Insurance Vent, Wouldn't this save money?

[DawnCt1]

Unfortunately, logic and common sense do not always prevail in the operations of health insurance companies.

"

So true, DS#4 started speech therapy at 17 months. (cleft palate) The provider was at a children's hospital 45 minutes away. I could get a speech pathologist for a home visit. They denied it. I found out the cost of the hospital visit (the actual amount they were reimbursed), got them to write a letter stating that home speech therapy would be optimal and then they finally approved it but I had to take it past the initial supervisor to a care manager and it was an uphill battle. A few months later they had an essay contest; "Write about your best Connecticare managed care experience". I wrote that one, made it sound more "favorable" to them and won the $100 U.S. savings bond. Later when his benefits ran out, as they do, I wrote to the Medical Director of Connecticare, explained that DS's speech therapy wasn't "rehabilitative" but HABILITATIVE because he has never spoke before, and they gave me another 45 sessions to use as we needed.

 

[tlbwriter]

My insurance company insists that you rent a CPAP machine for a year instead of buying it outright. Guess which costs a lot more?

 

[DawnCt1]

My insurance company insists that you rent a CPAP machine for a year instead of buying it outright. Guess which costs a lot more?

I guess they are counting on the patient that rents it, doesn't use it and then won't buy one. DS#1 had serious sleep apnea. They were so concerned in the sleep lab that they woke him up during the sleep study! He absolutely refused to get a C-PAP. He was in school for respiratory therapy at the time and actually did a paper on sleep apnea so he knew all of the risks. He went on a serious diet and exercise program, lost weight, which wasn't easy for him and it went away. He was lucky.

 

[daughtersrus]

Unfortunately, logic and common sense do not always prevail in the operations of health insurance companies.

Way back when, in the last 80s when insurance companies were not required to provide coverage for birth control pills under the prescription plan, I was on the pill, and my insurance company denied my claim to pay for my prescription. They didn't seem to understand my logical argument that it would be FAR less expensive to cover birth control pills for a healthy, sexually active young woman who WOULD statistically be likely to get pregnant than it would be to pay for the expenses of covering the resulting likely pregnancy. "Well, its not required that we cover it"

Our insurance plan still will not pay for BC pills but will cover pregnancy. Again, because they are self-insured, they are exempt.

The new law that went into effect last week does not apply to self-insured plans the same way either. It will apply 9 months after the plan renews. I'm not sure when ours renews (called the union but no one would/could give me the answer), but let's say that the plan doesn't renew until Sept 1, 2011, the new law won't go into effect until June 2012.

Hopefully, my DD won't reach her life-time max before then!

 

[TheBigBadWolf]

DH's company provides flu shots for all employees and family members for free. It isn't convenient to go there however. We also have no copay for flu shots.

Same here. I have to get mine this afternoon. I would prefer to get it at the pharmacy though, where it's convenient for me.

 

[bettymae1121]

I had a spider bite last year that I must have been allergic to, because the bite swelled up to the size of my hand! It was a saturday and my doc's office was closed for the weekend. It didn't look like something that could wait as it kept getting bigger and bigger. Yet it wasn't an emergency either. So, I go to an urgent care clinic that is run by the hospital my doc "belongs" to, figuring it would be covered.

Nope. Receptionist checked and said per my insurance, I had to get pre-approval from my doc to use urgent care. Uh, doc's office is closed, that's why I'm here in the 1st place! So, went to the ER and the got to pay 10X as much for an ER doc to look at my arm for 60 seconds, say "wow, that's quite a reaction you're having" and prescribing me an antibiotic to keep it from being infected and telling me to take a double dose of both claritin and benadryl to stop the allergic reaction.

I have excellent insurance, they pay 100% for everything, so no cost to me either way. But I thought the point of HMO's was to lower the cost of health care?

 

[allison443]

Hubby's work actually has someone come in to administer the shots. This open to all employees and their families. We have to pay $15, but we would have to pay $25 co-pay at the doctor's office anyways.

My sister told me the same thing...it is cheaper for her to get the flu shot elsewhere (and at her convenience) rather than make a doctor's appt. and pay her co-pay.

 

[tar heel]

I suspect that it's the doctors driving this. They don't want to lose the business to the pharmacies, so they get the company contractually obligated to them.

 

[golfgal]

I had a spider bite last year that I must have been allergic to, because the bite swelled up to the size of my hand! It was a saturday and my doc's office was closed for the weekend. It didn't look like something that could wait as it kept getting bigger and bigger. Yet it wasn't an emergency either. So, I go to an urgent care clinic that is run by the hospital my doc "belongs" to, figuring it would be covered.

Nope. Receptionist checked and said per my insurance, I had to get pre-approval from my doc to use urgent care. Uh, doc's office is closed, that's why I'm here in the 1st place! So, went to the ER and the got to pay 10X as much for an ER doc to look at my arm for 60 seconds, say "wow, that's quite a reaction you're having" and prescribing me an antibiotic to keep it from being infected and telling me to take a double dose of both claritin and benadryl to stop the allergic reaction.

I have excellent insurance, they pay 100% for everything, so no cost to me either way. But I thought the point of HMO's was to lower the cost of health care?

No, HMO's are there to make money. They do so by cutting corners with health care for their members.

