$700 Health Insurance

The BBQ Pit
141

To this I’ll add:

When I’m shopping for insurance, I want to know what you’ll cover. Every time I ask, they tell me “that should be covered if it’s medically necessary” Who decides if it’s medically necessary? Not my fucking doctor, that’s for sure. No, it’s the insurance company. And they won’t tell me if they deem it “medically necessary” until I have it done and send in the paperwork. And that’s the insurance I already have. Try to get that kind of info out of an insurance company if you’re shopping around for policies. On drug <x> and want to know if insurance company <y> covers it before you buy the policy and submit a claim? No way on earth can you find out that information. You buy the coverage and then hope that they cover the drugs/medical equipment you’re on.

142

Ah, I probably mistook you. We are subsidizing the needy in the sense that people who cannot pay don’t get turned away. They get billed, don’t pay the bills, and the rest of us do. But this means that they don’t go until an illness is bad enough to make going imperative, they tend to use expensive emergency rooms, and the cost goes equally to those who can afford it and those who have issues affording it.

It bugs me when those against UHC or even the passed bill pretend that those newly covered weren’t costing the system anything now. Sorry for thinking you were in that category.

143

Sometimes it’s even worse if you do know how much something’s going to cost.

Until this February, I was lucky enough to have health insurance through my workplace (a local hotel that’s part of a small regional chain). Then the hotel was unexpectedly bought by another company and my insurance coverage vanished. I did manage to get an individual plan, but it has a very high deductible and very few services that will be paid for until that deductible is met. I’ve had two different care providers tell me that I would be better off ‘forgetting’ to put down my insurance information and simply paying out-of-pocket, because then the amount I’m charged will be on a sliding scale based on my income. It’s not a huge savings, but it is a significantly lower cost.

I still want insurance for catastrophic care, of course, but I’ve heard enough horror stories to know that there’s no guarantee that the insurance company will pay for the medical bills when something horrible happens to me. And for more mundane day-to-day expenses, I can get the same amount of care for cheaper if I have no insurance whatsoever.

I ask you: What motivation do I have to purchase health insurance? At all?

144

My old insurance company sent statements giving the price of the procedure, how much the price was reduced by their negotiation, what they paid, and what I was supposed to pay. So I actually knew this for things I did more than once. However, if I was trying to get a price without the insurance company, it would be different, and it is probably different now with a different company. So, no wonder they can’t tell you. I can imagine going to a supermarket where you don’t find out the prices of groceries until you swipe your card at the checkout and the system sees what affinity group you are in.

145

If you’re talking about an EOB (Explaination of Benefits), that’s different. I know NOW how much a 30 minute med check with my psychiatrist costs vs. a one hour appointment because I get my little EOB after the fact showing exactly what you describe. But when I called BCBS to find out if a med check (generally 15-30 minutes) would be charged at my full co-pay (fifty bucks) they insisted that it would. Fifty bucks. Doesn’t matter if it’s just a med check or a full-tilt boogie appointment.

It’s not. After all is said and done, it’s $30 for a 30 minute appointment and $50 for 30+ minutes.

I realize they have thousands upon thousands of contracts, the details of which can vary in both huge and minute ways. Apparently, however, it is impossible to design a computer system that could spit out those details based on my member number. On the front end, at least. Because obviously, on the back end that’s exactly what’s happening.

146

:confused:
I said 85% of people with insurance are happy with their current coverage (and **emacknight **said it before me), and I was pointing out how that statistic was skewed by not including the uninsured. I never said anything about who is in favour of health care reform. Someone can be satisfied with what they have now and still want change in the future, perhaps because they feel compassion for those with no access to what they have.
In short, you failed to properly read my post (which was only one sentence long, so that’s quite an achievement), and you are now making me out as a Republican who watches Fox news, even though I posted a perfectly clear cite and in every post I’ve made it clear that I support UHC.
I really don’t appreciate these continued accusations of lying. If you want to insult my stance, a la Rand Rover, be my guest, but I’ve done absolutely no lying.

147

I spent yesterday trying to figure out if I was better off paying for my prescriptions myself and having lower premiums. Should be easy, right? Nope. The cost varies wildly based on the type of pill/tablet they use. On some medications capsules are cheaper, in another it’s tablet shape A, for a third it’s tablet shape B. Some medications you are better off with two 10 mg pills rather than one 20 mg, on other drugs (or pharmacies) it’s the reverse. Here’s the best part: generic Wellbutrin prescribed to help stop smoking is cheaper than if it’s prescribed for depression!!

