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Old 01-19-2018, 10:10 PM
psychobunny psychobunny is offline
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Every time I think the US health insurance industry can't get any worse...

I seriously thought the ACA was going to solve some of these problems.

Here's today's story from the front lines (details altered to preserve patient privacy but the story and insurance information is true).

Patient comes to me as a new patient. Does not have insurance known to us but it is under a PPO group of plans that we participate with. I see the patient who appears healthy and as per request perform screening blood tests. These tests reveal a significant abnormality with a test level 3x the normal value. Since this could indicate a serious problem, the lab is called and additional testing is added on, which returns within normal range. However, the original test was abnormal enough that a repeat is warranted. The patient is called back and the test is repeated and is now only minimally abnormal. Patient is informed that this may represent the early stages of disease and needs to be monitored closely and follow-up is arranged.

Today we get a call from an upset patient who is being billed by the lab for the second test. On questioning the lab, the patient was informed that patient's insurance only covers lab tests once yearly. Patient is asking us to pay for the test since we ordered it Patient is adamant that we should have know what the insurance would cover and ordered appropriately and does not want to listen to our explanation that the patient is responsible for knowing what their insurance covers or does not cover. Because we are trying to help, we call the insurance and ask them to send over some information to explain why what by any account was a necessary test was not covered.

The document we receive contains the following lines in big bold letters:
Quote:
[Plan has] no co-pays, co-insurance, or deductibles.
Two pages later in tiny type:

Quote:
[Plan] is intended to provide minimum essential care under the Affordable Care Act. It provides you with preventive care only...

What is not covered under [Plan]...

-sickness or disease of any kind...
-laboratory, radiology, or cardiovascular tests performed for the diagnosis or treatment of sickness, disease or injury
But wait! It gets better. Let's delve into the specific coverages. For example, it covers heart attacks and cancer.

Quote:
Daily Benefit for Heart Attacks- $1500 per day
Number of Daily Benefits Per coverage Year-1

Daily Benefit for Cancer-$2000 per day
Number of Daily Benefits Per coverage Year-1
What about surgery, you ask?

Quote:
Maximum Surgery Benefit Per Procedure-$750
Now looking at our billing, I note that the "insurance" allows $75 for an initial doctor visit. According to the Explanation of Benefits we received, the allowed amount under our contract for this visit was $80.76. The remaining $5.76 is listed under "patient responsiblity" but is not in the deductible, coinsurance or copayment field, but in an additional field marked "ineligible".

And the crap-ass poor excuse for health insurance is apparently ACA compliant! I told the patient to double check the out of pocket maximum since I am pretty sure that the ACA mandates a yearly limit. Now that the individual mandate is gone, we are going to see more and more of these plans that tout how they cover all "preventative services" sold to people who are going to be royally screwed if they get sick!

In addition, let me just rant a little about the patient's attitude (although I truly feel for the patient). I participate in about 13 major categories of health plans which means literally over a hundred different plans each with different coverages, copays, deductibles etc and you are upset that I didn't know that your plan excludes tests done for disease? I can't know every detail of every plan. It would take hours or days to read them all and I certainly couldn't remember the details. It is my job to know if I participate in your insurance but it is your job to to know what your "insurance" covers. If I had known that you were only covered for preventative services and not disease, I honestly would have ordered the exact same tests. I am sorry that you may be in the early stages of a disease that needs monitoring but just because the second test was significantly better than the first does not mean that I "should pay the lab bill because ordering the second test was [the doctor's] mistake".

That said, I am so much more upset with the insurance company that with the patient that I will do anything in my power to help. I have no authority over lab bills but informed the patient that the lab is usually willing to bargain down the price in these cases. Going forward, I don't know how to arrange treatment for the patient, except to tell them to get a better health plan.

grumble, grumble should have gone to Law School instead
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Last edited by psychobunny; 01-19-2018 at 10:14 PM.
  #2  
Old 01-19-2018, 10:33 PM
Chessic Sense Chessic Sense is offline
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Originally Posted by psychobunny View Post
I seriously thought the ACA was going to solve some of these problems.
...
[Plan] is intended to provide minimum essential care under the Affordable Care Act. It provides you with preventive care only...
I don't follow. It says "minimum" right there. The patient has crappy insurance, and likely pays accordingly. What's the problem?

Quote:
And the crap-ass poor excuse for health insurance is apparently ACA compliant!
Yeah? And? It's not like better health plans are unavailable. You are, in fact, able to get other health plans.

Quote:
Now that the individual mandate is gone, we are going to see more and more of these plans that tout how they cover all "preventative services" sold to people who are going to be royally screwed if they get sick!
What does the mandate have to do with more plans touting...whatever they allegedly tout? How does fining people for refusing to overpay for services they don't want prevent these plans? How does stopping those fines create such plans?


Quote:
I am so much more upset with the insurance company
Why? What did they do wrong? You buy health care Taco Bell, you get health care diarrhea.
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Old 01-19-2018, 11:01 PM
nearwildheaven nearwildheaven is offline
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Candy-assed "insurance policies" like this have existed for as long as we've had health insurance.

I wonder how much that person was paying for it; probably not much less than s/he would have for a plan that actually paid something, even if it did have a high deductible.
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Old 01-19-2018, 11:07 PM
Gary Kumquat Gary Kumquat is offline
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Chessic, is your position really caveat emptor to that extreme, no qualifications. You honestly believe that every person in the US is capable of reviewing contractual small print, so as long as someone out there is selling a decent policy at some price, it's perfectly ok for every other firm in the market to sell whatever? Fuck me, talk about devil take the hindmost.
  #5  
Old 01-19-2018, 11:21 PM
Wesley Clark Wesley Clark is offline
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Its not going to get better. Our health care is wildly overpriced and income inequality keeps getting worse, so people will be ending up with shittier and shittier insurance policies that don't actually cover anything.