It is strange that you needed a "referral" for Urgent Care-that kind of defeats the purpose. Did you call your ins co and verify this? Our Urgent Care co-payment is the same as our office visit co-pay.

 

[mamacatnv]

If you want the convenience of the local pharmacy/Costco etc. then pay for it yourself.

Lets just use my DH's employer with 2000 local employees. If they and their eligible dependents all went to different providers for a flu shot and then all those employees submitted claims imagine the paperwork for the insurance company.
By keeping the locations contained the insurance companies also keep their processing contained.

I am by no means a fan of insurance companies, I am a benefit administrator for my small company and the insurance companies make me crazy. However, in this instance, to me the logic is sound in keeping the providers contained.

You want convenience, a shorter drive or no wait time? Pay for it yourself. Seems reasonible to me.

 

[bettymae1121]

No, HMO's are there to make money. They do so by cutting corners with health care for their members.

It is strange that you needed a "referral" for Urgent Care-that kind of defeats the purpose. Did you call your ins co and verify this? Our Urgent Care co-payment is the same as our office visit co-pay.

I didn't bother calling, I saw the receptionist call BCBS so I know she checked, and I didn't think there was any reason to think she was incorect unless whoever she spoke to was clueless (which isn't beyond the realm of possiblity now that I think about it). Besides, I did my part to save the insurance company money, if they don't want to pay a lower amount then who am I to complain?

I suppose it would be a good idea to call BCBS and just ask for future reference just to be sure, though. Plus it was a year ago and they may have wised up since then, though I'm not taking any bets on that...

 

[npmommie]

I didn't bother calling, I saw the receptionist call BCBS so I know she checked, and I didn't think there was any reason to think she was incorect unless whoever she spoke to was clueless (which isn't beyond the realm of possiblity now that I think about it). Besides, I did my part to save the insurance company money, if they don't want to pay a lower amount then who am I to complain?

I suppose it would be a good idea to call BCBS and just ask for future reference just to be sure, though. Plus it was a year ago and they may have wised up since then, though I'm not taking any bets on that...

I would call the insurance co to verify and if you DO need pre approval to visit urgent care, just call your doc's office number even if they are closed they are still on call or have someone covering their call, just explain what is happening and they will most likely tell you to go to urgent care if needed, then you have your approval

 

[golfgal]

I didn't bother calling, I saw the receptionist call BCBS so I know she checked, and I didn't think there was any reason to think she was incorect unless whoever she spoke to was clueless (which isn't beyond the realm of possiblity now that I think about it). Besides, I did my part to save the insurance company money, if they don't want to pay a lower amount then who am I to complain?

I suppose it would be a good idea to call BCBS and just ask for future reference just to be sure, though. Plus it was a year ago and they may have wised up since then, though I'm not taking any bets on that...

I missed that the receptionist called BC/BS. We had a BC/BS plan and the Urgent Care co-pay was the same as an office visit co-pay. Again, it isn't BC/BS that sets these policies, it is whatever your employer or whom ever you have the plan with decides for coverages.

 

[bettymae1121]

I missed that the receptionist called BC/BS. We had a BC/BS plan and the Urgent Care co-pay was the same as an office visit co-pay. Again, it isn't BC/BS that sets these policies, it is whatever your employer or whom ever you have the plan with decides for coverages.

That was the strange thing, my company pays for one of BCBS's best plans, covers 100% of everything one could possibly need. If it was a bargin basement plan I could understand it, but the receptionist said that if i used urgent care, I'd have to pay 100% of the cost OOP if I didn't have a doctor's referal. I couldn't wait a day and a half for my doc's office to open (and really, had the doc's office been open I'd just have gone to her in the first place) so, I went to the ER.

But next time I have some free time to wait on hold, I'll call up BCBS and get a clarification on it.

 

[tvguy]

Guy I know had to fight with insurance to pay for an ambulance and emergency room treatment when he had a heart attack because the treatment was not pre-approved !

They sent him an appeal form on which he wrote "It was impossible to call for pre-approval because the paramedics were doing CPR on me".

As for flu shots. My company self insures, and pays the local hosptial to come in and give flu shots for free.

My kids get their flu shots at college, which is provided for free.

My wife has no interest in a flu shot, to her getting a shot is worse than the flu, but she would have to pay for it if she wanted one.

 

[DawnCt1]

Guy I know had to fight with insurance to pay for an ambulance and emergency room treatment when he had a heart attack because the treatment was not pre-approved !

They sent him an appeal form on which he wrote "It was impossible to call for pre-approval because the paramedics were doing CPR on me".

As for flu shots. My company self insures, and pays the local hosptial to come in and give flu shots for free.

My kids get their flu shots at college, which is provided for free.

My wife has no interest in a flu shot, to her getting a shot is worse than the flu, but she would have to pay for it if she wanted one.

I think denying the ambulance may be a standard way to save money....initially. Its a smaller bill than the rest of the bills, so I wonder how many people pay rather than argue. My mother's insurance/Medicare and her co insurance denied her ambulance because I called it on a "monday" at 11:30 pm and she wasn't admitted to the hospital "that day". She was admitted "tuesday" at 12.05 AM! When the time was pointed out to them, they paid it. I asked them, "what do you think they did, drive her around the block and then bring her home?"