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Alarming court decision for Alabama, Georgia, and Florida. Insurance gets last say, not doctor

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madfloridian Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 12:04 AM
Original message
Alarming court decision for Alabama, Georgia, and Florida. Insurance gets last say, not doctor
in the Medicaid plans in those states according to an appeals court. This is just shocking to me.

Hat tip to FLA Politics blog for this article.

"State-run insurance plans for the poor and disabled can't be forced to pay for a treatment if they disagree with a doctor over whether it's necessary, a federal appeals court ruled Friday."

Sicko

The decision from the 11th U.S. Circuit Court of Appeals said state Medicaid officials can't be excluded from determining the care of a 14-year-old Georgia girl who suffers from near-daily seizures. Her mother filed a lawsuit after the state cut the number of hours the girl was seen by a home nurse.

The ruling applies to Alabama, Florida and Georgia, where health-care advocates fear it could allow state health agencies to overrule doctors' reccomendations. They also worry it would allow for-profit Medicaid contractors to decide on treatments based cost instead of health needs.


More from the article from Tampa Bay Online

Court says insurance plan has final say in treatment disputes

MIAMI - State-run insurance plans for the poor and disabled can't be forced to pay for a treatment if they disagree with a doctor over whether it's necessary, a federal appeals court ruled Friday. The decision from the 11th U.S. Circuit Court of Appeals said state Medicaid officials can't be excluded from determining the care of a 14-year-old Georgia girl who suffers from near-daily seizures. Her mother filed a lawsuit after the state cut the number of hours the girl was seen by a home nurse.

The ruling applies to Alabama, Florida and Georgia, where health-care advocates fear it could allow state health agencies to overrule doctors' reccomendations. They also worry it would allow for-profit Medicaid contractors to decide on treatments based cost instead of health needs

Anna Moore's mother, Pamela Moore, sued Georgia Medicaid in 2007 after she was told they were cutting the number of home nursing hours from 94 to 84 a week. The teen, who suffered a stroke in utero, attends school occasionally, but often requires medical intervention because of the strokes and frequent breathing problems, Atlanta Legal Aid Society attorney David Webster said.

Florida and Alabama joined Georgia in fighting the lawsuit, citing a federal regulation which allows them to limit service based on "medical necessity."


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Solly Mack Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 12:07 AM
Response to Original message
1. K&R
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Political Heretic Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 12:21 AM
Response to Original message
2. Problems with state-care as well.
It's important that any sort of government health care be subject to strict policy on service provision and that individual states NOT be allowed to weaken it.
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ProgressiveProfessor Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 08:34 AM
Response to Reply #2
10. What would be the hammer to keep them in line and provide requried resources
The horrors stories that are spread widely of delays and the gov hiding their poor performance WRT state run health care in the UK and elsewhere are often dismissed here as isolated instances, but they are happening.

If you want a parallel case looks at Special Ed court case in Hawaii which took years to drag through the courts and then was fought by the teachers unions.

Not saying what we have now is perfect, but at least the gov can go after the insurance companies, since we know it will rarely if ever go after itself, and never effectively.
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MadMaddie Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 12:45 AM
Response to Original message
3. So it's the Insurance companies not the Government getting
Edited on Sun Apr-26-09 12:46 AM by MadMaddie
between patients and their drs.....hunh I wonder how the Repugs could have gotten it so wrong?:sarcasm:

Dammit...my enter button got stuck...my bad....





















































































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ThomCat Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 01:17 AM
Response to Original message
4. This is going to be just the start.
If insurance companies are able to do this and get away with it then it will become standard policy to make decisions based on cost. If they now they can overrule doctors then they will. Their profit will always come first.

Some finance director will be put in charge of implementing this as a cost cutting measure and it will be "just business," of course they have the best interest of the patients in mind but they have to run an efficient business too.

Somehow cutting cost will always come out on top because that maximizes profits.

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KT2000 Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 02:13 AM
Response to Original message
5. Office clerks
are entirely qualified to make medical decisions. They know what is best for all of us.
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Dirty Hippie Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 08:23 AM
Response to Reply #5
8. For the sake of accuracy
The medical determinations (at least in Florida) are made by case workers who are nurses and physicians. Their job is to make sure as many as possible are served given a fixed pot of money.

We are not talking about medically necessary treatments, but those services that are not normally covered by medicaid.

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Delphinus Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 03:53 AM
Response to Original message
6. Not good.
Kick the freaking insurance companies to the curb!
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Egnever Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 04:34 AM
Response to Original message
7. Misleading
"Both the state and Moore's physician have roles in determining what medical measures are necessary to "correct or ameliorate" Moore's medical conditions," according to the ruling. The case was returned to district court for a rehearing."

The court ruled that the states physicians get to review the case as well and give their input, then they kicked it back to the original court to decide the merits of the case.

There has to be some sort of barrier to abuse or there will be people getting liposuction and breast implants on the states dime because their doc says its needed for their health.

they didn't in any way say that the insurance company gets to determine whats necessary only that they get a seat at the table in the decision. Yes this can and likely will be abused but it would be abused were they to say the state has no say in it as well.

there is no mention of the weighting of either sides opinion in the ruling other than the writers opinion of what it means.

I would love to see the actual ruling.
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madfloridian Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 12:11 PM
Response to Reply #7
13. "State-run insurance plans for the poor and disabled"
It is their insurance source. These companies, whatever you want to call them...state, insurance...will get the final word over the poor and needy perhaps.

SO in reality it is not misleading. It IS their insurance.
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D-Lee Donating Member (457 posts) Send PM | Profile | Ignore Sun Apr-26-09 08:32 AM
Response to Original message
9. A State Medicaid rule was applied -- not really an "insurance" issue
Medicaid runs by service menu listing adopted by each state, which varies from state to state. With the budget problems of state governments, cut backs in what is covered is something likely to be seen in many instances.

Further, even Medicare permits declining compensation for treatments found not to be "medically necessary."

This is not an issue regarding private insurance plans.

Not in favor of the policies, just saying for information purposes ...
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ProgressiveProfessor Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 08:36 AM
Response to Reply #9
11. So you are saying that the state run health care denied her what the doctor said was needed
Edited on Sun Apr-26-09 08:36 AM by ProgressiveProfessor
This is not going to sit well with the rest of the thread
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madfloridian Donating Member (1000+ posts) Send PM | Profile | Ignore Sun Apr-26-09 12:10 PM
Response to Reply #9
12. "State-run insurance plans for the poor and disabled"
The article used those words. That IS the insurance plan for Medicaid people...it is just about all they have.

The "state-run" insurance plan gets to have the final say.

You can be technical, whatever.....the patients are getting screwed by their "State-run insurance plans for the poor and disabled"
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Mithreal Donating Member (1000+ posts) Send PM | Profile | Ignore Mon Apr-27-09 12:39 AM
Response to Original message
14. Kick nt
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