I may just move in my 50s to another country.
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Old 01-19-2018, 11:41 PM
psychobunny psychobunny is offline
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Quote:
What does the mandate have to do with more plans touting...whatever they allegedly tout? How does fining people for refusing to overpay for services they don't want prevent these plans? How does stopping those fines create such plans?
Sorry-the loss of the mandate has nothing to do with these plans. I was just too pissed to know what I was writing. What I was thinking is that the creation of "association plans" which do not have to follow ACA minimum guidelines will lead to these plans.

I do know that these plans have been around forever, but the ACA was supposed to require a certain minimum coverage that I thought was better than this.

Chessic Sense

I know it is the patient's responsibility to know what they have bought but look at it from my point of view. I run a small business on a razor thin margin that is dependent on word-of-mouth to keep going. I can't afford to have upset patients. The patient blames me and does not understand why I ordered tests that the insurance will not cover. My staff and I both tried to explain but could not make the patient understand that there is no way for me to search each insurance plan every time I order a lab. I can suck it up and pay for the labs and keep a happy patient but if I keep doing that I will go bankrupt, or I can tell the patient that it is their responsibility and risk an online review saying that I ordered unnecessary tests. Plus, nobody likes getting yelled at for something they had no control over.
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Last edited by psychobunny; 01-19-2018 at 11:42 PM.
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Old 01-19-2018, 11:41 PM
Beckdawrek Beckdawrek is online now
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And, guess what? It ain't gonna get any better anytime soon. Thanks; you great orange idiot!!
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Old 01-20-2018, 08:30 AM
asahi asahi is offline
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Originally Posted by Beckdawrek View Post
And, guess what? It ain't gonna get any better anytime soon. Thanks; you great orange idiot!!
It's not just the orange idiot, though. The corruption has existed for years and both parties have aided and abetted corporate behemoths holding millions of people hostages for years. I'd also add that people just need to be better educated on the subject too. There's nothing at all wrong with socializing health care -- it almost always works better than the mess that we have in this country. Without question, Americans get the worst value by far of any country on earth in terms of results for the dollars we spend.

And I'm afraid you and Wesley are right: nothing is going to change. In some ways, I kinda wish Trump and the GOP would just go ahead and blow up the entire health system just to get it over with. America's health system obviously cannot evolve; we need a healthcare revolution.
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Old 01-20-2018, 08:48 AM
Stranger On A Train Stranger On A Train is online now
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I seriously thought the ACA was going to solve some of these problems.
I’m not sure why you’d think the Affordable Care Act would address any of the issues you encountered. The ACA was literally the least worst legislation that then-President Obama could get Congress to pass that facilitated insurance some level of coverage for entire classes of people whom insurers would otherwise refuse to cover for “pre-existing conditions” such as having had complications in a prior childbirth or being over a certain age. The ACA did absolutely nothing to control or clarify medical costs other than some basic reporting requirements on what a plan would or would not cover, and even these are so vague as to be essentially worthless. I’ve read through the detail policy on my plan and even I can’t really figure out what it does and does not cover with regard to specific tests and treatments, and queries to the insurer have resulting in a response that doesn’t provide any answers but instead advises me to purchase supplementary policies from a third party insurer which are even more ambiguous about coverage.

The entire notion that medical services are some kind of commodity market that consumers can make well-informed cost versus benefit analyses about (while dealing with a family member or themselves in serious illness or trauma) is given lie by the fact that most medical practitioners have little or no knowledge of the costs of tests or procedures they recommend that are outside of their practice, and often enough even within it, notwithstanding that a non-medically trained consumer has no basis to evaluate the necessity or consequence of a treatment recommended by a physician, and generally not the time or money to obtain multiple opinions from different practicianors in all but the most chronic or dire of cases where it is clear that their GP or specialist is out of his or her depth. Other nations with government provided or regulated ‘socialized medicine’ may not be perfect (and many of them in poorer nations are not even particularly good at technically advanced procedures and treatments) but at least the populations of these countries have access to basic medical care without the risk of being bankrupted or turned away for lack of insurance.

When we’re having a policy debate over the necessity of providing ‘free’ basic health care to chiildren who are not covered by their parents’ medical coverage, if any, all courtesy of the self-ascribed “Party of Family Values” something is seriously out of joint with the United States as an international leader and a society of fundamental decency. But hey, keep those campaign contributions from Big Pharma and insurance companies rolling in! Keep that train moving even if the bridge is out!

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Last edited by Stranger On A Train; 01-20-2018 at 08:49 AM.
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Old 01-20-2018, 09:13 AM
BeenJammin BeenJammin is offline
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It's rather interesting to me that so many people remain ignorant of the simple fact that big business of all kinds run the U.S. government. And even more so that these same people continue perpetrating the illusion that some political savior in the personna of whoever presently appears to oppose their perceived political adversaries, will somehow save the day.

Greed has no electoral preference.
  #11  
Old 01-20-2018, 09:15 AM
Wesley Clark Wesley Clark is offline
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Originally Posted by Beckdawrek View Post
And, guess what? It ain't gonna get any better anytime soon. Thanks; you great orange idiot!!
He doesn't help, but you can't blame the republicans. In states like Vermont (under Shumlin) and California which have massive democratic majorities, they aren't willing to pass state level health reform either. Sure they'll talk about it, but they won't actually do it.

Neither party wants to take on the medical industrial complex. The democrats just want to tepidly expand coverage while leaving the brutal, broken, overpriced system intact. The GOP is worse, but the democrats aren't willing to fix the system.

I don't know what the answer is.
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Old 01-20-2018, 09:18 AM
j666 j666 is offline
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And how many people do you need just to deal with the billing requirements for each insurance company? If your staff had billed the test differently, for example as a re-test because the first test was done incorrectly (which might actually be the case), would the insurance covered it?

