In reply to GIRTHQUAKE :
And corporate hospitals and the doctors they own aren't much better.
In reply to GIRTHQUAKE :
And corporate hospitals and the doctors they own aren't much better.
In reply to GIRTHQUAKE :
Yup, I work in cardiac surgery and blood on the floor is like teflon, I actually ended up on the floor once. Not a good evening...
Its truly a bizarre industy. My wife works for an insurance co., my insurance is thru the her company, and she has significantly worse coverage. WTF? And I can't per her on my plan or I get a 225/mo surcharge.
In reply to OHSCrifle :
Sorry - insurance company's board of directors
Regarding lawyering up, a friend's bride had serious problems during her pregnancy. Taking care of it was obviously involved and expensive, with a long hospital stay.
Talked to his lawyer and he sent The Letter to the insurance company. They ended up paying nearly everything - he didn't even reach the deductible.
Friend thought it was the best $300 he ever spent.
YMMV
XLR99 (Forum Supporter) said:In reply to GIRTHQUAKE :
Yup, I work in cardiac surgery and blood on the floor is like teflon, I actually ended up on the floor once. Not a good evening...
Its truly a bizarre industy. My wife works for an insurance co., my insurance is thru the her company, and she has significantly worse coverage. WTF? And I can't per her on my plan or I get a 225/mo surcharge.
My wife's employee plan (at the hospital where I was admitted) is a lot better than mine. We carry our two sons coverage on her plan. I cannot join hers myself because my employer offers a plan. Our system is well and truly berkeleyed.
CJ said:In reply to OHSCrifle :
Sorry - insurance company's board of directors
Okay now that makes more sense. Thanks for clarifying!
I didn't read the entire thread, but I experienced the same thing in June. My neck broke and my insurance sent me a rejection letter saying the emergency ACDF to fix it wasn't medically necessary. To get it covered, the neurosurgeon had to call the "doctor" the insurance company employs to review claims. At best these guys are GPs. If that "doctor" doesn't know or understand what the procedure involves, they deny coverage. My Dr. said they do this all the time hoping people give up and pay out of pocket. He said the insurance "doctor" claimed he'd never heard of allograft and so decided it wasn't necessary.
Seems like if you were admitted, a competent doctor decided it was medically necessary. They would likely issue a statement stating that or your medical records show this.
For the 20 hour hospital stay + blood tests every four hours - I ended up paying $1,100 out of pocket (which was 20% of the "reduced" amount agreed by the employer health plan.. So $15k immediately reduced to $5,500).
Since I have had an interesting year already (skin cancer scare, multiple biopsies and facial surgery, plus a colonoscopy) I have already met my multiple thousand dollar deductible for the YEAR. That payment sucked but I thought I was done.
Then 2 weeks later I got my first bill for an independent ER doc whom they say evaluated me during the visit. Super!
I'm fortunate to be able to absorb the cost (emergency fund) without being wrecked financially but I totally understand why so many Americans are so far over a barrel in this berkeleyed up system.
In reply to OHSCrifle :
It's damn sure a shell game and the only way to win is to not have to play. It would be nice to be able to trust a certain entity to manage it for the benefit of all, but there is pretty much zero chance that will happen due to that cursed P word.
Disclaimer: Only read the OP
I've fought over the past ten years for my wife to get care for her unique issues. Countless phone calls, Emails, and letters to executives in Blue Cross. Fight like a dog. Be kind to the people on the other end of the phone. Don't give up.
I just don't get what the point is from the insurance denial perspective.
It's not like an ER is going to keep you overnight just because you asked nicely.
It's not like a Doc is going to open you up just because he was curious.
If the patient wants something paid for, pay it, damnit. If the patient doesn't want to pay their Doctor, there is usually good reason for it (medical malpracitse). Most of the time, however, we're happy to have recieved care and will pay the bill.
I don't care whether your think our system is the best or not, it's still a long way off from perfect and we've still got tremendous improvements that could be made.
In reply to OHSCrifle :
Currently the US govt is pushing something called the "no surprises act" which will make it illegal for that ER doc to bill you separately after the fact if they didn't give you heads up before you received the care.
My understanding is it is passed into law but implementing still.
In reply to Robbie (Forum Supporter) :
I'm sure that I signed a form that told me. I just was under the impression that the ER visit that turned into an inpatient stay was all rolled into one bill. The "gotcha" one month later pisses me off. The fear of additional bills does too.
..apparently the sales floor and the service department bill separately.
In reply to pheller :
You are assuming everyone has the same interest. Here's a hint. None of them are in it for your healthcare.
Doctors and hospitals are in it to make money.
Insurers are in it to not spend money so they can make money.
None of them are trustworthy so they hire people to keep an eye on each other that are dedicated to their employer's purpose.
I'd be more interested in knowing how a $15k bill becomes a $5k bill after the backroom deals are done.
pheller said:I just don't get what the point is from the insurance denial perspective.