I’m going to print out the costs and sit down with my doctor to see if he can prescribe things so that it’s cheaper. Then I’ll get a pill splitter so I can make up my own doses. I wise I believed in Hell, then at least I’d have the satisfaction of knowing that the pubs who opposed UHC are going there.

148

They do get turned away. Go to a hospital without insurance and you will find out. They will send you to a hospital that has to cover you because they are on public land or receiving tax breaks. But they can and will send you away. if you are in bad shape, they have to stabilize you before they ship you off.

149

Right. The current system is complicated for the user, so let’s just institute UHC, because then the government will pay for everything, so it won’t be complicated for the user.

Don’t you think you are missing something in your analysis? Couldn’t there be other factors to consider besides the complication to the user? And couldn’t there be ways to reduce that complication without instituting UHC?

150

At least for prescriptions, they should be able to tell you if it’s on their formulary. I have access to that information for the plans I write and can tell you over the phone if a particular prescription is covered. (If you’re my customer, which you aren’t) What I can’t tell you is if that prescription will be written for you. I have no way of knowing if it is the appropriate drug or not.

I also just went to Healthnet.com and found their formulary online. I wouldn’t be surprised if other insurance companies had them posted as well.

The ‘medically necessary’ statement has to be said. For example, reconstructive surgery would be available usually if you have a nose injury (broken or the like), but not covered if you are doing it solely for cosmetic reasons. As an agent, I can’t tell you that specific treatments, tests or other things will absolutely be covered because I am not a doctor. I don’t know if what you are telling me or asking me about is medically necessary or not and wouldn’t even try to guess.

151

A single-payer style system will also significantly reduce complexity (and therefore overhead costs) for medical care providers–this is in fact one of its biggest advantages.

At what point, though, will the regulations necessary to ensure reduction of complications become too restrictive for free-market-advocates to stomach? And will that point be before or after the problem is solved?

Let’s make it more concrete–suppose that insurance companies had the following new laws attached to them:

  1. Not allowed to drop insurance customers for any reasons other than lack of payment or fraud that is proven in court.
  2. Not allowed to raise rates on individual customers, only on broad classes of customers and only proportional to the actual actuarial costs of insuring those groups (for simplicity, let’s propose these “broad classes” are five-year age/sex bands–that is, all 20-25 year old males have the same insurance rate). Group insurance policies may cost no more than the average rate of all customers in the group. Actually, I’m not Satan, rate increases will also be allowed for increases in G&A or Overhead percentage, subject to audit. Insurance companies are permitted to allow individual discounts for good behaviors.
  3. Must publish a schedule of procedures, listed by common name and a universal code (to be defined by either regulatory fiat or the AMA or someone), with attached payout information, so that every insurance customer knows exactly how much a procedure will cost if insurance pays for it. Related: Doctors will publish a similar fee schedule. It is the responsibility of the individual Doctors and Insurance Companies to align their varying published rates if desired. Sweetheart rates for being in-network will not be permitted. Insurance companies may, in lieu of a payout schedule, simply affirm they will pay whatever asked for any procedures not on the schedule.

To me, this is about where I’d start with insurance reform. That would make it end up pretty close in practice to how my car insurance currently works.

Those are in order of priority. I think 1 is essentially non-negotiable under any circumstances.

152

No no no–that’s the beauty of the free market. If health insurance providers are forced to operate in a free market (i.e., where individuals–not employers–choose their health insurance provider, and they can buy across state lines), then users can choose those that are easy to work with.

And cue all the anti-market hobgoblins in 3 . . .2 . . .

153

In Rovertopia, anti-market must mean pro-Constitution, because you favor taking away the authority of the states to regulate insurance in their own state. How is that an originalist position?

154

Yeah, prescriptions are the easiest to find information out about, for sure. I’m more talking about procedures, doctor’s appointments and medical devices. I’ve had more than one occasion where I had no assurance that something that cost in the thousands of dollars would be covered, even though I tried like hell to figure it out before committing to it. The best I could get it “it should be covered”, which makes me nervous as there’s no way in hell that the clinic is going to take “well, my insurance said it SHOULD be covered but lookee here! It’s not!” as payment.

155

I presume you favor aggressive anti-monopoly and trust-busting procedures similar to those undertaken in the Teddy Roosevelt era, then?

