I want to take my health care providers and insurance providers by the hair, knock their heads together as hard as I can, several times, and tell them "LOOK, motherFUCKERS! You, insurance provider: your job is to pay claims and STFU. If you have a question regarding my health care providers’ billing, ASK THEM…you got that?.. ASK THEM! Plus, quit nickel and diming them; you’re causing the quality of health care in America to drop like a rock because of this.
Health care provider: my insurance company, the shitbrained douchebags that they are, are the payors of all of the health care you have provided me. I’m sorry they’re scumbag shitheels that are slow to pay, but seriously, DON’T FUCKING ASK ME ABOUT IT; IT’s THE GODDAMN INSURANCE COMPANY’s RESPONSIBILTY, PERIOD, I DON’T CARE WHAT SILLY RULE YOU ARE ATTEMPTING TO FOIST UPON YOUR PATIENTS. YOU’RE NOT GETTING ONE FUCKING DIME FROM ME OTHER THAN THE COPAYMENT, SO QUIT FUCKING ASKING OR I’M GOING TO COME OVER THERE AND BLOW EVERY FUCKING ONE OF YOUR USELESS HEADS CLEAN OFF.
“absurd” yeah, but for frustration, on a scale of 1 to 10, I’d rate yours as a 10 and mine as maybe a 3!
Regarding the senator / congressperson, I think (it was early and my brain is fuzzy) my thought process was “so they know the sort of things people deal with, due to lack of a coherent health policy”… I’m not surprised they can’t help with your specific situation, though it’d be nice if they could have. Oh well. You’re a poster child for why we need something better than the mish-mash of options we have now, but that’s getting into GD territory.
Doper Zakalwe used to work with (Florida’s) Office of Insurance Regulation, and had good advice for me when I had some similar issues with my homeowners’ policy.
The bottom line here, Maia’s Well, is that you must take care of yourself FIRST. You must do what is best for yourself FIRST. If that means the taxpayer’s cover your insurance instead of the pirate health insurance industry so be it. If that means you don’t fight the good fight because you simply don’t have the energy/health/whatever then so be it - there are others out there who will take up the cause. We’d love to have you along, but will understand if you can’t make it to the parade.
You MUST take care of yourself before you take care of anyone else, because if you don’t take care of yourself you won’t be able to help anyone else.
That sounds very frustrating. From my experience working with benefits in HR, I can suggest a few things that may work.
I do think it’s possible that, IF the private insurance company pays, they will provide a higher level of coverage to you than Medicare does. As you know, there are things Medicare doesn’t cover. If there is anything the private insurance doesn’t cover that Medicare does, Medicare would still cover that as secondary.
That leads me to one comment. Do you need to maintain your Medicare coverage? Having primary and secondary coverage is nothing but hell, for the reasons you’ve described. If you dropped your Medicare coverage, could you get it back if you needed it? Can you drop your Medicare coverage? I kind of assume so, since you have to pay a premium for it. Anyway, something to look into. (If you do this, you wouldn’t have Medicare as secondary coverage, but IME Medicare would only very rarely pay anything as secondary anyway).
Second, I would say talk to your husband’s company’s HR. See if there is something they can do to verify you are correctly recorded as having primary coverage through them. The company has somewhat of an interest in NOT being your primary coverage, also, so be persistent. On the other hand, they have somewhat of an interest of getting value for money for what they pay towards the insurance. Does your husband know of anyone else who works there and is disabled or has a disabled family member? Find out what worked for them.
Third, a nitpick. Don’t say “more than 25 employees” or “more than 140 employees.” Say the approximate actual number. It will be less confusing to phone rep. They should be more familiar with the Medicare laws, but to be fair those are entry-level jobs for people with HS diplomas in many cases, and health insurance is damn complicated.
Fourth suggestion - write to United and see if you can get hooked up with a specialist or case manager or whatever they have above the entry level. The entry level reps really don’t have the training to help someone with really complicated health issues. While it would be to the company’s advantage to lose you as a customer, the way the laws work, it is their tough noogies and you have the legal right to be their customer. In the long run, it will be more expensive for them to pay your claims after fighting them and fumbling them. Maybe you can get someone to see it that way.
One final idea. If they’ve repeatedly denied claims, go ahead and file them with Medicare. I don’t hold out much hope for that, but would try it before paying them myself.
OK, I used to run an Operations division for “Untied”, and I’ll tell you a couple of things you should know. Some you’ll find useful, some will sound like a company guy backing up an over-complex system.
In regards to paying claims, the provider is usually at fault (and I’m not trying to pass the buck here). The natural thought is to point fingers at the huge, unfeeling Insurance Company, but they make money processing claims, and generally do it very well. When I was at “Untied”, we routinely processed millions of claims per day, and adhered to a <1% error rate. Sounds crazy, but true. Providers are responsible for telling us what happened with you, and three things generally affect the “payability” of the claim: CPT code (what process the doc performed), Diagnosis Code (what’s wrong with you), and type of submission (arcane, but breaks down to how the provider bills…as a facility or individual doc). Most often, it’s the provider’s fault.
