When I first read that, I thought “Where else can you have a c-section? In your foot?”
Actually, they don’t employ doctors. They don’t even hire people with medical training. They just hire the same kind of folks you’d find at any call center in America (or India, or the Philippines, or Russia, or Ireland) and give them an amount of claims they can approve on any given day.
One would think that if the free market system really worked in such cases, that someone would be able to launch an insurance company which was easy to deal with, covered what they promised, and paid promptly. No doubt that they’d have thousands of corporations pounding on the door, wanting to sign up. Yet, that hasn’t happened.
Also, many companies are “self-insured.” They hand the paperwork over to the insurance company, but they’re the ones that pay the money. So then the question becomes: Is it the insurance company that’s screwing you over, or is it your employer?
You’d think. But a company like that probably couldn’t compete on price, and that’s where the employers look first.
Probably not. The initial investment would be huge. Bill Gates or Warren Buffett could pull it off, but it’s doubtful that anyone with that kind of cabbage would see the need for such an operation.
Shit like this drives me crazy. I mean, why the fuck would you even go to the doctor if the insurance companies were qualified to make these kinds of decisions?
Insurance companies should not be making clinical decisions. Period. Now, if they only want to pay for the generic med and there’s no reason for the patient to be on an alternative, then fine. Require the switch. If they think some treatment is unnecessary, then have the patient get a second opinion from a different bloody doctor. DON’T just refuse to pay. For a lot of people, refusing to pay may mean they don’t get the care. In my mind, the insurance company is now practicing medicine. Fuckers. You want to practice medicine? Pass the goddamn licensing exams and get a fucking degree.
If ever there was a class-action lawsuit I could get behind, here it is.
I’ve been with Blue Shield for many years, with several different employers.
I gotta say, it’s been pretty hassle-free. And I have had:
- Minor Elbow Surgery
- Minor Shoulder Surgery
- An ER trip when I thought I was having a heart attack (I wasn’t)
- An ER trip for my wife when she fainted
- I’m diabetic, so I see my Dr regulary and get bloodwork done often
I get sent notices of bills all the time (the ones that say ‘This is NOT a bill’) and I would need to take a twisted accounting class to understand them, but I have never been asked to pay more than the co-pay or an amount determined in advance (for the surgeries).
I work for a very small HMO (<50,000 covered lives) ducks rotten tomatoes
We do have a pharmacist and a medical dr making all of the drug decisions. When a new drug comes onto market a group of local practicing drs (P&T committee) gets together and reviews the literature. They make their decisions first on efficacy and then on cost, and they only rarely exclude drugs entirely.
I sit in on those meetings because I’m the analyst that gathers the studies together and projects usage, etc and I’d have to say that they are very fair.
So if you come onto our plan you may have to ask your Dr to write our Dr a letter explaining why you need (expensive brand name drug) over (cheap therapeutically equivalent generic drug) but if you have a case they’ll approve it. I passed these requests and decisions between Drs for about 6 months and in that time there were no denials that I thought were unfair., quite the opposite. And you’ll get a response within 3 days, usually more like 24 hours.
Our medical clinical decisions are usually decided by RNs, many of them with 20+ years of experience. Claims processors (usually with a high school diploma only) are only allowed to adjudicate claims on a non-clinical basis (ie member not eligible on date of service, amount billed is greater than allowed amount, or diagnosis not covered on plan, etc).
IMO much of the frustration patients feel is caused by the Direct to Consumer pharma Marketing that makes them think that they need the latest shiny new drug, even though the pharma companies never do studies comparing their drug to older drugs, only to placebo. You have a right to a drug that works for your with your unique body chemistry. But if your drug is going to cost 10x that of other drugs in the same family we have a right to ask you to try some of those out first (or ask your Dr to send us a letter saying you already have tried those other versions).
I used to answer phones there and we did have a lot of unhappy people, but they could be divided into 3 categories:
- People who were mad that we wouldn’t pay (or that their copay was higher) for a brand name medication when the same medication (I mean molecularly identical) is available generically.
