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formerclimber
Boulder climber
CA
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Shut up, Nazi
I know ones like you don't even get why people "b#tch" about healthcare.
It's all good and S&P had made you rich, blah blah
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Norton
climber
The Wastelands
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Medicare is not free
you pay into it all your life at a rate of 1.9% as an employee and double that if you are schedule C self employed
Medicare is also not free when you get on it at age 65
your monthly Medicare payment is taken automatically out of your Social Security
it is around $120 a month for myself
Medicare also has co payments to see specialists, and annual deductibles
the reason it is cheaper insurance than private plans is because the profit factor is removed, Medicare has by far the lowest administrative cost of all the plans and does not have shareholders to make profit for
Medicare basic is a 80-20 plan, for that reason many people pay monthly for a supplemental plan to pay for what Medicare does not
I elected to a Medicare "Advantage" Plan, which means that as long as I stay within "network", like private plans, then it is the cheapest plan with the best benefits
and no monthly payment to a Supplemental plan is required or needed
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capseeboy
Social climber
portland, oregon
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I saw stats that 30-40% of claims get denied on the first submittal by big insurance companies: it's simply a numbers game in hopes that a person will give up, being too sick or unaware of the appeals process - a lot of people never appeal.
This is a form of guilty (ineligible) until you prove yourself innocent (eligible). Evil, vile, disgusting industry. So much for a gentler and kinder nation. Partisan politics...denied.
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August West
Trad climber
Where the wind blows strange
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if you have no insurance you pay the "Arab Prince" price
if you do have insurance then your insurance company has negotiated a set price for their plan members to be charged for every single thing, well lower than the Arab Prince price. You will usually have to pay a co-pay and then a specific amount depending if you have met your annual plan deductible or not.
Yes, but even if your insurance company has negotiated a set price for their plan members to be charged for every single thing, nobody can tell you what price that is. You have to do the procedure and wait for the bill. If you have high deductibles, that is a concern.
If my back acts up again, it would be nice to know if I'm looking at a $300 bill or a $2000 bill before I decide to do it.
And again, R's talk about this fantasy of the free market using competition to keep the price down. Yea right.
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EdwardT
Trad climber
Retired
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I saw stats that 30-40% of claims get denied on the first submittal by big insurance companies
A more accurate stat is 14%.
The Department of Labor estimates that about one claim in seven made under the employer health plans that it oversees is initially denied
But we do know they deny claims.
My advice is once there's any hiccup in a claim, start a file. Document ever correspondence (phone, email, text, letter). When they give you a date of approval, call on that date.
Following a surgery, I was assured of approval within a month. I called after a month. They said that issue was resolved, but there's another issue. I called 2-4 times a month for another five months. About three months after surgery, I started hearing from the doctor, the hospital, the anesthesiologist. Everyone who was owed money. Finally, I asked the insurance company if i needed to hire an attorney. The next day, they called "with great news". My claim was approved. Well how about that!
Remember. Document everything. Don't forget about the lawyer card.
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MarkWestman
Trad climber
Talkeetna, Alaska
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In early April of 2016 docs discovered an 11 centimeter adrenal tumor in my abdomen.
I had to leave Alaska for treatment as there was only one surgeon in Alaska who had removed an adrenal tumor before and he had done it...once. And he wasn’t an oncology surgeon. Bearing in mind that adrenal cancer is exceptionally rare and lethal and requires highly specialized knowledge to treat.
So I set up a consult at Seattle Cancer Care Alliance and UW physicians. Prior to going I verified with my insurance company that these providers were in network. They said yes. After the consult, I had a surgery date set for second week of May but I didn’t trust my I insurance company so I called again to verify. The rep I spoke to put me on hold and spoke to her supervisor. When she returned she said, verbatim: “you are in network. You have nothing to worry about”.
The day before surgery, after what one can imagine was the longest month of my life, I’m in Seattle with my wife. UW hospital calls to inform that insurance has just approved my surgery, but that they’ll be charging me out of network rates for the entire procedure and five day hospital stay. If this stands it will cost me an additional $14,000 out of pocket.
I obviously have no time or energy to address this now and damned if I’m going to delay this surgery.