I really don't want to throw half your office staff and the entire health insurance industry out of work, but I think single payer would give us a lot fewer problems to deal with.
  #13  
Old 01-20-2018, 09:19 AM
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I was in a motorcycle accident last June- totaled my bike, and in the process broke my collarbone and three ribs.

At first, I really wanted my wife to come pick me up to take me to the hospital- because I had no idea how much the ambulance ride would cost me. First off, is this really the sort of thing one should have to worry about in the moments after an accident?

Anyway, the paramedics convinced me that I'd soon be in a lot of pain, so an ambulance ride would really help. They were right on this- a few minutes later, I started really hurting.

When I got to the hospital, they took good care of me.... but at no point could I figure out how much the stay was going to cost me. I couldn't even tell how much the food on the hospital menu would cost me (eventually I found out- it was free).

I spent the night there on the advice of the doctor, because I had what looked like a partially collapsed lung. In the morning, though, I was fine, and went home.

A month later, it was clear my collarbone wasn't going to heal on its own, so I had to go in for surgery. I'm mostly recovered at this point, however... even though I maxed out my deductible for the year, I'm still getting bills. The insurance company says they paid, the hospital says they didn't- so I'm stuck in the middle, trying to get the two entities to talk to each other. I've already paid about $2000 in addition to all of the money I got back from my totaled motorcycle... but I'm still seeing bills for at least another thousand bucks.

And I feel like I got off lucky. I didn't have to file bankruptcy, and I'm mostly healed. But this system sucks; in my opinion, the last thing a patient should have to worry about in a life-threatening situation is how they're going to pay for it. The system shouldn't be caveat emptor, with patients viewed as cash cows. Eventually everyone needs healthcare, but it turns out that even with insurance we can still be screwed over.
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  #14  
Old 01-20-2018, 09:25 AM
Clothahump Clothahump is offline
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Originally Posted by Beckdawrek View Post
And, guess what? It ain't gonna get any better anytime soon. Thanks; you great orange idiot!!
Ummm....Trump didn't implement the ACA clusterfuck. Big hint - the name Obamacare should give you an idea who to blame for this.
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Old 01-20-2018, 09:38 AM
asahi asahi is offline
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Ummm....Trump didn't implement the ACA clusterfuck. Big hint - the name Obamacare should give you an idea who to blame for this.
...as if the healthcare system was functioning fine before Obama got his hands on it.
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Old 01-20-2018, 09:40 AM
Stranger On A Train Stranger On A Train is online now
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Ummm....Trump didn't implement the ACA clusterfuck. Big hint - the name Obamacare should give you an idea who to blame for this.
The Affordable Care Act (a.k.a. “Obamacare”) didn’t create this system, and if it doesn’t do much to control ever increasing costs of health care its enactment is coincident with a relatively flat rate of cost as a share of gross domestic product in comparision to historical cost growth in the early 1990s and 2000s (”National Health Care Spending In 2016”, Center for Medicare and Medicade Services, Office of the Actuary, National Health Statistics Group, Page 4, chart titled “National Health Expendatures as a Share of Gross Domestic Product, 1987-2016”).

You know, if you want some actual facts instead of the usual baseless invective and ad hominem.

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...as if the healthcare system was functioning fine before Obama got his hands on it.
That just shows how powerful he is! He can actually go back in time and retroactively destroy health care before he was even in elected office. He’s like Nick Fury, except smart enough not to trust somebody and lose an eye for his faith. Badass!

Stranger

Last edited by Stranger On A Train; 01-20-2018 at 09:43 AM.
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Old 01-20-2018, 09:41 AM
watchwolf49 watchwolf49 is offline
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Let me see if I have this straight ... the first lab test was done in error, but the lab got paid ... now we have to do the test again and, yup, the lab gets paid again ... thus increasing the lab's shareholder dividends ...

Sounds like this system works GREAT for investors ... Hospital Corporation of America (stock symbol HCA) is currently trading at $93.01 ... buy some shares today !!! ...
  #18  
Old 01-20-2018, 09:48 AM
Bryan Ekers Bryan Ekers is online now
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I got clumsy with a table saw a while back, cut the little finger of my left hand pretty seriously.



Good thing I was Canadian that day.
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Old 01-20-2018, 09:50 AM
Wesley Clark Wesley Clark is offline
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Ummm....Trump didn't implement the ACA clusterfuck. Big hint - the name Obamacare should give you an idea who to blame for this.
American health care without the ACA is a D+ grade. With the ACA it is a C (by western standards. Our health care is incredible by Ugandan standards). The ACA made it better than it would have been otherwise but it still sucks.

We want a system that is a B+ or better. Single payer with massive reform would get us there.
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Old 01-20-2018, 10:00 AM
Beckdawrek Beckdawrek is online now
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What I mean is the big Orange-one promised to fix or repeal Obama-care. He ain't done crap I personally have great health care insurance.
That's not to say I don't worry. One big illness and that jig is up.
We need universal health care, Medical facilities need to cut there cost and waste.
  #21  
Old 01-20-2018, 10:09 AM
Stranger On A Train Stranger On A Train is online now
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Good thing I was Canadian that day.
There have been a lot of days in the last twenty-odd years where you could say that.

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Old 01-20-2018, 10:20 AM
Chronos Chronos is offline
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Why are we discounting the simplest explanation? It's by far most likely that the patient's insurance is not, in fact, compliant with the ACA or any other relevant regulations, and the company is just lying and running a scam. This explains nicely why they say they have no co-pays, and are now charging a co-pay.
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Old 01-20-2018, 11:29 AM
Bryan Ekers Bryan Ekers is online now
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There have been a lot of days in the last twenty-odd years where you could say that.

