Dilemma over deceit

This dilemma occurred to me while pondering various conversations with insurance company representatives. I've already shared that in one conversation a representative viciously spat out, "You can get a prescription for anything."

OK, so you can get a prescription for anything.

Now here's the dilemma. According to the insurance company, you can't trust a doctor to tell you what is medically necessary. They'll break the bank. No problem right? They're balanced by the insurance company.

Unfortunately the insurance company has been telling me that Linda's speech therapy is not medically necessary as far back as June 29th. They later re-evaluated that and decided that gosh they were mistaken, but the re-evaluation effectively said, "OK. It was necessary then, but now it isn't." And they won't pre-authorize anything.

According to every professional in the field that I talk to, Linda's speech therapy is medically necessary. It's a no-brainer. So I keep sending her, and I tell the insurance company I want them to think about it again (haven't heard anything).

Fine. But it isn't always going to be a no-brainer, and eventually it isn't going to be medically necessary. So here's the dilemma. It's clear that you can't get a truthful answer from the insurance company or their experts. Yet doctors will sometimes prescribe things that aren't necessary. If you can't trust anyone, how am I to decide when we've crossed the line from necessary to unnecessary?

I'm not looking for answers. So far the doctors and therapists have been a lot more honest than the insurance company. No piece of information I get from the insurance is actually useful. For example, I just got the pre-authorization certification for a bunch of Linda's in-patient therapy in March and April. It was dated September 3. Glad I didn't need that little piece of paper to make an important decision.

I just ponder what I would say about the situation in front of a judge. After all, if it comes to fighting, that's whose going to have to decide what was appropriate. My attorney asks me what I have in writing. Nothing in writing says they won't pay for something. It turns out that they never say they won't pay for something--smart, that. They simply say what they will pre-authorize (although even there, the fine print points out that pre-authorization isn't a guarantee of payment). They tell me certain things on the phone, but everything appears to be an attempt to bully me into withdrawing Linda from (needed) treatment.

They are just now starting to pay for Linda's June therapy. I have no idea how long it will be until we are actually talking about payment for the not-pre-authorized therapies she is doing right now.