Insurance Woes

[kbkids]

Similar situation when my DD was born. Had to have an emergency c-section, put to sleep due to the urgent nature. Anway, anesthesiologist, not in-network, so they refused to pay. I called them (insurance) and luckily talked to someone with common sense who recognized it would be a little difficult to be cut open without some type of anesthesia, so they paid it.

 

[bicker]

With enough consumer outcry and newspaper articles etc etc that could easily change.

I disagree. We have "Help me Hank" here in Boston, and she's reporting on surprises with medical bills. She's actually got a very bad success rate with regard to "resolving" the problems, but even if she had a decent success rate, she's still only fixing one at a time, and we know there are new cases like this every day. Most of her reports end up with what we were talking about before: a warning. "Beware. This is the way it is and it won't be changing."

No, this cannot "easily" change. Change will require a change in government.

I suspect if things don't change, that gap insurance will become more popular. It is already widely available for folks in the Medicare HMO, but is available in a few states for folks in regular HMOs.

 

[WebmasterAlex]

I disagree. We have "Help me Hank" here in Boston, and she's reporting on surprises with medical bills. She's actually got a very bad success rate with regard to "resolving" the problems, but even if she had a decent success rate, she's still only fixing one at a time, and we know there are new cases like this every day. Most of her reports end up with what we were talking about before: a warning. "Beware. This is the way it is and it won't be changing."


No, this cannot "easily" change. Change will require a change in government.

I suspect if things don't change, that gap insurance will become more popular. It is already widely available for folks in the Medicare HMO, but is available in a few states for folks in regular HMOs.

I didn't mean it would change on a case by case basis. With enough outcry laws will be passed that will at least require that consumers be informed.

 

[Disney Ella]

I live in the Philadelphia metropolitan area, and after PA legislators voted themselves a nice pay raise, a newspaper columnist here wrote column after column urging readers to write to their representatives asking them to repeal the raise. Not too long ago, the pay raise was repealed. I think newspapers can be powerful tools for consumers. I don't see things immediately changing becasue of articles, but if enough people are aware and enough people complain to those in power, government and the hospitals themselves, a change can be effected.

 

[bicker]

I understand what you're saying, Alex, but do you really think that legislators will happily give up all their campaign contributions from big business, just because of "outcry"? No, "outcry" isn't enough... people have to actually vote based on which legislators support the kind of laws they want to see on the books. The people sitting in those offices in the capital need to be motivated by more than just words. Talk is cheap.

Find out which legislators support these kinds of laws. Then ask yourself would you really start voting for them, instead of who you currently tend to vote for. I believe the answer for the vast majority of Americans is that either they're already voting for those people (and they're not winning) or they're not willing to vote for those people.

We talk a good game about how health care reform is important to us, as an electorate, but again, talk is cheap: Look at who we vote in; look at who we vote out. We aren't serious about health care reform. We're like the good people of Hamelin, who want the problems to go away, but don't want to "pay the piper" for resolving the problems.

 

[Kteacher]

navigating health insurance in this country is a nightmare! I haven't had any out-of-plan problems (yet!) , but I've had numerous problems caused by someone inputting the wrong codes or information during the billing process. When my son ,dangerboy, was in the ICU someone put in my date of birth instead of his. The insurance company refused to pay ( 64,000! ) because they claimed he was too old to be a dependant covered under my health insurance plan Dangerboy is now getting solicitations in the mail for credit cards, and retirement plans ( ! ) , which means somehow his incorrect info from his hospital stay made it onto numerous mailing lists. You do need to contact your legislators-start with your state rep. and state senator. To the original OP- you are right to not pay any of the bills yet- once your insurance company sees that you are paying it will be difficult for you to plead your case with them. Good luck-let us know how you make out!

 

[Kitty 34]

My DS was hurt in a varsity basketball games several years ago and needed stitches immediately. Of course we took him straight to the ER of "our" hospital. He received 7 stitches from the ER doctor there.

Well.........six months later we start getting billed from the office of this ER doctor for her stitching our son up that night in ER. Our insurance had paid for our ER visit no problem and hadn't sent a penny to the ER doctor.

We fought tooth and nail with many many phone calls to mainly our Ins co. Two years later it was finally paid. Turned out somewhere, somebody hadn't given our insurance the right NUMBER.

 

[bicker]

Medical billing is so complicated that there is a whole specialty -- folks who's job is based on knowing how to "code" medical treatment, so that they get billed properly. That's probably what got messed up in your case.

