central disc protrusion on the woman's spinal cord — commonly known as a slipped disc — that appeared to be caused by the weight of her breasts.
"Neck pain, headaches and pain in the face, shoulders, arms and hands may be created when the disc protrusion presses on the neck nerves," says the website of Britain's Spinal Foundation.
"This may cause numbness or 'pins and needles' in the face, shoulder, arm or hand, and may also be associated with weakness of shoulder, elbow, wrist or hand movements," it says.
Corwin said UnitedHealthcare got back in touch to say it wasn't happy with the photos he'd sent in of his patient. It wanted new ones.
He had new photos taken and sent them to the insurer.
Finally, UnitedHealthcare made up its mind: The treatment wouldn't be covered.
But this time, the decision had nothing to do with questions of impaired functionality, protruding discs or unsatisfactory photos.
"They said the patient has a specific plan that excludes any breast surgery that isn't covered under the Women's Health and Cancer Act," Corwin said.
That 1998 law applies only to women with cancer who elect to have breast reconstruction surgery after a mastectomy.
Needless to say, it's bad enough that an insurer would include fine print like this in any woman's health coverage, not to mention that treatment would be denied for what appears to be a valid medical complaint.
But Corwin also was left wondering why UnitedHealthcare didn't just say at the outset that it had inserted this weaselly provision into his patient's insurance policy.
"I and my staff had to spend hours of our time over three weeks dealing with this," he said. "They put us through all these machinations for no reason."
Well, there probably was a reason.
Dr. Michael McGuire, a Santa Monica plastic surgeon and former president of the California Society of Plastic Surgeons, said insurers are prudent to closely examine claims for breast reductions. Not all are for medical reasons, he said.
But McGuire said it seems that most insurers deny first and ask questions later for this and other procedures, gambling that doctors won't have the patience or persistence to run a bureaucratic obstacle course.
"It's a game for them," he said. "They know that if their denials and demands for more information take up a lot of staff time, most healthcare providers will give up or not make the effort."
McGuire commended Corwin for going the extra mile for a patient. "Most practitioners won't go that far," he said.
The main issue here is whether UnitedHealthcare even bothered to read its own policy before it started issuing denials. McGuire said insurance-company workers often skip — or are instructed to skip — such a time-consuming task
Claire Brindis, director of the Philip R. Lee Institute for Health Policy Studies at UC San Francisco, said what happened in Corwin's case could have just been human error — or "an insight into the adversarial relationship that can exist between insurers and healthcare providers."
Matthew Yi, a UnitedHealthcare spokesman, declined to go into detail about the company's procedures. He said only that "medical necessity and an individual's policy is quickly reviewed" whenever a doctor inquires about coverage.
Obamacare takes some modest steps toward fixing things. By standardizing some policies, it makes coverage more transparent for people who purchase insurance through the program.
But the reform law doesn't go far enough.
"We should have complete standardization of insurance," said Alain Enthoven, a health economist at Stanford University. "This would eliminate questions of what's covered and would make it much easier for people to shop for insurance plans."
At the very least, there should be a requirement that insurers read the terms of policyholders' coverage before making any decisions about treatment. It's deeply troubling that a conversation about people's healthcare would transpire before such a basic step has been taken.
And if an insurer can be shown to have made decisions without first consulting a policy — as seems to be the case with Corwin's patient — the insurer should be required to cover any medically valid claims that may not be covered.
"If this was a slipped disc that didn't involve her breasts, there's no question that UnitedHealthcare would cover her treatment," Corwin said. "But because it involves her breasts and because of the way they wrote her policy, they won't cover it. They're just telling her to live with the pain."
Corwin said the woman will likely pay about $8,000 out of her own pocket to fund the procedure.Back to News »