Six days later, on my discharge day, I’m supposed to be discharged at 10:00 AM, but it takes until 4:00 PM because my doctors want to send me home with a 28 day supply of self injecting blood thinner syringes, which they insist is SOP after such a major surgery. MODA Health, my insurance company, disagrees of course, as their team of “experts” says I only need 18. My doctors and nurses argued on the phone with them over a six hour period over 10 syringes that cost about $30 each. My doctors won the argument at last, but I’m certain that the six hours longer that I occupied that hospital room cost far more than those syringes. Meanwhile I spent those six hours not resting but arguing on the phone with MODA about the false information they gave me and the bait and switch on in network benefits. They tried to claim that because UW informed me of the benefit status THE DAY PRIOR TO SURGERY that I was given “proper notice”.
Over the following weeks and months I had my doctors write letters supporting my case, which were categorically ignored and rejected, all the while I am sick from radiation therapy, They also told me I didn’t need to see the endocrine oncology surgeon that I used at UW, giving me the name of a doctor in Anchorage. I looked up this doctor, and she was an endocrinologist (I already had one, on the same floor of her building), and she was neither an oncologist nor a surgeon!! Finally I forced them to pull the TWO different recorded phone calls in which they told me I would be in network, telling their review board that I planned my treatment around the information they provided. I won, however they also stipulated that any further treatment at these doctors and facilities would be billed out of network. So much for continuity of care, but fortunately I did not need to return. And fortunately I was able to switch to Premera Blue Cross at the end of the year, and they have been hassle free.
Someone above noted that insurance companies make a policy of screwing with people, and counting on them being too sick to fight back. That’s unfortunately been my experience as well. My advice is to do what I did and write down dates and names and times of all contacts you have with your insurance company. You may need it later!
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formerclimber
Boulder climber
CA
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^ And need to record phone conversations about important questions with "rep" drones (if not possible to get anything in-writing like pre-authorization). If in two-party consent state don't forget to tell them you're recording. What I hear from "reps" at my insurance is usually either random blatant lies pulled out of you now where or non-sense, have to get to unreacheable "supervisors" to get any of more accurate info. These people got nothing to lose other than minimum wage I guess so they dk.
(I said it about them counting on people being unable to fight back wrongful denials, it's a deliberate strategy/game of numbers. Kind of like there're fraudulent companies that bill cards unauthorized and hope that only a percent will fight the charges - and it works. It's a well-known (bad) business strategy)
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Ghost
climber
A long way from where I started
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Here's my tale of battle with the US health industry. In this case it wasn't the insurance company, but a hospital. But since it is all interconnected...
Two years ago, I suddenly lost most of the vision in one eye. It was late afternoon, no time to start looking for anyone new, but I remembered that the eyeglass shop I used (in a Fred Meyer store) actually had a real doc working in it, so I phoned, they said they'd see me, and Mari drove me over.
The doc took one look into my eyeball and said "There is a good chance you're about to lose the other eye. You need to get your ass straight to your pharmacy where I'll make sure they have some meds ready for you, and then straight from the pharmacy to the ER at this hospital where I'll have them lined up to do a blood test, because there is a protein that shows up if you're on the verge of another one of these events.
Everything went smoothly from there. When we got to the hospital ER -- which was empty other than Mari and I -- we were put into an examination room, a nurse took my vitals, did a blood draw, and disappeared. About 45 minutes later, a doc came in, said she'd gone over the lab results, found no sign of whatever it was that might predict the loss of my other eye, and that I was okay to go.
So far, all great. Then I received two bills. One for just under $800 for the services of the ER doc, the other for about $2,800 from the hospital, for "emergency services". And since I was nowhere close to my $4K deductible, there was no insurance coverage.
The $800 for what the doc had done seemed high, but, well, she was on night shift at an ER, so okay, I paid it.
Then I called the hospital to find out what their $2,800 was for. "Well, emergency services are expensive, you know." I pointed out that the only services were the five minutes it took the nurse to draw a blood sample, along with whatever the lab work cost, so their must be some mistake.
They said they'd look into it, but when the next statement arrived, it broke out $96 for the lab work, and now showed $2,100 for emergency services.
I paid the $96 right away, and then called to explain that, while I would immediately pay for any other service they had provided, they would first have to identify that service.
This went back and forth many times over the next year, both with the hospital and a collection agency. As pointed out by posters above, I was careful to make sure all calls were recorded, and also put my position in writing to both the hospital and the collection agency.
Interestingly, the collection agency quickly gave up -- pretty clear evidence that they saw the charge as unjustifiable. The hospital still says I owe them $2,100, but they've given up bugging me about it.
