Tick Bites and Insurance Companies
This story in the Washington Post exemplifies why our healthcare system is so screwed up and why Direct Primary Care is needed. If you read it, you will realize how ridiculous the whole thing is.
Leah Kovitch was pulling invasive plants in the meadow near her home one weekend in late April when a tick latched onto her leg. She did not notice the tiny bug until Monday, when her calf muscle began to feel sore.
A tick bite is responsible for making the lady’s calf sore? Hmmm. After two days? Nope. Serendipity. She worked in her garden, pulling invasive plants.
She made an appointment that morning with a telehealth doctor — one recommended by her health insurance plan — who prescribed a 10-day course of doxycycline to prevent Lyme disease and strongly suggested she see a doctor in person. So, later that day, she went to a walk-in clinic near her home in Brunswick, Maine.
No rash. No information that the tick was engorged with blood. She gets an insurance telehealth doctor (I seriously doubt it was a doctor, but I digress) to give doxy. Ok, an aggressive call, but maybe the “doctor” asked the right questions. This lasts a few hours until the lady has to see a doctor in person. Over a tick bite? Boy, she really gave the doxy a chance to work.
It’s a good thing she did. Clinic staffers found another tick on her body during the same visit. Not only that, one of the ticks tested positive for Lyme, a bacterial infection that if untreated can cause serious conditions affecting the nervous system, heart and joints. Clinicians prescribed a stronger, single dose of the prescription medication.
Oh my goodness, another tick on her body!!!!! That’s outrageous. Get the ICU bed ready. Oh, and I know of no doctor or clinic who would EVER test a tick for Lyme’s disease. Yet, and I am trying hard to stop laughing, this clinic was able to test that tick immediately and find it positive for the bacteria. And what single-dose medication is better than the ten-day dose of doxy? Yeah, they probably gave her doxy again. Remember, this is all about calf pain. Most symptoms of real Lyme disease NEVER start in 48 hours.
But Kovitch’s insurer denied coverage for the walk-in visit. The reason? She had not obtained a referral or preapproval. “Your plan doesn’t cover this type of care without it, so we denied this charge,” a document from her insurance company explained.
Something tells me that someone is lying. I thought the “doctor” told her to go to the urgent care for some unknown reason? Wouldn’t that be in the telehealth EHR notes?
Health insurers have long argued that prior authorization — when health plans require approval from an insurer before someone receives treatment — reduces waste and fraud, as well as potential harm to patients. And while insurance denials are often associated with high-cost care, such as cancer treatment, Kovitch’s tiny tick bite exposes how prior authorization policies can apply to treatments that are considered inexpensive and medically necessary.
We can all agree that health insurance companies are evil and suck. But was this lady’s treatment (going to an urgent care) really medically necessary? Of course not.
Kovitch’s bill for her clinic appointment was $238, and she paid for it out-of-pocket after learning that her insurance company, Anthem, didn’t plan to cover a cent. First, she tried appealing the denial. She even obtained a retroactive referral from her primary care doctor supporting the necessity of the clinic visit.
So, $238 gets you a Washington Post story? They have no other stories to write about? And what primary care doctor would do a retroactive referral? Why wasn’t her primary care doctor involved in the beginning? That doctor would have gotten the initial phone call instead of the insurance telehealth “doctor.” That doctor also could have seen her in the clinic that Monday, but nope, it didn’t happen in the broken fee-for-service system.
Meanwhile, in October, Anthem sent Kovitch an updated explanation of benefits showing that a combination of insurance company payments and discounts would cover the entire cost of the appointment. She said a company representative called her and apologized.
In early November, she received her $238 refund.
Wait, she got her money back? Then what was the whole story about? I’m really confused.
The article was called, “One woman’s tick bite sets off fight over insurance and prior authorization. The case of one Maine woman shows how prior authorization rules can block coverage for even simple, medically necessary care.”
In reality, it was a nothing burger.
Listen, I hate these insurance companies like the next person, but they need to show real heartbreaking cases where these companies play with people’s lives and screw them over. This one isn’t it! You can read all the discrepancies and poor care I listed above.
Now, if this lady had a Direct Primary Care doctor, then it would have been settled without the insurance involvement at all. And this story wouldn’t have been written. The DPC doctor would have knowledge of the patient, including, most importantly, all her psychopathology, and would have talked her down from seeing an urgent care. She would have come into the DPC clinic that Monday, and once again, her DPC would have spent time explaining how the first Rx of doxy would still be working fine. End of story.
Direct Primary Care is the fix for 90% of our healthcare woes. We don’t need insurance companies to be involved with tick bites. We only need health insurance for catastrophic issues, so you don’t go bankrupt for a major medical illness. DPC + HSA + some type of very affordable catastrophic plan is the answer.