If **parth-'s **company is over 500 lives or so, next time you call, ask to speak to your company’s “ADVOCATE”. It’s an Operations person with a good deal of power to pay claims, and they’re much better trained that the run-of-the-mill claims payors. Be nice, explain in detail, and it’s likely they’ll fix everything. This only works at “Untied”.
Piggybacking on Harriet TS, if your “Untied” insurance pays more than 80% In-Network, then keep it. Medicare pays 80%, and the negotiated rates are low…reimbursement normally takes longer.
Indeed. If you are insured under an employer-provided group health plan, you cannot sue your insurance company for ANY damages, much less triple damages. Employer provided health insurance plans are governed by the federal ERISAstatutes, which ban any damages:
You can get them to pay for benefits that they denied, but no damages.
Based on my own experience and on what I was told by an acquaintance in the medical insurance business, the first – and I mean the very first – rule is to deny the claim. A fair number of people will accept that and go no farther. If they fight it, and even if they eventually win, the insurance company has had the use of the funds for a longer time. It’s not as if they pay interest to make up for it.
Also, another second to documenting every call and every mailing of any kind. It may be worthwhile to send all correspondence with a verification of receipt.
Several years ago, my husband and I were both covered by a company whose name begins with the letter ‘P.’ He had to have emergency heart surgery. It took two years to get the bills paid. At one point the company admitted that they had given permission for the emergency treatment at a hospital that was not part of the “network.” But, they added, after 2 days he should have gone to an in-network hospital, so the other 3 days were not covered. Excuse me? On the second day he was still in intensive care and only minimally conscious! He was supposed to check out and go somewhere else?
Our employers at the time both offered family medical plans, so we could file for anything not covered under Plan 1 to be paid by Plan 2. At one point I had a person from P tell me I had to write to “the other insurance company” instructing them to provide certain information. “But you ARE the ‘other’ company!” Yes, that’s right. “So you want me to write a letter to YOU telling YOU to tell YOURSELF the answer to this question.” Yes.
I would talk to one person one day and the next day be told there was no such person. I’d send things in the mail and they were supposedly never received. That stopped when I started sending with a return receipt or certification. The final insult was that they finally agreed to pay the last disputed charge, but never actually sent the check. I found that out when we got a notice to appear in court.
I love the scene in “As Good As It Gets” where the mom curses out the insurance company.
Well, I’ve never had a spouse with emergency heart surgery, but the dual coverage you describe sounds exactly like the BS we had to deal with. Re non-covered hospital: it reminds me of an anecdote someone one a preemie mailing list described. Their baby was in the NICU at hospital X, which was in-network.
Only, the NICU physicians’ group - the only option for neonatologists there - was NOT in-network. So their care got denied as being out of network. The parent wasn’t quite sure what they were expecting - sure, keep the critically-ill neonate in the hospital but don’t offer any care? Their other alternative would have been to transport the baby to a hospital 3 hours away. Er, no. I never found out how that all worked out.
When Typo Knig had an ER visit, 10 years or so ago, it took 6 months for us to get secondary insurance to pay their share (this was before the “they paid, so we don’t have to pay a dime” rule was instated). I’d talk to somoene, they’d say they would look into it, a month later, they had not done so. Or I’d talk to someone, they’d say “it’s taken care of, it’ll be paid tomorrow”, a month later… you guessed it. It ultimately went to collections. And yeah, the insurance finally paid it.
I really think there need to be penalties to the companies when they pull this shit, instead, we’re all stuck with “thank you for FINALLY paying what you owe, yassuh massa”.
This talk of “dual coverage”, “non-covered hospitals” and “out of network” makes me extremely glad that I’m living in a country with universal healthcare.
After removal of my wife’s brain tumor, the last thing we needed to worry about was “who is going to pay for this”. While she was recovering at home, I did not need to fight with anyone about the bills - the doctors, nurses, technicians, etc. did not have to worry about hassling an insurance company for the money they were owed either.
The net result of this is superior health outcomes for significantly less cost to the public.
Wait times can be a problem, but this is generally for procedures that are non life-threatening, or can reasonably be delayed (ie a student of mine had to wait 6 months for knee surgery - he could walk just fine, but could simply not play soccer at a competitive level) The majority of whining about wait lists is from people that want gold-plated immediate service because they are rich, and are not used to waiting behind a stinky hippie for anything; they are used to their money buying them entitlement, and are pissed off that this is not true for health care.
IANAL, but my company offers us free legal council for stuff like this. I was taken to court over one of my husband’s hospital bills, and my company provided legal advice which helped us win the case. You might check to see if this is one of the benefits your husband’s company offers.
Without getting too far into GD territory, the only advantage I can see is that in general, in the US, if you want treatment (and can afford it or happen to have good health insurance), you can get such treatment faster than in some other countries.