Sometimes, standing your ground can work.
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mouse from merced
Trad climber
The finger of fate, my friends, is fickle.
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The HSA worker called me back this morning to answer my questions about being cut from MediCare Part B, and she told me I was now covered by a different program, and that I was not to worry.
Long story shortened, I have a temp. MediCal card coming by Saturday and a permanent one from the State is due in three weeks.
Big sigh of relief here.
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Ghost
climber
A long way from where I started
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Ghost Yeah... I had one where they billed me later for services my doctor said should be covered. But I procrastinated (mostly just ignored it) the subsequent billing, even after it went to collections. Eventually I got a statement requesting to pay a reduced amount
In my case, I did not procrastinate. I was all over them, all the time, with the question: "What service are you billing me for?" Of course, I knew, and they knew, that there was no service. That they were simply asking me to pay $2K for walking through their door. But I wanted to make sure that, if it ever came to law, I could point to a long trail of honest attempts on my part to sort it out.
BTW, How is your eye?
I was fortunate that the doc in the eyeglass retail place was as good as he was. In addition to what I mentioned above, he managed to get me an appointment in three days with the top vitreoretinal guy in Seattle. A guy I couldn't have talked my way into an appointment with in three months. Top notch care saved partial vision in a case that would normally have led to complete removal of the eye within three months (look up "100-day glaucoma").
Anyway, I'm now back in Canada after almost 20 years in the US, and free of the "healthcare" system you all are stuck with.
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Ken M
Mountain climber
Los Angeles, Ca
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MGuzzy, and the audience:
They even sent a letter to the insurance company explaining why their procedure was better. Either way I wasn't going to budge. I related my story to a friend that worked in the Health coverage biz and he said stand close with the predetermination they gave me. It was my proof the Dentist was informed of the Insurance coverage terms. Finally the Dentist started threatening to turn the bill over to collections.
What may not be clear, is that the bad guy in your story was the dentist, who attempted to pull a "bait and switch".
When you have something like you had done over two days, there are separate charges that kick in for the two days: exam, anesthesia, for example.
When you get it in one day, you don't generate those charges, because you don't provide those services.
He got authorization to do one thing, but then did another thing. He got caught.
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Ghost
climber
A long way from where I started
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formerclimber
Boulder climber
CA
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Installed Android app "Call Recorder" on my phone last week....it automatically records all calls. I don't see an option to play the warning of recording so I verbally warn that the call is being recorded, being in two-party consent state.
Really good to have these recordings (I've been stuck in the web of misinformation and lies by new insurance and also medical group/IPA - in thier system there're 2 levels instead of one to deal with regarding preauthorizations and related questions)
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formerclimber
Boulder climber
CA
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Apr 3, 2019 - 09:45am PT
I saw stats that 30-40% of claims get denied on the first submittal by big insurance companies
A more accurate stat is 14%.
14% might be the average accross all types of plans including government ones.
The above stats belonged to major commercial insurance plans, as I recall.
40% was for Cigna, others like BCBS had around 30%. I don't have the link now - saw these stats in 2017 (and may be they'd improved since). Also, stats might include denial upon the 1st submit attempt - sometimes a simple resubmit can be paid without appeal (one tactics they use is to reject the 1st attempt with "no patient record found" while valid info was submitted - this doesn't even register on the insurance side as a rejection officially so will fall through the stats on the insurer's side)
A couple of reports:
Until the Government Accounting Office (GAO) issued a report in 2011, there were no official or comprehensive statistics on how often insurers denied coverage for prescribed treatments. The GAO’s study, which reviewed data on insurers in six states, found that the rate of coverage denial varied significantly across insurance providers, from 6 to 40 percent.  this was data for "six large insurers"
ACA transparency data show denial rates by issuers were highly variable, ranging from 1% to 45% of in-network claims.
Earlier info:
Nationwide data collected by HHS from insurers showed that the aggregate application denial rate for the first quarter of 2010 was 19 percent, but that denial rates varied significantly across insurers. For example, just over a quarter of insurers had application denial rates from 0 percent to 15 percent while another quarter of insurers had rates of 40 percent or higher.
From 2002 through June 30, 2009, six of the largest insurers operating in California rejected 47.7 million claims for care – 22 percent of all claims.
My personal experience with, say, imaging/tests was around 30% denials, either doctors or myself appealed with success.
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