 

[froglady]

With modern computer systems it would be a ridiculously simple matter for each doctor to know whether he was covered under a patients insurance plan. The problem is the hospitals don't WANT things to work that way, they prefer the present system. With enough consumer outcry and newspaper articles etc etc that could easily change. Patients should be given the option to be informed PRIOR to incurring charges if they are going to be treated by an out of network doctor or as I said just cross out where it says they can do that and write in you want to be informed. In an emergency they still HAVE to treat you and you will drive the ER staff completely insane.

I'm not sure that if I show up in the ER with chest pain, I want to be told that I have to wait for the Cardiologist to check to see if he has a contract with my insurance company, and if he doesn't, that I have to wait until an in-network provider is found, or pay out of pocket. Since I, and most people, would opt for the latter, why waste time with the former?

The same goes for less emergent issues. A specialist (who may be the only person in that field on call) arrives in the ER to treat your child. Do you want him to take the time to look up your insurance before starting treatment? If you were seeing him in his office, that would be handled by his staff, so you would know before you got there, and could make other arrangements.

 

[froglady]

Medical billing is so complicated that there is a whole specialty -- folks who's job is based on knowing how to "code" medical treatment, so that they get billed properly. That's probably what got messed up in your case.

My primary care (GYN) doctor finally got so frustrated that she stopped taking ANY insurance. I pay out of pocket, and I can file on my own. Her secretary has forms for all of the major insurance companies, and has a list of labs that are in-network.

That, and stopping all OB, has reduced her costs to the point that she can devote an HOUR per patient (if needed) and still have a similar income. She only needs two nurses, and one secretary, vs the billing and coding people she needed before. She has a list of surgeons that she will refer you to, and will let you choose the one in your plan.

I'm happy paying the extra money (filing is too much of a hassle for me) for the individualized attention I receive.

 

[Pin Wizard]

Unfortunately, that's not uncommon. In the hospital I worked at in FL, the anesthesiolgists the hospital contracted with did NOT take our insurance! They work in the hospital and don't accept the hospital's insurance? What's with that?

This past week I took darling son for his annual physical at the pediatrician's office. They informed me that my insurance does not cover some of the labs he wanted done (to be done in his office) and that I had to have them done somewhere else where the insurance company has a lab. This is a PPO, I'd hate to see the HMO! I was past my boiling point when I was at the lab and they said one of the tests needed darling son to be fasting. Right! At 4:00 p.m.! I don't think so. I told them they could run the others and skip that test or else I'd be leaving and not returning. They called the pediatrician who said forget the fasting test he wanted. Would have been nice for anyone in the pediatrician's office to tell me that on the way out the door!! Again, I'm now working for a hospital system. It's terrible that a simple doctor's appointment takes a half day being I now work quite a distance from home and the doc's office.

 

[The Mystery Machine]

WOW! Very informative thread. I am glad I read it.

Now how to get info to people???

They make you sign a "book" for treatment, right? How about the you sign a paper that states the insurance company that the doctor or specialist takes BEFORE you are treated.

I am not saying it will "solve" it but at least you could look at the paper, see your insurance is NOT listed, then you can get up and go somewhere else, if possible, of course.
At least throw us a bone or something. I know it will work both ways and the Doctors can now say you signed the paper and knew I didn't take YOUR ins., but at least you are informed.

 

[WebmasterAlex]

I'm not sure that if I show up in the ER with chest pain, I want to be told that I have to wait for the Cardiologist to check to see if he has a contract with my insurance company, and if he doesn't, that I have to wait until an in-network provider is found, or pay out of pocket. Since I, and most people, would opt for the latter, why waste time with the former?

The same goes for less emergent issues. A specialist (who may be the only person in that field on call) arrives in the ER to treat your child. Do you want him to take the time to look up your insurance before starting treatment? If you were seeing him in his office, that would be handled by his staff, so you would know before you got there, and could make other arrangements.

Obviously if you are having a heart attack you will do what you need to do but even most "emergencies" aren't that emergent. If I was told I could save $5,000 dollars by waiting 1 hour for the right doctor to show up to treat my broken leg would I wait? You bet! Also most insurance plans have different coverage for "true" emergencies.

 

[chrissyk]

What is the "gap" insurance that Bicker mentioned? Is that like Aflac or something? I didn't think that gap insurance would work with an HMO, since there is no out-of-network annual cap.

 

[bicker]

This is how Allstate explains its brand of gap insurance:

If you’re like most Americans, your primary health insurance doesn’t cover everything. Whether you make co-pays for prescriptions, pay out-of-pocket for vision and dental expenses, have to come up with the cash for services not covered by Medicare or your insurance plan, it can quickly add up.

Supplemental health insurance is designed to help defray these kinds of expenses that aren’t usually covered by major medical insurance plans. A variety of supplemental health insurance plans are available so that you can customize your healthcare coverage and bridge the gaps between your actual medical bills and the amount your insurance covers.