For that matter, I can choose my own health care provider right now. I go with the employer plan specifically because the group rates, regardless of my personal health and actuarial risks, are lower than ANY individual plan offered. (yes, I know how much my employer’s half of it costs). Moreover, they are lower by at least 25%. Moreover, they are lower still when you consider the personal tax benefit I get from having health insurance costs as a pretax payroll deduction.

So obviously group negotiating power (as implemented in employer-subsidized health insurance) is a net advantage for consumers at the present time. What needs to change to make this not the case?

156

We’re too tired from working two jobs to meet the underwater mortgages on our giant homes and paying off our SUV’s to mount a respectable riot.

No, more seriously - most people I know have been told so often that we have the “best system” that they really believe it and have zero experience with any other health system. It’s somewhat like the North Koreans don’t rebel because they’re unaware that things actually could be better. It’s a societal blind spot.

157

Nearly all the news and talk shows tell us we have the best system in the world. We have had TV shows for decades showing doctors selflessly solving difficult cases in one hour. The TV docs are never in it for money, but for a love of serving their fellow man. After a life time , you don’t even think about doctors screwing the system over for money.

158

I’m happy to announce that I got to spend another of what I call “Freedom Hours.”

After going to a physiotherapist 6 weeks ago, I get a notice from my insurance telling me I received treatment. Then a letter from my insurance saying I owe money. Then a letter from them saying they paid. But then a rather sternly worded letter from the clinic saying I owed money, with a specific note saying my insurance said they weren’t paying, and that I shouldn’t contact the clinic, I should contact my insurance.

So 20min on the phone with my insurance, and they think they paid, telling me to call the clinic.

When I call the clinic, during the voice prompts they actually repeat the point about, “if there is an asterisk by a claim amount, it means your insurance won’t pay, call them instead of us.”

When I finally get through to billing, she ums and ahs over it. Then finally realizes that yes, insurance did pay. But their automated billing sends a statement anyways.

This isn’t the first time that’s happened, nor will it be the last. But should I ever disregard it, you can bet their collection agency will come after me as fast as it can.

But we can rest assured knowing the government isn’t involved, because the government sucks at doing things and would surely screw up.

ETA The part that the insurance company pays for is labeled, “Amount You Owe.”

Where else would we tolerate this? I’m going to get groceries later, can you imagine if they sent me a bill 6 weeks later for a random amount and a code that has no discernable meaning to anything I’ve eaten?!

159

My best insurance cluster fuck story is what happened to me after I had (approved) breast reduction surgery.

Per normal, I get a bill from my surgeon for thousands and thousands of dollars. No worries, I contact them an make nominal payments to keep my account current until BCBS can pay them.

A couple of months later I get the surgeon’s office sending me another bill in the thousands, threatening to send me to collections. I call BCBS to find out why they haven’t paid. They say the surgeon’s billing office is incorrectly coding their paperwork, so they deny the claim.

I call the billing office. They say they’re correctly coding, can’t figure out what BCBS’s problem is. They keep resubmitting and BCBS keeps denying.

Both parties refuse to get on a conference call with me as the “mediator” to try to resolve this problem. Finally, I go to my HR rep who goes to the BCBS rep to find out what the hell the problem is.

Important information: technically, when doing a bilateral reduction mammoplasty (IIRC), reducing each breast is considered a separate surgery.

Apparently, the billing office tried submitting the claim coding it as two surgeries. Denied. Then one surgery. Denied. Then, in frustration, submitted the claim coding it as both two surgeries and one surgery. Denied.

As the BCBS rep told my HR rep who told me, “Blue Cross does not approve reduction surgery on a woman with three breasts”.
(My HR rep thought, and I agreed, that that was hilarious. She thought it was so funny she had to come and tell me as soon as she got off the phone with the BCBS rep. Yes, they eventually paid the claim.)

160

Well, for those that are curious: In Canada, breast reduction surgery is covered 100% when “medically necessary” which means you need your family doctor to agree your watermelon sized boobs are hurting your back. Easy peasy. Doctor agrees, you get a free breast reduction, a few guys go to bed a bit sadder for the loss.

The problem is that liposuction is considered elective and the government won’t pay for it. And the way things are labeled anatomically, side boob does not actually count as boob.

So more often then not, a patient will have to pay out of pocket for the lipo that is usually required for a proper breast reduction.

I expect this to show up soon as a reason why the Canadian health care system sucks…