- People who were mad that we wouldn’t pay for oxycontin (we’ll pay for as much non-time-released oxycodone as you want, but the research we did showed that most oxycontin was being diverted to the street)
- People who didn’t understand Medicare part D (my answer: join the club - that’s a whole 'nother rant in itself)
And Kilvert’s Pagan is right - we do have very high patient satisfaction scores, but we don’t make a lot of profit. Plus we’re a non-profit organization anyway so if we do make too much we have to get rid of it somehow.
Maybe I should post this in GQ or IMHO but I’d love to keep the happy feeling in this thread going.
Do you Merkin’s every complain about the Doctors too ?
Over here we don’t have the shit you’re talking about with insurance companies and I like it. I’ve gotten good treatment both times I’ve been in hospital and with other medical related stuff, as did my chronically ill sister and brother.
But our media loves to point out medical mistakes, we’ve had a mass-murdering doctor fairly recently and people are suing hospitals left, right and centre.
Part of this is no-doubt just the media playing on minor incidents but I gotta wonder if your doctors are better than ours, or if their incompetence just pales next to the insurance companies.
Whereas, SusanStoHelit, in comparison to what sounds like an excellent process in your insurance company, I know a guy who runs a small HMO who not only has zero medical background but is solely, totally, and completely oriented towards saving money at the cost of just about anybody and anything. Amoral doesn’t even begin to describe his attitude towards the coverage folks in his plan receive. He outright brags about how they deny coverage for this, that, or the other thing based solely on the bottom line, without any medical rationale whatsoever.
While I’ve known him for years and in a non-business context have always like him, I just say that what he does professionally just makes me outright queasy. I’d love to be able to alert all the victims of his plan to let them know just what kind of people are running their insurance. Or, better yet, contact the folks who buy his insurance plans for their employees. Because they’re as frequently motivated by bottom-line considerations as are the shady folks running these plans.
I am also involved in medicine - although not professionally (yet). My mother has been an RN/NP for decades and she very regularly complains about this type of stuff. Bravo to SusanStoHelit’s company, but that doesn’t seem to be the way a lot of companies work and I’d like to see them called out for essentially practicing medicine without a license.
My mom said one of the best ways to get around these assholes is to let them know, in no uncertain terms, that the medical team wants Treatment X. The insurance company is denying it against medical wishes and to document it in the chart. Let them know, that if something happens to the patient because they denied care, it’s their ass on the line. She said it usually works as a last ditch effort…they want to make the decision but they don’t want any of the responsibility for making the decision. I look forward to trying it myself in a few years.
Ten years ago this summer I had my gallbladder removed and United HealthCare was our insurer. It was embarrassing, how long it took them to pay the bill. Phone call. Phone call. Phone call.
And then they had the balls to ask for a reduction in charges. After 6 months of ignoring invoices.
IIRC I filed a complaint with the Attorney General’s Department of Insurance.
They paid the bill in full.
Just out of curiosity. Did you bother to read the stories above? The issues enumerated above are not about projecting usage or direct marketing.
For instance, as an infant I wasn’t watching nebulizer commercials and then visiting my pediatrician or immunologist and requesting a certain brand. In fact, as I understand the story I came out of the womb and the OB was the one who threw my tiny gasping body at lots of machines and drugs. I also doubt that percypercy went to go break his arm thinking how useful it would be to request certain drugs or treatments seen on tv for broken bones or the like. I’m not usually a big fan of the Pit but you appear to be showing the kind of ignorace that 1) proves most of the points made here and 2) provides the reason for the Pit itself.
Thanks for your response, SusanStoHelit. I can only speak for myself, but none of the hassles I’ve endured with my insurance companies have fit anything you describe. I have never asked a doctor for a specific medication (and least of all not one I saw a cool TV commercial for).