Stranger
It has indeed proved useful on numerous occasions.
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  #24  
Old 01-20-2018, 11:32 AM
Dante Dante is offline
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I suffered a fall and fractured my skull, had bleeding in my frontal lobe, and had to stay in the emergency ward for three days to see if I was going to need a hold drilled in my skull to relieve pressure from swelling. I had three CT scans and multiple consults. At the end of that, i got a firm handshake and well wishes from the hospital staff. Canadian health care may not be perfect, but I never had to worry about a co-pay, deductible, or worse. The thought of not being able to "afford" to be sick or injured is unconscionable, and I can't believe a country like America allows it for its citizens.
  #25  
Old 01-20-2018, 11:43 AM
Stranger On A Train Stranger On A Train is online now
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The thought of not being able to "afford" to be sick or injured is unconscionable, and I can't believe a country like America allows it for its citizens.
Only for those who lack the moral fortitude to not earn enough money to afford medical care, and those too stupid to avoid getting cancer or encephalitis. Sick people are just lazy slackers with bad attitudes, right?

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  #26  
Old 01-20-2018, 11:55 AM
FloatyGimpy FloatyGimpy is offline
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I got clumsy with a table saw a while back, cut the little finger of my left hand pretty seriously.



Good thing I was Canadian that day.
I honestly feel nauseous when I read about health insurance horror stories (and they're all horror stories to me) from Americans. It's something I can't wrap my head around. I just can't imagine going through something like when I had gallbladder stones and was in agony, even trying to think about insurance and if I'm covered and then knowing I'll have forms to fill out and calls to make after.

I feel so sorry Americans who end up bankrupt because they were unlucky enough to get sick.

I don't know what's more unbelievable to me, that the health system exists the way it does or that there are actually people who think it's great

It's the least Christian thing from a supposedly Christian country - denying healthcare to the sick and poor.
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Old 01-20-2018, 12:04 PM
running coach running coach is offline
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I honestly feel nauseous when I read about health insurance horror stories (and they're all horror stories to me) from Americans. It's something I can't wrap my head around. I just can't imagine going through something like when I had gallbladder stones and was in agony, even trying to think about insurance and if I'm covered and then knowing I'll have forms to fill out and calls to make after.

I feel so sorry Americans who end up bankrupt because they were unlucky enough to get sick.

I don't know what's more unbelievable to me, that the health system exists the way it does or that there are actually people who think it's great

It's the least Christian thing from a supposedly Christian country - denying healthcare to the sick and poor.
This pretty much sums it up.
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Old 01-20-2018, 12:28 PM
Morgenstern Morgenstern is offline
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Originally Posted by FloatyGimpy View Post
...

I feel so sorry Americans who end up bankrupt because they were unlucky enough to get sick.

....

What the fuck do you want, the government to pay everyone's medical expenses? Where do you suggest the government gets that money with a big wall to build?
  #29  
Old 01-20-2018, 12:42 PM
nearwildheaven nearwildheaven is offline
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Here's an anti-Pit post.

I was diagnosed with breast cancer in October. I'm self-employed and purchase my own insurance, and so far, it has paid claims without a smidgen of hassle. This has been almost as big a load off my mind as it was to find out that I did not need and would not benefit from chemotherapy.

http://boards.straightdope.com/sdmb/...d.php?t=836996
  #30  
Old 01-20-2018, 12:52 PM
Helena330 Helena330 is offline
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Back to the OP, no disrespect intended, but I find it nuts that you're annoyed with this patient. You've told them they may have a possibly serious disease, so of course, they're freaking. You then tell them they need another test to confirm it or rule it out. Of course, they'll jump at it without thought to their insurance. THIS is the point where you should've informed them they should be sure their insurance covers it. They can't be the first person you've encountered who doesn't know their insurance doesn't cover something. It sounds to me like you need some procedures in your office to deal with those situations. I doubt very many people know the mind-numbing minutiae of what tests and re-tests in what situations their insurance covers. You stressed this patient and made their already-scary situation worse.
  #31  
Old 01-20-2018, 01:03 PM
Jackmannii Jackmannii is offline
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Originally Posted by FloatyGimpy View Post
I don't know what's more unbelievable to me, that the health system exists the way it does or that there are actually people who think it's great
It shouldn't be unbelievable that people think current U.S. healthcare has decent coverage, because for most it does. It's the exceptions (and there are too many) that furnish the horror stories.

What struck me most about the OP was the (apparently) grossly inaccurate result on the first lab test (something that can happen in any healthcare system), and why it probably would've been better to repeat that one test before moving on to a battery of others.

It's well known that if a bunch of screening blood tests are done on a healthy person, odds are that one may show a markedly abnormal result as a false positive. Years ago, I had a liver function test result that was indicative of serious liver damage. My first reaction was that I probably had chronic viral hepatitis secondary to job exposure, Mrs. J. was at risk too and we were in for serious problems. The repeat test was flat normal. There was never an explanation as to why the first reading was so abnormal.

This source gives an illustrative example - if you get a standard chemistry screening profile (Chem-15), odds that all 15 test results will fall into the normal reference range for a healthy person would be only 46% (though the false positive abnormal reading(s) tend in such situations to be mildly out of range. Still, it's an indication that if the person seems healthy, jumping to conclusions (or going overboard in further testing, or worse, therapy) is not a good idea.
  #32  
Old 01-20-2018, 01:27 PM
Stranger On A Train Stranger On A Train is online now
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What the fuck do you want, the government to pay everyone's medical expenses? Where do you suggest the government gets that money with a big wall to build?
I thought Mexico was going to pay for that wall, Vincente Fox’s amusingly profane tirade to the contrary notwithstanding. No? Well, shit, Donny, what campaign promises can you keep? Can’t put the bitch in prison, can make the spics pay for a wall, can’t repeal Obamacare, can’t bring back coal jobs to Kentucky or assembly jobs to Indiana, can’t even find those “three to five million illegal ballots”.

