I believe there is a formal appeal process. Whoever decided it was not “necessary” will have to prove their medical credentials that proves they know what they are talking about. That’s part of the Regulatory dept at the Ins Co. They cannot get out of that one, since the denier is usually some hourly schlub. Anyway, this is how I’ve seen these stories get worked out. It will likely involve legal action however. He should win.
I like your analogy. As someone who lived in the US for several years and had good insurance I felt adequately covered from the goblins but was definitely annoyed that life events (like having children) cost me several thousands. It is quite foreign to have to budget a couple thousand a year for insurance deductibles and co-pays.
What really seemed bizarre was the multitudes working in the insurance industry. I knew someone who worked at a general practitioner / doctors office. They had 3 doctors and about 15 support staff. Why so many staff? Many of the staff, including my friend’s only job was to call insurance company’s and harass them for the money owed to the doctors.
So it is also worth mentioning that there is a huge industry built up around these goblins and their treasure. Goblin trackers, goblin hunters, goblin trappers etc. The Health Insurance is the medieval Goblin middleman - who is controlling their access to Health Care.
…because the one thing you really need after major surgery is an extremely complicated, probably years-long lawsuit involving multiple possible defendants, and all their lawyers, who are all pointing the blame at the other people.
You can’t trust the opinions of *sick *people. If they knew what was good for them, they wouldn’t be sick in the first place.
In other words, it’s a feature, not a bug? And what happens while the patient slogs through the appeal process, the doctors and hospital turn the bills over to collection agencies, and the insured patient’s credit is ruined.
Yes, basically, that’s it - there’s always a formal appeals process, but it’s lengthy, full of paperwork and red tape, if you don’t get ALL the forms and fill them ALL out completely and carefully you can be summarially denied (again), and yes, it’s very much a feature and not a bug - the insurance company wants to delay paying as long as possible. Even better if the patient gives up, or is too tired/sick to continue
On top of that, if a patient is unable to do the appeals themself, HIPAA is used to deny access to concerned relatives/friends, sometimes necessitating that one of them go to court to be declared legal guardian and in possession of medical/legal/financial proxy (best to ask for all three at once). Which process may or may not be completed before time runs out for appeals (because of course there are time limits).
This sounds like a fantastically efficient system. The free market in action. And great for the patient as well!
I only wish that in my country, we had the opportunity to have a major legal battle between my doctors and insurer after I have undergone a major medical treatment. Sadly, I am denied this freedom.
</sarcasm>
I guess I just know and am a shitty poor person - Almost everyone I know does NOT have insurance.
On one hand, I can count the people in my family, immediate and extended that have employer insurance. I don’t think any of my friends or acquaintances have it either.
Is really only 8% uninsured in the US? I would say that from my position (mid 30s in age) only about 8% actually have insurance. Its bizarre to hear people talking about their insurance to us “poor unwashed folks”. Part of me wants to slap them up side the head and say, “Bitching about your co-pay to go to the doctor? At least you get to fucking go to the doctor at all, buncha jackasses.”
I was reading this thread earlier, and asked everyone around work, “Hey who has insurance?” The CFO of our company and the CEO do. That’s it around here of the 40 or so people around this bubble. They are on Medicare.
I went through my cell phone contacts, and of the 180 or so that are real people, about 10 have insurance through their employer. A lot of their kids are on CHIP though.
This is absolutely a real thing: HIPAA is used by healthcare bureaucrats as an all-purpose cudgel. I recently had an Kafka-esque appointment at a prominent teaching hospital in Oregon—an Oregon health & science university, if you will.
The hospital administration would not tell me where my appointment was, with which provider or even confirm that I had an appointment at all, citing HIPAA. They caved when I pointed out that I couldn’t possibly show up at the right place at the right time if they wouldn’t tell me where it was.
That experience can be blamed on an overzealous bureaucrat, but there’s a more serious side: my mom is slipping into dementia and has begun confabulating when asked about meds and appointments. I am her medical executor, but that doesn’t kick in until she’s ruled incapacitated. Of course, my mom’s doctors won’t talk to me—let alone help me help her—until my full power of attorney has kicked in.
My mom thinks that she just has to call her doctor and say it’s ok if they talk to me. It doesn’t work that way. And this is a case where the providers likely want my help—if my mom’s doctors’ billing departments were fighting me for fighting a charge, I don’t doubt they’d try to fend me off with HIPAA.
Maybe I’m naive, but I doubt most people who say “I can’t tell you because HIPAA” are doing so cynically. But because so many medical bureaucrats see it as a trump card to make the questions stop, it gets abused—a lot.