Not everyone needs supplemental insurance. If you’re a healthy individual whose primary health insurance plan covers all or most health-related bills and who already has disability coverage, you may not benefit from buying supplemental insurance.

On the other hand, if your primary insurance requires you to pay high yearly deductibles, make expensive co-pays, or places low caps on the amount it covers for certain services and products, you should consider supplemental health insurance. Additionally, you may want to look into purchasing supplemental insurance if:

• You lack disability coverage, which would pay your bills and lost wages if you were to be injured off the job or became chronically ill. (Many employers have insurance for on-the-job injuries and short-term disability leaves.)
• You are at a high risk for developing cancer, heart disease or other serious illnesses that would require expensive medical treatment.
• You belong to an HMO or other managed plan that won’t cover out-of-network services or certain procedures, such as experimental cancer treatments.
• You don’t have an emergency fund that would cover at least three months of living costs.
• You want to protect the savings and assets you have.

Gap insurance is very expensive. That's because it covers the part of health expenses that least profitable to cover. Since this type of insurance is so expensive, that's why Allstate says, "you may not benefit from buying supplemental insurance" -- while the insurance is surely available to you, you may find it more cost-effective paying those expenses out of your own pocket.

 

[AllyandJack]

Don't forget that out of pocket expenses are tax deductible if you itemize and the amount is 7.5% of your income. I have about $100./week in co-payments, not to mention the co-payments for my medication and the $300. co-payment I'll have for my "out patient surgeries" and I'm saving all those receipts and cashed checks for tax time and hoping beyond hope they meet 7.5% of my income.

 

[vivilasvegas]

My primary care (GYN) doctor finally got so frustrated that she stopped taking ANY insurance. I pay out of pocket, and I can file on my own. Her secretary has forms for all of the major insurance companies, and has a list of labs that are in-network.

That, and stopping all OB, has reduced her costs to the point that she can devote an HOUR per patient (if needed) and still have a similar income. She only needs two nurses, and one secretary, vs the billing and coding people she needed before. She has a list of surgeons that she will refer you to, and will let you choose the one in your plan.

I'm happy paying the extra money (filing is too much of a hassle for me) for the individualized attention I receive.

Doctors are notoriously bad a choosing their own code level for office visits! Trust me, it's what i do all day long.

A doctor will circle 99215 (highest level office visit/exam). When I review what was actually documented in the note, it usually levels to a 99212 or maybe 99213, which cheaper to the patient/insurance.

Doctors need coders.

 

[Free4Life11]

m not saying it will "solve" it but at least you could look at the paper, see your insurance is NOT listed, then you can get up and go somewhere else, if possible, of course

What confuses me is that I don't even know what my insurance is! I get it through my parents. My card says Blue Cross Blue Shield, the back of the card says HIighmark, and I have to send a form verifying school enrollment to something called Bethany Benefit!

 

[Mackey Mouse]

Tomorrow should prove interesting for me with this insurance question we are discussing here. I need to go to a specialist that works on hands, also a plastic surgeon for reconstructive, he does not take my insurance, so I will be paying for this out of pocket...or he will submit to my insurance as an out of network supplier and then bill me for the rest. If my hand needs surgery, he will not be the one doing it, but I will let him diagnose as there is no one else here where I live that has his qualifications. Bottom line is I need a diagnosis before I can go on with someone else......I might have to go into Boston.

I was thinking here does anyone remember when you were told if the hospital or doctor billed you for the difference between what insurance paid and what they thought they should get paid, that you were not to pay it. Now I think you get these bills for difference and have to pay it.... Or is it just my insurance that does it?

 

[DebbieB]

Tomorrow should prove interesting for me with this insurance question we are discussing here. I need to go to a specialist that works on hands, also a plastic surgeon for reconstructive, he does not take my insurance, so I will be paying for this out of pocket...or he will submit to my insurance as an out of network supplier and then bill me for the rest. If my hand needs surgery, he will not be the one doing it, but I will let him diagnose as there is no one else here where I live that has his qualifications. Bottom line is I need a diagnosis before I can go on with someone else......I might have to go into Boston.

I was thinking here does anyone remember when you were told if the hospital or doctor billed you for the difference between what insurance paid and what they thought they should get paid, that you were not to pay it. Now I think you get these bills for difference and have to pay it.... Or is it just my insurance that does it?

It depends on your plan. If your doctor is "in network" and overcharges, you usually don't have to pay the difference. They will only pay him the contract rate and you only pay the co-pay or coinsurance. If the doctor is "out of network" then you will have to pay the difference.