Seems like Don the Vulgarian’s biggest accomplishments are number of Twitter posts per day and spending the most time on the golf course. He’s in the running for “Least Effective President” with William Henry Harrison and Zachery Taylor, and despite their advantages of dying relatively early into their respective terms Trump appears to be chugging along competitively in functional non-progress despite his double fisted Big Mac attacks and bowl of Colonel Sanders Extra Crispy diet plan.

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  #33  
Old 01-20-2018, 01:32 PM
FloatyGimpy FloatyGimpy is offline
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It shouldn't be unbelievable that people think current U.S. healthcare has decent coverage, because for most it does. It's the exceptions (and there are too many) that furnish the horror stories.
http://www.pbs.org/healthcarecrisis/uninsured.html

From the link: "About 44 million people in this country have no health insurance, and another 38 million have inadequate health insurance."

That's 82 million people without proper insurance. That's more than just "the exception".
  #34  
Old 01-20-2018, 01:46 PM
Chessic Sense Chessic Sense is offline
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Originally Posted by Gary Kumquat View Post
Chessic, is your position really caveat emptor to that extreme, no qualifications. You honestly believe that every person in the US is capable of reviewing contractual small print, so as long as someone out there is selling a decent policy at some price, it's perfectly ok for every other firm in the market to sell whatever? Fuck me, talk about devil take the hindmost.
No, my position is that we already know this sort of thing happens. This is a very mundane story that has no remarkable features in it. I thought "Surely the OP knows there are shitty health insurance plans. I guarantee they've met or heard about people who have no insurance at all, so it can't be a shock to encounter a person with a plan barely above that. Also, people are dumb, so (s)he can't be surprised to hear someone yelling at a doctor's office that they should've somehow understood how the patient's insurance works. That must happen three times a day, every day. Then there's some part about the ACA and the individual mandate, but this person has a plan, so the mandate is satisfied anyway, so that can't be what this story is about."

So I truly can't understand the OP. It's like a story where someone says "I ordered the medium fries at Wendy's, and get this, they charged me $1.99!" My response is "Uh hu. Yeap. That's...that's certainly how that works, mhmm."

Quote:
Originally Posted by psychobunny View Post
Sorry-the loss of the mandate has nothing to do with these plans. I was just too pissed to know what I was writing. What I was thinking is that the creation of "association plans" which do not have to follow ACA minimum guidelines will lead to these plans.

I do know that these plans have been around forever, but the ACA was supposed to require a certain minimum coverage that I thought was better than this.
Ahah! Now we're getting somewhere!

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Originally Posted by psychobunny View Post
I know it is the patient's responsibility to know what they have bought but look at it from my point of view. I run a small business on a razor thin margin that is dependent on word-of-mouth to keep going. I can't afford to have upset patients. The patient blames me and does not understand why I ordered tests that the insurance will not cover. My staff and I both tried to explain but could not make the patient understand that there is no way for me to search each insurance plan every time I order a lab. I can suck it up and pay for the labs and keep a happy patient but if I keep doing that I will go bankrupt, or I can tell the patient that it is their responsibility and risk an online review saying that I ordered unnecessary tests. Plus, nobody likes getting yelled at for something they had no control over.
A stupid customer yellilng at you? You're damned if you do, damned if you don't? Now that's a rant I can get behind!
  #35  
Old 01-20-2018, 01:51 PM
FloatyGimpy FloatyGimpy is offline
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Originally Posted by Chessic Sense View Post
So I truly can't understand the OP. It's like a story where someone says "I ordered the medium fries at Wendy's, and get this, they charged me $1.99!" My response is "Uh hu. Yeap. That's...that's certainly how that works, mhmm."
That's not what's happening though. A better analogy would be seeing someone starving on the street because all they've eaten in the last 3 days is a cup of coffee that they bought with some change they found and saying "well, no wonder you're starving, you only bought coffee - what do you expect!?".

It's not about only buying coffee, it's about not having enough money to buy proper food so that you don't die.
  #36  
Old 01-20-2018, 02:01 PM
Wesley Clark Wesley Clark is offline
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Originally Posted by Dante View Post
I suffered a fall and fractured my skull, had bleeding in my frontal lobe, and had to stay in the emergency ward for three days to see if I was going to need a hold drilled in my skull to relieve pressure from swelling. I had three CT scans and multiple consults. At the end of that, i got a firm handshake and well wishes from the hospital staff. Canadian health care may not be perfect, but I never had to worry about a co-pay, deductible, or worse. The thought of not being able to "afford" to be sick or injured is unconscionable, and I can't believe a country like America allows it for its citizens.
Americans hate each other a lot, and because of that we'll never get UHC. Whenever it is discussed, people start dog whistling to turn whites against non-whites and the middle class and working class against the poor. 'why should middle class whites pay so poor black people and latino immigrants can see a doctor' comes up a lot. People think the UK is a classist society, but the US has very deep racial and class divisions that get in the way of any social welfare program.

Plus the medical establishment is a 3 trillion dollar a year industry now. Nobody wants to take it on. To truly reform health care, we'd have to cut the industry down to 2 trillion a year. No industry gives up 1 trillion a year in business without a fight. Plus now that our health care system is 18% of our economy, nationalizing it is difficult. We should've implemented UHC back in the 60s when we were spending 6% of GDP on health care. Now people balk at the price tag of UHC despite the fact that it'll actually be cheaper.

Basically, as americans, we are fucked. Totally fucked. Help isn't coming. I do wish other nations would politically pressure us to adopt UHC though. Just like the US uses political and social pressure to make other nations improve their human rights, I wish other nations did the same to us to make us adopt UHC (or more fair elections, or ending plutocracy, etc).