As to your three categories, 1) I always prefer generic if it’s available, 2) Damn straight I’d be angry if I were prescribed Oxycontin by a doctor and you told me you weren’t going to pay for it because I might sell the pills, and c) You have me there, I don’t use Medicare and wouldn’t know the slightest thing about it.
In fact, I don’t recall any of my problems being related to medication at all. It’s always in the bills for doctor visits or lab work, and usually involves a claim being underpaid or refused outright, requiring the office or lab to resubmit the claim however many times it takes until they hit the right esoteric code that gets the insurance carrier to finally cooperate and pay. It typically takes weeks, often months, and I had one claim that I noticed was just paid, for a visit over a year ago.
You seem to be of this mindset that doctors are infallible.
Like they just make these scientific decisions that are either right or wrong and they advise patients accurately. Like they’re not susceptible to over-prescribing. Or they don’t make decisions that bring them repeat business. Or they’re immune to the pressure put on them from the drug companies.
I’m (obviously) no fan of insurance companies, but at least insurance companies act as a check on corruption that would be present in doctors and hospitals if left unchecked.
The whole thing is a medical-corporate complex and I think doctors, hospitals, big pharma, or big insurance can equally share the blame.
I disagree with you’re argument but agree with some of what you say. Doctors are not infallible. However, as a sick person or as a near death person (both of which I’ve been on more than one occasion) I don’t have much choice. However, its pretty obvious that insurance companies are not providing the solution. PEOPLE are fallible. We’re doing what we can. But when I can’t breath or am in anifilactic shock or am on a ventilator I have a hard time asking pointed questions about my doctor’s rate of infalibility.
They can all share the blame, however, as a unit they perpetuate the problem. If we didn’t have the circle jerk problem we have now they would each be fucking us over less and less.
OK, I’ll take some of the heat off of Ms. StoHelit.
I work for the aforementioned United Healthcare. I work in the large-client division as a Client Manager. As such, I’m respoinsible for all service processes, and am the point of contact for my clients.
A few disclaimers…
[li]This is ASO insurance…as such, it’s not really insurance. We perform all administrative functions for our clients, and they use their own $$ for claims. We pay the claims, administer the network, manage all pre-admission processes, appeals, etc.[/li][li]I have a pretty solid background in our pharma interactions as well.[/li][/ol]
We used to have the idyllic system so many of you want…about 15-20 years ago, we had what’s now called “indemnity” plans. They were very simple, giving the patient a percentage (usually 100% or 90%) of payment, with no networks, pre-certification, appeals, etc. The patients were happy.
Unfortunately, that system went away. Because we are in a capatilist society, we are a business (and we are for-profit, unlike the majority of Blues), and as such need to differentiate ourselves from our competitors. We also need to deliver maximum product for the client’s fees, and deliver maximum discounts from providers with whom we negotiate. We also have to deal with a long, proud history of fraud in this country (hello, Chiropractors!).
I forget who mentioned that we don’t employe nurses or doctors…but they’re wrong. In Illinois, we’re the fifth-largest employer of RNs in the state. We also employ nearly 100 doctors. Why do we employ them? Because we monitor ongoing care, decide if prescribed care is appropriate, and develop programs to help members stay healthy.
Here’s the contentious part. Do we know more than the doctors? Yep. We know WAY more than all but the largest medical systems. We not only hire the very best medical professionals to design and maintain our programs, but we also have access to a truly astronomical amount of clinical data through our claims systems (data warehouses). Through reviewing history, we can offer a solid clinical opinion on pre-certification, standards of care, and the best ongoing treatment.
Are we also obligated to reduce costs? Sure! This doesn’t mean we pick on Johnny Lunchbucket when his doctor submits a claim for his broken elbow. We monitor on a gross basis…trying to limit costs from fraudulent providers (howdy, Podiatrists!), negotiate better network discounts, and create ongoing care programs.
