What is up with insurance?

[ark-two]

I had a patient with extensive cardiac history. He came in with symptomatic brady and developed tachy-brady syndrome. The cardiologist wanted to place a ppm/icd due to active lifestyle and cardiomegaly. He went to surgery at 5pm and did not come back until 9pm. Doesn't usually take that long for ppm. I asked the family what happened because nothing unusual was given in report. The cardiologist had to fight with the insurance over the ICD. Their insurance only covered one major surgery every three months and he had stents placed last month. Now in three months he has an appointment for icd placement. I realize that the icd is not mandatory for him like it is in some patients, but come on!:angryfire

[RN12345656]

Doesn't sound right to me. I don't consider a PPM/AICD major surgery. It is a procedure that takes a couple hours. When did the cardiologist actually start? The pt could have been waiting for the cardiologist. Happens all the time from case to case. Then, the staff recovers the pt before returning to the floor. It is typical to have a 4 hr turn around.

I do know that insurance will not pay for a AICD just b/c the pt is getting a PPM. There are perimeters for insurance to pay for the ICD. I know the pt. must have poor ventricular dysfunction with associated rhythm disturbances, ie: VTACH, VFIB.

I actually had a pt who had a BIVPPM whose EF was 10%. Insurance did not pay for an ICD initially. The pt coded on me. I had just assessed the pt, left the room to chart. About 15 mins later I heard a LOUD BOOM. Ran to the room to find him face down. He was unresponsive and without a pulse. Long story short...shocked him twice on the floor. He was in Vfib. Needless to say, the insurance company paid for an ICD.

[SEOBowhntr]

Insurance is a scam in many cases, but so too are doctors. I've seen many patients who had a "suspected" run of VT, often times reperfusion ectopy, and then had nothing for days afterwards, and were still sent for EP studies. And when there was nothing reproducible, there was an ICD placed anyhow because of the history of VT. One having been a co-workers father, who just went ahead and did "everything" is doctor said. Now at the same time, I've seen very few patients with BiVPM who didn't have some ectopy, and wouldn't have been candidates for an ICD were they to desire one.

Continuing, I have a friend who used to work for one of the larger HMO's in the country who said that they would regularly refuse a % of charges for miscellaneous stuff such as labs, because often times the Dr.'s office would spend more trying to justify why the lab needed done than it would to just eat the cost, so they saved millions each year just hap-hazardly refusing to pay some charges. Now that is VERY SAD.