As I mentioned upthread, even in deep blue states like California or Vermont, all they do is give lip service to health reform while not actually doing anything meaningful .
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Last edited by Wesley Clark; 01-20-2018 at 02:04 PM.
  #37  
Old 01-20-2018, 02:38 PM
kaylasdad99 kaylasdad99 is online now
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Originally Posted by Chessic Sense View Post
I don't follow. It says "minimum" right there. The patient has crappy insurance, and likely pays accordingly. What's the problem?



Yeah? And? It's not like better health plans are unavailable. You are, in fact, able to get other health plans.



What does the mandate have to do with more plans touting...whatever they allegedly tout? How does fining people for refusing to overpay for services they don't want prevent these plans? How does stopping those fines create such plans?




Why? What did they do wrong? You buy health care Taco Bell, you get health care diarrhea.
I was under the impression that the ACA rendered “health care Taco Bell” non-existent.
  #38  
Old 01-20-2018, 02:59 PM
Chessic Sense Chessic Sense is offline
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Originally Posted by FloatyGimpy View Post
That's not what's happening though. A better analogy would be seeing someone starving on the street because all they've eaten in the last 3 days is a cup of coffee that they bought with some change they found and saying "well, no wonder you're starving, you only bought coffee - what do you expect!?".

It's not about only buying coffee, it's about not having enough money to buy proper food so that you don't die.
Except there's no evidence that the person with the coffee is starving, or that they're too poor to buy food. All we know is that they didn't buy good food and wants the restaurant to pay for food that evidently didn't taste very good.

This is identical to a "free refill misunderstanding" story where the cafe bills a customer for 6 cups of coffee and the patron complains that they should be billed for one, with free refills. The shopkeeper replies "We don't offer free refills," and the patron says "Well I thought you did, and that's your fault!"

Sometimes I think I'm the only person that actually cares about what people did and did not write. It's like 99% of the world just sees the word "healthcare" and thinks that's some ticket to just respond with any ol' comment tangentially related to healthcare. It's like you (generally speaking) read "This lady had healthcare insurance and it ended badly" so you go "Well let me tell you about healthcare insurance ending badly!" with total disregard for the rest of the conveyed story.


Tell me, where does the OP say that the patient is poor?
  #39  
Old 01-20-2018, 03:12 PM
running coach running coach is offline
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Quote:
Originally Posted by Chessic Sense View Post
Except there's no evidence that the person with the coffee is starving, or that they're too poor to buy food. All we know is that they didn't buy good food and wants the restaurant to pay for food that evidently didn't taste very good.

This is identical to a "free refill misunderstanding" story where the cafe bills a customer for 6 cups of coffee and the patron complains that they should be billed for one, with free refills. The shopkeeper replies "We don't offer free refills," and the patron says "Well I thought you did, and that's your fault!"

Sometimes I think I'm the only person that actually cares about what people did and did not write. It's like 99% of the world just sees the word "healthcare" and thinks that's some ticket to just respond with any ol' comment tangentially related to healthcare. It's like you (generally speaking) read "This lady had healthcare insurance and it ended badly" so you go "Well let me tell you about healthcare insurance ending badly!" with total disregard for the rest of the conveyed story.


Tell me, where does the OP say that the patient is poor?
What difference does that make? if they can't afford the bill, they can't afford the bill. Tell me, where in the story was the actual cost mentioned? Some tests can be very expensive.

I don't see any mention of a restaurant until your idiot supposition. Just how much food do you think someone can buy for the price of a cup of coffee?

What is it with you asshole conservatives? Instead of fixing a broken system, you look for ways to blame the person without even knowing anything about them.

Why do you consider adequate healthcare to be an evil thing?
  #40  
Old 01-20-2018, 03:18 PM
Eonwe Eonwe is offline
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As someone who works in, or maybe adjacent to the health care industry, and whose customers are doctors, I hear you, OP.

I am amazed at the number of non-medicine things PCPs (particularly if they are running their own practice) need to be proficient in in order to stay in business, stay accredited, get paid (and get paid fairly), and keep the lights on. It's overwhelming. While it would be nice if the doctor could answer definitively in the moment exactly what each patient's insurance will and won't cover, and at what rate, that's just not a realistic burden to put on the docs.

I also understand, though, why the patient yells at you; doctors are the human interface of the health care industry. They don't have a relationship with (or direct access to) anyone at BCBS or wherever, so any problem is your problem.
  #41  
Old 01-20-2018, 04:08 PM
wolfpup wolfpup is online now
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Originally Posted by Eonwe View Post
I am amazed at the number of non-medicine things PCPs (particularly if they are running their own practice) need to be proficient in in order to stay in business, stay accredited, get paid (and get paid fairly), and keep the lights on. It's overwhelming. While it would be nice if the doctor could answer definitively in the moment exactly what each patient's insurance will and won't cover, and at what rate, that's just not a realistic burden to put on the docs.
It doesn't seem like too much to ask for a doctor to know what each patient's insurance will cover and at what rate. In the single-payer system where I live, not only does the doctor know, but so does anybody who may interested. There's no deep mystery about fees which insurance companies have turned into some kind of mysterious black art -- the exact fees are all in a document called "Schedule of Benefits, Physician Services Under the Health Insurance Act, Ontario Ministry of Health and Long Term Care". And it's of course the same for every patient, and everyone is covered unconditionally, so there's no question or hassle about getting paid.

These are the pertinent responsibilities:

What the doctor or hospital must do: Enter the appropriate code(s) in the OHIP online billing system.
What the patient must do: Show their health card. After that, nothing. Literally, nothing.

Doctor gets paid automatically in the next billing cycle.