Friends in Canada and the UK have never reported any problems with getting needed treatment. Sometimes they’ve had to wait a month or three if it’s something deemed non-essential (a spouse needed stomach surgery, for example). And another online acquaintance (in Canada) had severe, intractable asthma that sent her to the ER several times a month despite top of the line care. If she’d been in the US with insurance she could have gotten into National Jewish which is arguably the best in the world, but as a Canadian with the nationalized health care, she could not get coverage for such a visit. She ultimately disappeared from the mailing list I knew her from… I’ve often wondered if she simply died suddenly
OTOH, with every hospital encounter we’ve had, we spend months getting bills from miscellaneous medical practitioners… the hospital, the ER doc who saw the kid, the X-ray company, the lab, the specialist who saw the kid… all ultimately settled at a stiff discount from the “list price” which appears to be pulled out of thin air (Typo Knig had sinus surgery a couple years ago; list price - JUST for the surgeon - was 42,000 dollars for a 2 hour surgery; the insurance negotiated rate was about 6,000, of which we paid 1,500). Similar discounts for the anesthesiology portion, the hospital portion, the X-ray portion, which all lead me to believe the list prices are pulled out of someone’s ass and bear no resemblance to what the various parties expect to get from anyone… confusion on all levels. I think we spent about 4000 out of pocket on that whole thing.
Based on my own experience and on what I was told by an acquaintance in the medical insurance business, the first – and I mean the very first – rule is to deny the claim. A fair number of people will accept that and go no farther. If they fight it, and even if they eventually win, the insurance company has had the use of the funds for a longer time. It’s not as if they pay interest to make up for it.
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You and your acquaintance should stop huffing toner. Does anyone really believe that an insurance company could exist, sell product, and comete against other insurance companies with a “deny first” mentality?
Where insurance companies run into trouble is when they encounter complexity (like most industries, I expect). If it’s an Office Visit claim for Rhinitis…I’m betting it gets paid accurately 99.9% of the time (most insurance companies need to meet DOI goals for claims payment accuracy or pay penalties). If it’s an ER claim coupled with an Inpatient admission, coming in with contraindicative diagnosis/CPT codes…I’m sorry, but it’s going to a live person to review, and when people get involved, mistakes happen.
I’d like to know how many adherents of The Cult of The Single Payor are even aware of the (primarily) three plans currently in discussion. I’d also like to hear exactly why those people believe the folks responsible for Medicare could do a better job with the same system inputs. Medicaid, Medicare, CHIPs and other plans all have shortcomings, and you will always find people upset with process and payment issues.
Educate yourself before lashing out at a complex industry, and be aware before you ask for a government-run program that would in effect be built from scratch, cost you tons of tax $$, and (IMHO) run more poorly and frustrate millions.
I don’t see how it could be any worse. I would rather be screwed by the incompetent indifference of a government program than the intentional, greedy avarice of a corporate insurance provider. I am sorry, I hate them. I have personally had so many bad experiences, I want to chuck them all into the deepest trench in the ocean and start over. They have forfeited their right to scare me with the ‘gubmint’ bogeyman any longer. I want socialism, and I want it now.
Absolutely. My husband’s company at one time worked as an contractor for a large insurance company here in NJ that we’ll call Whorizon. During a meeting with them, he happened to be present for such a conversation, after which he came home disgusted and ranting. They aren’t in the business of covering people’s medical bills; they’re in the business of selling a product to large numbers of people, most of which are mostly healthy.
There are also a number of other businesses where such a policy is an open secret, though admittedly only governmental examples spring to mind at the moment. Ask any lawyer dealing with disability applications, for instance, where it’s basically not secret at all.
Even WITH health insurance in the US no one is guaranteed a trip to Jewish National, no matter how much they need, deserve, or want it.
Might as well argue that the US system is crap because you can’t get in Shouldice clinic for a hernia repair, as it is a Canadian facility, despite being frequently hailed as the world’s best.
Yes, if all the other insurance companies were doing the exact same thing - which, more or less, they are.
As opposed to automation, where a computer can be programmed to automatically “unbundle” codes or kick out the tiniest of discrepancies quickly, efficiently, and with the human honestly being able to say “I had no idea…!” a month later when the bill is already heading towards collections.
Because I see how Medicare works for my parents (going on two decades for them) and how pirate health insurance works for me, and frankly, even my “Cadillac” policy (which I got when I worked for the pirate health insurance industry) sucked compared to what my parents got when it came time to actually file a claim or get anything paid.
I worked for the “complex industry” for 13 years, and for 4 years prior to that on the other side, in provider billing. The Medicaid and Medicare stuff was a LOT less troublesome as a billing provider.
Sure, a NHS would cost more tax money - but I doubt it would cost as much as the premiums we are already paying to the pirate companies. Either way, we pay. If I could ditch the premiums I’d be willing to fork over more for tax money, particularly if it gets me a net gain. In this case, not only would I get health insurance, it would be insurance that will cover me and mine regardless of what job I do or do not have and can not exclude anyone due to pre-existing conditions. I find that a fair trade.
Frustrate millions? How about the 49 million with no health insurance at all? You think they don’t find that frustrating? How about the millions more with crappy, inadequate insurance, you think they don’t find that annoying? How about what the OP went through with pirate insurance - you think that THAT is somehow not frustrating?
Built from scratch? Who are you kidding? Expand Medicare to cover everyone, or at least use it as a jumping off point.
