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Re: [IP] Kaiser Permanente

Darlene <email @ redacted> wrote:

> How can a insurance company deny coverage for medical devices/supplies 
> ordered by a doctor rx.
> Who is doing the doctoring - insurance company or medical professionals?

This is the trend in all HMOs (not starting with Kaiser, strangely enough).  They are finding that it is more cost effective (which is the way the insurance companies think) to simply allow what the doc ordered rather than question.  

The whole matter of pumps is in flux because the HCFA/Medicare regulation change went into effect yesterday -- that is, as of yesterday, April 1, Medicare will pay for pumps in type 1 diabetics.  Insurance companies are pretty much following that lead for most patients, but since children rarely qualify for Medicare, there are few rules to follow.

I guess my question is whether the pump was ordered by an endocrinologist or by the pediatrician.  In any case, I think Kaiser policy is that both primary and endo have to agree.  The most effective way is to *educate* those who don't understand how a pump can be used by children.  And this will take some delving into scientific literature, and, unless one has the resources to do so, it can be a rather daunting task.  OTOH, both MiniMed and Disetronic have experts in the field and can supply you and your doctors with the literature needed.  Once we know they have the literature, then keep on them until they *read* it.  Once they realize you are serious and you aren't going to go away, they'll change.  

Jim Handsfield
mailto:email @ redacted

The opinions expressed are mine and do not necessarily reflect those of my wife who runs this house and makes more important decisions than I do.

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