Just to be clear, HIPAA unambiguously prevents my mom’s doctors from talking to me under these circumstances. I’m not arguing that they should disregard HIPAA and talk to me anyway. I’m saying that, once I have medical power of attorney, I expect to get stonewalled unless I can wave the relevant documents in the face of the person saying “no.”
If they won’t tell me when/where my own appointments are “because HIPAA,” I expect to get an avalanche of false-positive “no” responses even after I’ve got my mom’s medico-legal ducks in a row.
Many providers’ offices are outright patient-hostile under the best circumstances. It’s unlikely that will change when you’re fighting an erroneous bill.
Translucent Daydream, I appreciate your empirical contribution to this thread. Can I ask for a clarification, however? Are you sure your young work force co-workers are on Medicare?
I ask because I keep seeing people in this thread, not just you, mixing up the terms, Medicare and Medicaid. It’s confusing, but it’s important to understand the difference between these 2 programs.
Medicare is a federally funded program for folks who have attained the age of 65 or who have become permanently disabled and unable to work. They and their employers have paid into the program during their working lifetimes. They are entitled to it.
There are lots of components to Medicare, meaning Parts A, B, C and D, and each covers different things. But the main point to keep in mind about Medicare is that it is for people over age 65 or people who suffer from a permanent disability.
Medicaid is for low income folks and is a safety net program funded with combined state and federal funds. You can apply for Medicaid at any age, but you must have a very low income to qualify. One thing to keep in mind about Medicaid is that there are claw-back provisions – meaning that if you have tangible assets such as a home, or you receive an inheritance, or if your income at some point exceeds the low income threshold, you can and probably will be made to pay the money back and/or be kicked out of the Medicaid program.
Medicare has no such provision. Once you qualify for Medicare, you qualify. No claw-backs.
When Democratic candidates advocate for a Medicare for all system, they’re talking about offering the existing Medicare program, now available mostly to only those over the age of 65, to everyone in some form or another.
Exactly. Medical expenses follow a power law distribution.
1% of Americans make up about 25% of medical spending in a given year.
5% make up 60% of spending.
20% make up over 80% of spending.
50% make up 97% of spending
So you flip that around and it means that
50% of Americans make up 3% of spending
80% of Americans make up 20% of spending
95% of Americans make up 40% of spending
99% of Americans make up 75% of spending
Most people are mostly healthy for most of their lives. So they think they have good insurance because the only health care they get is the occasional doctors visit and a few generic medications.
Plus the way our system is set up, people with truly expensive health problems tend to get pushed onto public plans. Medicare covers the elderly. Medicaid covers the destitute elderly and the disabled.
Even with the public sector socializing the risk and taking the highest risk, highest cost patients off of the marketplace, the private insurance marketplace is still garbage.
As I noted upthread, I work in the industry, and, yeah, nationally, 8% is accurate. But, it does vary (quite a lot) by state: the Kaiser Family Foundation has a site where you can look at the rates by state – Texas is at 17% uninsured, Oklahoma and Alaska at 14%, etc.
But, if you limit the data on that KFF site to people age 19-64 (since low-income children may be on CHIP, and the vast majority of those age 65+ are on Medicare), the national uninsured rate is 12%, and in Texas, it’s 24%.
One factor in whether or not people have employer-based health insurance or not is the size of the company: if a company has 50 or more full-time employees, they must offer health insurance to the full-time employees. If they have under 50, it’s optional (and many don’t). It sounds like the place you work, with 40 or so employees, doesn’t have to offer coverage.
And, the above also alludes to another factor: people who aren’t employed full-time at a single job likely won’t be offered health insurance coverage by their employer, even if the company is big enough.
And, finally, ACA (Obamacare) policies tend to be expensive. Although the ACA features subsidies for moderate-income people to help them afford coverage, part of the law around the subsidies depended on a plan in which the individual states would raise the income ceiling for qualifying for Medicaid. But, a number of states (particularly “red states”) chose not to, leading to a situation in which someone can be making too much money to qualify for Medicaid, but not be making enough money to qualify for a subsidy to buy an ACA policy.
I took what Translucent Daydream was saying was that only two people at their employer – the CEO and the CFO – have health insurance, and that the two of them have it because they’re on Medicare (and, thus, they’re both age 65+). But, I may be mistaken in my interpretation.
Oh, I think you are right, and my apologies to Translucent Daydream if I misunderstood. Which it appears I did.
All the same, there does seem to be confusion around the 2 programs and I’ve been wanting to clarify the differences for awhile now. There’s even a thread floating around here touting ‘Medicaid for all’ – and no one is pushing for that.