It's not like an ER is going to keep you overnight just because you asked nicely.
It's not like a Doc is going to open you up just because he was curious.
If the patient wants something paid for, pay it, damnit. If the patient doesn't want to pay their Doctor, there is usually good reason for it (medical malpracitse). Most of the time, however, we're happy to have recieved care and will pay the bill.
I don't care whether your think our system is the best or not, it's still a long way off from perfect and we've still got tremendous improvements that could be made.
Unfortunately our medical system is biased much closer to "perfect at any cost" than it is to "reasonable care for reasonable cost". (My belief is that the whole idea of heath insurance is what promoted this in the first place, but that's beside the point).
What it leads to is when anyone shows up to the medical system, many "very unlikely but possible" things can be tested for, and then charged for. Health providers are rewarded for providing as many services as possible, so of course there is conflict of interest. The insurance companies (Medicare leading the charge in many cases) are pushing back on this by refusing to pay for things that are medically unnecessary. They don't always do it elegantly, and I'm sure some have ulterior motives in some cases as well, but in general I see it as a good thing because they are pushing back against rampant charging for irrelevant services.
Most unfortunately, the patient is usually the one who gets put in the middle of this battle, like two divorced parents fighting with each other via the kid.
However I think another natural fix to this issue is also something the govt is pushing currently, which is the high deductible health plan. If patients have to pay for the first $5-10k in medical services each year and then insurance covers the unforseen emergency type stuff above and beyond that, then healthcare providers will have to provide services that are right sized to their patients, which would include doing the very unlikely but possible tests for rich patients but for everyone else just "reasonably likely" stuff.
There are a lot of good forces pushing things in good directions, even though it is still easy to point at many things that could be improved.
Robbie (Forum Supporter) said:In reply to OHSCrifle :
Currently the US govt is pushing something called the "no surprises act" which will make it illegal for that ER doc to bill you separately after the fact if they didn't give you heads up before you received the care.
My understanding is it is passed into law but implementing still.
The No Surprises Act should require them to give you a total at the point of sale. It should also require posting of costs in a public place. No backroom deals. No shenanigans.
Toyman! said:Robbie (Forum Supporter) said:In reply to OHSCrifle :
Currently the US govt is pushing something called the "no surprises act" which will make it illegal for that ER doc to bill you separately after the fact if they didn't give you heads up before you received the care.
My understanding is it is passed into law but implementing still.
The No Surprises Act should require them to give you a total at the point of sale. It should also require posting of costs in a public place. No backroom deals. No shenanigans.
You're in luck because that is exactly what it does.
The no surprises act requires providers to provide a "good faith estimate" (GFE) prior to services. I believe the first phase is for uninsured patients but the second phase is for patients with insurance. I also believe the providers are penalized if they are off by more than $400.
The posting of costs in a public place is being handled by CMS using their hospital price transparency initiative, which started penalizing hospitals that do not have a published price list as of Jan 1st 2021.
Perhaps the most impactful (in a very good way) recent legislation change however is the part of the inflation reduction act that allows Medicare to negotiate with pharma companies on drug prices. Previously it was illegal for Medicare to do so, and is the main reason drug prices are way out of control in the US.
You can find more info about these and more at CMS.gov (under priorities and key initiatives).
Edit, there are still backroom deals, because insurance companies can negotiate lower prices for health services with large providers because they "buy in bulk". Currently that is an area where there isn't a good solution yet but you can bet it's coming down the line.
In reply to Robbie (Forum Supporter) :
Thanks for the info!
Toyman! said:I'd be more interested in knowing how a $15k bill becomes a $5k bill after the backroom deals are done.
I'm a pretty firm believer that the $5k bill in this scenario is a lot closer to the actual cost of the parts and labor, the extra $10k tacked onto the bill to bring it to $15k when it first gets to the patient after the insurance denial is the "eat E36 M3 you're poor/unlucky/cheer for the wrong sportsball team/unironically listen to Nickelback/remind the insurance claims person or hospital billing department of their ex/whatever other slight you may have committed against the healthcare/insurance industry" fee that hospitals tack on because they figure even if they fail 99 times out of 100 trying to collect the full amount, that last 1 time still made them an extra $10k for essentially nothing.
But, I am pretty cynical and jaded on this topic, due to having to fight a certain insurance company that starts with A and isn't a synonym for "song" during the duration of my treatment for a nasty motorcycle crash a few years back, and the notion that if they were treating me like that, they certainly were treating other people the same who may have been in less of a position to fight back or didn't have someone in their corner advocating as skillfully for them as I did
In reply to BumpHeadRacing :
They never collect the $10k. It's dumb, but it's just like harbor freight or Walmart "buy this $100 widget ON SALE for ONLY $60!"
The problem is not everyone gets the same sale price.
Usually Medicare gets the best sale prices (they buy in the most bulk). If you don't have insurance, make sure you are clear with the provider that you will not be paying a cent more than the Medicare rate.
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