To: Lily Tyson, Chief Health Insurance Bureau
NJ Department of Banking and Insurance
Re: Horizon BCBS discrimination
Dear Chief Tyson,
This letter is to make you aware that Horizon BCBS and its affiliates are harming a patient with their precertification, prior authorization, appeal and denial of services processes. The patient indicated below has diabetes and multiple medical conditions, which he diligently and routinely follows up at our office. For the past three months, the patient and I have aggressively pursued a continuous glucose monitoring device to assist both of us in getting his blood glucose under best control.
Despite the fact that the patient and I agree on this, Horizon BCBS and its affiliates have denied the patient this medically necessary item. Further, while the Endocrinology Society, The American Association of Clinical Endocrinologists and the American diabetes association clinical societies all recommend continuous glucose monitoring for best management of diabetes Horizon BCBS and its affiliates insist on harming the patient by denying him this medically necessary tool.
Furthermore, Horizon BCBS medical directors have denied this patient the necessary medical monitoring device, thereby potentially causing their insured harm, and may be liable as they are making care decisions and denial of care decisions for the patient.
- Do they have the patient’s informed consent to make care decisions?
- Are they licensed physicians in NJ?
- What is their malpractice coverage for this activity?
- Are they specialty trained in endocrinology?
- As employees of Horizon BCBS, do they have a conflict of interest?
Horizon BCBS precertification, prior authorization, appeal and denial of service processses are harmful to both patients and physician providers of medical services. Please put Horizon BCBS on notice to case and desist making clinical care decisions for patients through their onerous and harmful money making processes. This is especially critical in light of the pending NJ law that would mandate the purchase of insurance products like those offered by Horizon BCBS.
Craig M. Wax, DO, Family Physician
DPC physicians and patients take note!
An aspect of Alexander-Murray will exacerbate an under-appreciated flaw in ACA requirements for plans considered “catastrophic plans.”
Alexander-Murray will allow anyone to have a “catastrophic plan” as such plan is defined by ACA. ACA limits enrollment in these plans to enrollees under 30 years of age or enrollees who have a waiver. Alexander-Murray would do away with these limitations. So far so good.
Another ACA limitation on these plans — found in ACA section 1302(e) — is that the plans will provide no benefits until the enrollee’s annual out of pocket limit has been reached, except that the plan must cover “at least 3 primary care visits.”
This will harmful to patients of DPC practices and is bad policy. It essentially forces primary care to be handled in-network — great for the insurance companies but not for the patients orthe doctors.
Ideally the requirement should be struck from ACA. Alternately, a small change along the lines of this or something similar [in brackets] might help fix this problem:
(B)the plan provides—
(ii)coverage for at least three primary care visits, [unless the enrollee is separately contracted with a direct primary care physician, in which case the plan will refund to the enrollee an amount equal to the value of such coverage.]
Here they go again. Once again the AMA is promoting what’s best for the big government / big insurance / big hospital cartel instead of advocating solutions that will truly empower patients, physicians, and increase access to high-quality, low-cost care.
From our friends at Independent Women’s Voice:
For the Senate to pass ObamaCare repeal and replace with only 51 votes, they’ll need to take action by September 30th.
How can we motivate Congress to act? By President Donald J. Trump ending Congress’ illegal exemption from ObamaCare.
Here’s what you need to do STAT:
- Sign the petition at www.NoWashingtonExemption.com
- Write President Trump and tell him to end the illegal exemption: https://www.whitehouse.gov/contact
- Read this explainer from Michael Cannon of CATO to become an expert on this crucial issue: http://www.washingtonexaminer.com/congress-illegal-and-egregious-obamacare-exemption-explained/article/2633383
Most agree that we need a healthcare system that encourages people to take care of themselves and covers catastrophic injuries and disease for all people.
I trust the free-market more than government, and some trust the government more than the free market.
MACRA, ACA, HIPAA, HMO act, Medicare and Medicaid were supposed to reduce costs and expenditures. Obviously government only makes it all worse. Looks like a job for the freemarket!
Either way, whichever philosophical system is selected by the people, individuals must freedom of choice and bear their own responsibility to the extent that is humanly possible.
– Craig M. Wax DO
Medical emergency: ER costs skyrocket, leaving patients in shock
- Americans are being overcharged by more than $3 billion a year for ER services, according to data from Johns Hopkins School of Medicine.
- Bills can be nearly 13 times the rates paid by Medicare for the same services.
- Americans in the Southeast and Midwest, and poor and minority patients, are the most exploited by emergency-room billing practices, especially at for-profit hospitals.
Read full story:
“Socialism is great until you run out of someone elses money.” ~Margaret Thatcher
Remember: Doctors for America was Doctors for Obama(partisan organization)
Read more: “Both Parties are Responsible for Healthcare Disaster” by Dr. Wax, published in Medical Economics, June 27, 2017 http://medicaleconomics.modernmedicine.com/medical-economics/news/both-political-parties-are-responsible-healthcare-disaster
IP4PI founder Craig M. Wax, D.O. presents on Capitol Hill at the March 2017 meeting of the National Physicians’ Council for Healthcare Policy. Learn more about NPCHP efforts at http://npchcp.org. Read a synopsis of the principles here and view slides here.