Thanks for the catch! 
How many American slaves in 1860 were scared and maybe even angry at the prospect of Emancipation? I don’t know how many there were, but undoubtedly there were some who preferred the devil they knew to the uncertainty that was freedom. Sure, with slavery you had to constantly live with the threat of violence hanging over your head like a dangling 500-lb anvil. Sure, you couldn’t become educated, acquire wealth, or have kids without worrying they’d be snatched away from you at any time. And sure, you had to put up with all kinds of indignities like rape, being literally treated like a brute animal, and being worked beyond exhaustion so white folks could have nice big fancy houses and wear the finest clothes. But it was a system you knew. As long as you played by its rules—as oppressive, inhumane, inefficient, and ridiculous as those rules were—you could get by. Maybe even be happy sometimes.
I have to think that people like the OP have fallen prey to the same change phobia these slaves had. Employer-based health insurance is the only system we know. Most of us barely can conceive of anything different. So I’m going to ask the same question that I would ask all those change phobic slaves: what about it is worth defending? Corporate executives see to it that people pay more into the system than they get out of it…tell me, why should the common man fight to see this continue? What exactly as we afraid of? Being able to get the lump in our breasts checked out without worrying about co-pays, deductibles, whether or not our preferred doctor is in the network, and other crap like that? Being able to quit a bad job *without *instantly jeopardizing everyone in our family’s access to healthcare?
I might be persuaded that government-run car insurance is a good idea, but the point I was making is that since it is, in fact, truly insurance in the correct meaning of the word, there is at least a risk that a public plan might be structured in a way that limits your coverage options. But the OP’s concerns are without merit since the kind of single-payer system being proposed isn’t insurance at all, but essentially a payment system for all medically necessary health care.
In a sense it works that way in Canada, too, since one can take out private insurance for drug coverage and for dental. In my view the critically important thing about UHC is that all medically necessary services must be covered, from doctor’s visits to the most expensive surgeries.
I disagree that there aren’t major differences, or that car insurance is simpler. My car insurance policy runs to many pages of fine print, with lots of terms that I don’t even understand. My health care coverage is basically defined by the fundamental principle that it pays in full for all medically necessary services. That sure seems simple to me.
Which supports the notion that comprehensive health care coverage such as the single-payer system being proposed or the one we have in Canada isn’t “insurance” at all and shouldn’t be thought of that way.
In the “almost all” reference, I think I had a $35 co-pay.
In your “not much” question (I love how people demand that I have perfect knowledge, but no one else gets these kinds of questions), I don’t know exactly what they paid, but it was such that I never heard them utter anything at all about cost. And I know they have the same insurance I have, since we work together, so again “almost all” of their costs were covered, as we don’t have high deductible plans and coverage on major illnesses is very good. Maybe over a year or two, they paid out a few hundred bucks…These are anecdotes to answer your questions of course, but many people on this board use anecdotes.
My cursor must have jumped. The two people with insurance at my work are on Medicare because they are over 65 years old. Sorry that was jumbled. When I lived in Oregon I was on the state program and that was the only time I’ve been insured in the past 10 years I think. That was the only time my wife has had insurance either.
Why on Earth would the government want to limit your coverage options? Because government is inherently eee-vil and wants people to suffer? With all due respect, you’re thinking like some Americans who think government can’t be trusted to provide basic services, like health-care. 
The principle of our mandatory insurance is that everyone has the same basic coverage, thought necessary to address most liability issues. But nothing stops you as a consumer from buying more (e.g. More third party liability coverage) if you want to, and you’ve got the extra cash to pay for it. And if by chance you’re hit by someone who doesn’t have insurance (e.g. Driving even though they don’t have a permit), the eee-vil government will pay you out from the Uninsured Motorist Fund, so you get compensated and don’t have to make an insurance claim and take a hit on premiums. It’s almost as if the eee-vil government wants to help its citizens. 
That was an auto correct typo - meant to say “there are major diffs between car insurance and health care.” Darn technology! :eek:
I was referring to US health care policies, which sure seem a lot more complex than auto insurance. What’s the premium? What’s the co-pays? Who’s in network? What medical conditions are covered? (Using the example in this thread, is back surgery to prevent paralysis covered?) I’m not a car guy, but I’ve got a pretty good idea of what’s covered by my car insurance. Does the average US person know what’s covered by their health “insurance”? Personally, I would have thought back-surgery-to-prevent-paralysis would be covered by most insurance policies, but if you don’t read the fine print carefully …
No dispute here.