As for gonzomax…brilliant! Go back to your grassy knoll, because we certainly don’t operate on a “pay less money” claims theory. As if the state insurance audits (oh yes…every year!) wouldn’t pick up on that!
As for Medical Billers…geez. We should each have such well-informed and respected champions. I’ll share my own personal experience here…In years of being involved with insurance company Operations, I can say that at leadt 70% of claims are screwed up due to poor billing submissions. I can’t count how many times I’ve seen Preventive claims submitted with diagnosis codes, how many times I’ve seen a whole surgery submitted under a simple office visit CPT code, or how many times a bill is sent out to the member before the insurance company even receives the bill from the facility.
Is the system perfect? Is sure isn’t. But before you paint the the insurance
companies with that broad brush, look to the providers, look to tort reform, and look to the states that monitor us.
You act as if we haven’t already looked at those things. I have. I simply find that the vast majority of the problem is with for-profit medical insurance.
Okay, time for me to put my other hat on. Like I said, I worked at a pediatric office for about a year. One of my various jobs was obtaining precerts for our patients to get MRI’s, CAT scans, that sort of thing. It was excruciating 90 percent of the time. I won’t deny that the insurance companies had doctors and nurses on staff, but the first person you talk to was clearly reading from a list. Does patient have A symptom, if yes, go to 2. If no, move to question 8.
Eh…I was probably guilty of broad-brushing my reply.
I agree that the for-profit insurance companies have skin in the game…I’d be foolish not to. I would argue, though, that we are driven by two main forces:
[li]Need to deliver lower total benefit costs due to market forces.[/li][li]Need to adapt to changing insurance needs, often driven by #1.[/li][/ol]
Before we attack the insurance companies for administrative errors, let’s look at the inputs that require that particular setup.
Any insurance company would prefer to deliver a simple, non-complex insurance solution. It’s easier, requires fewer FTEs, makes reporting easier, and generally makes everyone more happy with the results. Because we have to adapt to changing legislation, changing market desires, and changing patterns of utilization, we’re foced to make the system much more complex. At that point, some claims get lost, and errors get made. HRAs, HSAs, Managed Care, and other complex delivery vectors all share some root in the changing needs of clients and their employees.
We also act as a check on the provider community. If we weren’t guarding against fraud, who’d catch it? Medicare? I don’t think so. Who would stop your provider from ordering 50 MRIs on your broken ankle? Who would act as a (admittedly not that effective) check on malpractice rates for providers? Believe it or not, we have a substantial role in that fight as well (fewer docs, less negotiating leverage). Who keeps provider costs down? Who keeps the Martians under wraps??! (wait…wrong thread)
If anything (yeah, I’m a home-teamer), I believe that the insurance companies, as well-audited, market-responsive entities, are the more consumer-friendly of the health-care landscape.
percypercy, I won’t deny that. Having been in the industry, I think you understand the volume involved. When we have someone less-trained answer the first call, it’s to weed out those “easier” pre-certs. For example, if it’s a pre-cert for a gallbaldder surgery in the presence of a diagnosis noting gallbladder inflammation, that’s a “gimme”. When you are pre-certing detailing surgical plans for multiple diagnoses, this initial person will shoot it up the line to a more experienced RN.
The radiological stuff is tough on our end as well. As you know, MRIs are hideously expensive (@ $1,500, last time I checked), and can be used for darn near anything. Because we answer to the client, we have to make sure you’re not prescribing MRIs for a broken arm (absent spiral fracture, etc.). We need to apply standards of care to keep costs down. CATs, PETs, and otehr radiological stuff ain’t cheap, either!
I’ll also mention (can’t provide a cite, sorry!) that our auto-adjudication rate minus follow-up (AARMF, for those that care) is somewhere around 96% as a company. That means that we process a claim, and receive NO followup (complaints, rebillings) on that claim 96% of the time. Is the other 4% important? Statistically, it’s almost irrelevant, but we actively act to manage that 4%, with internally-posted goals of reaching 6-sigma levels of AARMF.