If it sounds simple and streamlined, it is. This is what happens when you take useless parasitic insurance companies out of the system.
  #42  
Old 01-20-2018, 04:30 PM
Beckdawrek Beckdawrek is online now
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The clinic I use for health care has a patients advocate and an insurance person (s) employed. The Doctor doesn't usually get involved with that. Altho' I see a P.A. on normal visits and she will get into insurance questions with me. I have a long history of asthma and a family history of breast cancer. She makes sure I do all the yearly tests that my insurance covers 100%. I appreciate her, to no end. I realize this is not the norm. But it easily could be
  #43  
Old 01-20-2018, 04:51 PM
wolfpup wolfpup is online now
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Originally Posted by Beckdawrek View Post
She makes sure I do all the yearly tests that my insurance covers 100%. I appreciate her, to no end. I realize this is not the norm. But it easily could be
No, with all respect, it couldn't be the norm. The essence of any insurance business model is to discourage claims by requiring deductibles or co-pays or some other form of monetary disincentive and cost reduction strategy, as well as (usually) payment limits, and secondly to adjudicate each and every claim with a view to improving the bottom line by either (in the case of health insurance) requiring less expensive treatment protocols or, if legally possible, denying the claim altogether. The lack of a uniform coordinate fee structure and the lack of centralized cost control also means costs will continue to spiral out of control and, as noted, no one will ever really know what they are or know for sure that they're even going to get paid.

I'm glad to hear that you're getting your tests covered in full but this sounds more like a case of your health interests and the insurance company's cost-saving interests being aligned in that preventive medicine and early detection saves them money. It's not because they care about your health.
  #44  
Old 01-20-2018, 07:53 PM
j666 j666 is offline
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Americans hate each other a lot, ...
It is more complicated than that.

American's are raised to be self-reliant in theory, but not in practice. Therefore, each of us think whenever s/he needs help help, s/he deserves it, but the Other Person just needs to be taught to fish. In my experience, we are amazingly ignorant, not venal.
  #45  
Old 01-20-2018, 10:13 PM
pohjonen pohjonen is offline
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Now that this awful system has finally begun to annoy and inconvenience the providers as well as the patients, I don't understand why the professional medical associations don't band together and get their lobbyists to lean on congress for change, if they truly don't like the system as it is. They are the ones with some actual clout. We patients have zilch in the way of clout.
  #46  
Old 01-21-2018, 12:34 AM
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@ psychobunny — I asked this in an earlier thread, but didn't catch your answer:
What do you think about U.S. going to a "single-payer" system?
  #47  
Old 01-21-2018, 01:00 AM
septimus septimus is offline
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In another thread, one of the right-wing idiots (Hi, Starving Artist !) praised health insurance companies which return 97% of their premiums as health benefits. I asked him if he had to subtract the salaries of 2.6 million (with an M) employees of insurance companies from premiums in order to come up with this stat. He replied, in effect, that these employees were productive members of society who I wanted to put on the unemployment rolls, that their denying of care was essential to insurer profitability. And that, yes, he was too stupid to realize insurer expenses like salaries were not included in "profit."

If insurance companies are barely able to turn a profit under Obamacare, someone forgot to tell the Job Creators who invest in insurer stocks. It's true that Anthem shares have multiplied by only 4.5x over the last seven years — they haven't even quintupled — but shares of Cigna and Aetna have each sextupled over the same period, and the biggest insurer of all, UnitedHealth Group has septupled in value.

That's sextupled and septupled, each with an S. No wonder the Republicans, party of rich stockholders, have been loathe to fully vent their spite against ACA.
  #48  
Old 01-21-2018, 02:04 AM
Gary Kumquat Gary Kumquat is offline
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Originally Posted by FloatyGimpy View Post
It's the least Christian thing from a supposedly Christian country - denying healthcare to the sick and poor.
But to do anything else would be socialism, and the US is only in favour of collective funding of national services when it comes to military spending.
  #49  
Old 01-21-2018, 02:17 AM
psychobunny psychobunny is offline
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Let me add a little clarification. I’ll give an example of what would be a similar situation. Assume I have a patient that is a premenopausal woman.If the initial blood test was a screening blood count, for example, it would have shown the patient to be anemic, enough to cause symptoms. I would have added on an iron test to the original sample to see if she needed iron. This test was normal. I then would have told this hypothetical patient that since she was completely asymptomatic I would recommend watching for problems and repeating the blood count in 2-3 weeks rather than doing extensive further testing, She came in to repeat the blood count and it showed mild anemia and she was informed that I would recommend monitoring the labs. It was only the equivalent of this second blood count that was denied.

Since I order over a hundred tests on at least 10-15 patients daily, and reviewing an insurance plan to see if each and every test is covered would take hours, and I participate in hundreds off plans, it is not feasible to check the patient’ Insurance each and every time. I obviously know the basics, which labs take which common insrances etc but when I get one of the less common ones I sometimes ask the patient to check. If a patient has a high deductible plan, I have a list of labs and prices and can direct them to the least expensive but the patient usually knows that they have a high deductible and lets me know as soon as i tell them they need tests. I have never had a plan that would not pay for a repeat blood count for anemia unless it fell under the patient’s deductible.

As far as how I handle billing, let me just say that I have been burned too many times to count.
Billing solution #1- I hired a full time biller with 20+ years of experience and good references. She made a good salary but the money wasn’t coming in. I had a computer system for scheduling but did manual billing. When I checked on her she seemed to be ignoring the rejected bills. At the end of the year, there was $5000 in cash unaccounted for. My receptionist saw her down at the local bar selling viagra pills. I fired her which meant she left her mess of billing behind.

