Every time I think the US health insurance industry can't get any worse...

The BBQ Pit
1

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:

Two pages later in tiny type:

But wait! It gets better. Let’s delve into the specific coverages. For example, it covers heart attacks and cancer.

What about surgery, you ask?

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

2

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.

3

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.

4

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

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.

6

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.

7

And, guess what? It ain’t gonna get any better anytime soon. Thanks; you great orange idiot!!

8

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.

9

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!

Stranger

10

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

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.

12

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

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.

14

Ummm…Trump didn’t implement the ACA clusterfuck. Big hint - the name Obamacare should give you an idea who to blame for this.

15

…as if the healthcare system was functioning fine before Obama got his hands on it.

16

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.

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

17

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

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.

19

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.

20

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.