Billing solution #2-I vowed never to leave one person in charge of the billing again and hired a billing company used by several local practices. Because in primary care we bill smaller amounts for more visits (rather than one big amount for global surgical care) the billing is more work and therefore more expensive. I paid about 8% of gross collections to them. They did the billing and sent reports and while the account receivables were better and I got monthly reports, there were two company cofounders and the one we worked with left the company and moved to another state. This was when the government was pushing for electronic medical records and I wanted to put one in. He was pushing for a system he had a deal with. I investigated and found 5 plans that met government standards for meaningful use and his was not one of them. He was not happy about working with another plan. I eventually chose a plan that actually integrated the billing with the EMR and the entire deal was less than I was previously paying. However, while they could import demographic data and scheduling they insisted on starting billing clean. I struck a deal with the billing company to continue to clean up accounts receivable for 6 months for a portion of collections. It later turned out that his notion of cleaning up accounts receivable was to bill the patient If the insurance didn’t pay and If the patient didn’t pay he simply sent them the same bill every month without doing any further investigation. The 6 months passed and I again wrote off thousands of dollars.

Billing solution #3- I have an integrated medical record and billing system. They automatically kick back bills that are not “clean” and I can fix them right away. They check on denied claims and call the insurance to try to fix them before sending them back to us. My staff can deal with some of the easier stuff, like name changes and requests for more information but I insist on seeing all other denials personally. I can run my own detailed reports whenever I want. It is not perfect but it is much better than anything else I’ve done. That said, there are always problems, like if a Medicare patient switches to an HMO that we don’t participate with and when we double check at each visit for insurance changes tells us that they are still on Medicare without understanding that the HMO is different. In these cases, we are not their primary provider ( Medicare just assigns one if the patient doesn’t choose) and Medicare does not pay us but Medicare rules forbid billing patients for covered services and even uncovered services require a signed form beforehand. In these cases, the only solution is for the doctor to call to get a one-time exemption until the patient can change back to the regular Medicare they thought they still had. ( I posted on another thread about dealing with a Medicare PPO that is refusing to pay earlier this week)

Tl:dr I have been burned in the past and now oversee my billing personally much more closely.
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  #50  
Old 01-21-2018, 02:20 AM
psychobunny psychobunny is offline
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Let me add a little clarification. I’ll give an example of what would be a similar situation. Assume I have a patient that is a premenopausal woman.If the initial blood test was a screening blood count, for example, it would have shown the patient to be anemic, enough to cause symptoms. I would have added on an iron test to the original sample to see if she needed iron. This test was normal. I then would have told this hypothetical patient that since she was completely asymptomatic I would recommend watching for problems and repeating the blood count in 2-3 weeks rather than doing extensive further testing, She came in to repeat the blood count and it showed mild anemia and she was informed that I would recommend monitoring the labs. It was only the equivalent of this second blood count that was denied.

Since I order over a hundred tests on at least 10-15 patients daily, and reviewing an insurance plan to see if each and every test is covered would take hours, and I participate in hundreds off plans, it is not feasible to check the patient’ Insurance each and every time. I obviously know the basics, which labs take which common insrances etc but when I get one of the less common ones I sometimes ask the patient to check. If a patient has a high deductible plan, I have a list of labs and prices and can direct them to the least expensive but the patient usually knows that they have a high deductible and lets me know as soon as i tell them they need tests. I have never had a plan that would not pay for a repeat blood count for anemia unless it fell under the patient’s deductible.

As far as how I handle billing, let me just say that I have been burned too many times to count.
Billing solution #1- I hired a full time biller with 20+ years of experience and good references. She made a good salary but the money wasn’t coming in. I had a computer system for scheduling but did manual billing. When I checked on her she seemed to be ignoring the rejected bills. At the end of the year, there was $5000 in cash unaccounted for. My receptionist saw her down at the local bar selling viagra pills. I fired her which meant she left her mess of billing behind.

Billing solution #2-I vowed never to leave one person in charge of the billing again and hired a billing company used by several local practices. Because in primary care we bill smaller amounts for more visits (rather than one big amount for global surgical care) the billing is more work and therefore more expensive. I paid about 8% of gross collections to them. They did the billing and sent reports and while the account receivables were better and I got monthly reports, there were two company cofounders and the one we worked with left the company and moved to another state. This was when the government was pushing for electronic medical records and I wanted to put one in. He was pushing for a system he had a deal with. I investigated and found 5 plans that met government standards for meaningful use and his was not one of them. He was not happy about working with another plan. I eventually chose a plan that actually integrated the billing with the EMR and the entire deal was less than I was previously paying. However, while they could import demographic data and scheduling they insisted on starting billing clean. I struck a deal with the billing company to continue to clean up accounts receivable for 6 months for a portion of collections. It later turned out that his notion of cleaning up accounts receivable was to bill the patient If the insurance didn’t pay and If the patient didn’t pay he simply sent them the same bill every month without doing any further investigation. The 6 months passed and I again wrote off thousands of dollars.

Billing solution #3- I have an integrated medical record and billing system. They automatically kick back bills that are not “clean” and I can fix them right away. They check on denied claims and call the insurance to try to fix them before sending them back to us. My staff can deal with some of the easier stuff, like name changes and requests for more information but I insist on seeing all other denials personally. I can run my own detailed reports whenever I want. It is not perfect but it is much better than anything else I’ve done. That said, there are always problems, like if a Medicare patient switches to an HMO that we don’t participate with and when we double check at each visit for insurance changes tells us that they are still on Medicare without understanding that the HMO is different. In these cases, we are not their primary provider ( Medicare just assigns one if the patient doesn’t choose) and Medicare does not pay us but Medicare rules forbid billing patients for covered services and even uncovered services require a signed form beforehand. In these cases, the only solution is for the doctor to call to get a one-time exemption until the patient can change back to the regular Medicare they thought they still had. ( I posted on another thread about dealing with a Medicare PPO that is refusing to pay earlier this week)

Tl:dr I have been burned in the past and now oversee my billing personally much more closely. I think single payer would be the best solution. I have no problem with a two tier system as long as there is a basic health plan for all free of charge financed by taxes.
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