Even if you get insurance, and even if you can meet the deductibles and copays you can still not get covered. Off the top of my head you have situations like
The hospital is out of network
The hospital is in network, but provider is out of network
The insurance decides that your treatment wasn’t medically necessary
I’ve heard you can get charged if you leave against medical advice. But I’ve also heard that isn’t true.
I was told today by someone who works in healthcare that if you are deemed an ‘out patient’ admission to a hospital you end up with the bill, insurance will only pay for in patient admissions. How the fuck does a person have any role in determining that?
Is there anything a person can do? Not everyone has access to an insurance plan with out of network coverage. I’ve looked, I don’t see high deductible supplemental insurance that covers out of network charges to cover what primary insurance doesn’t cover.
The PPACA offered some coverage against abuses (pre-existing condition coverage, ending recissions, etc) but it left a lot of situations where a person could still go bankrupt. If anything it may have made them worse because the ACA seems to encourage the rise of narrow networks and insurance w/o out of network coverage.
Evenso, even with out of network coverage you seem like you can still fall through the gaps. Moving to Canada keeps sounding more and more appealing.
I’d suggest having lots and lots of money. That’s the only way you’re going to guarantee that you will be able to obtain exactly the healthcare you want.
Other than that, the only thing you can do is pay attention to the specific rules of your insurance (read all the fine print), so at least you do your best to know what is and is not covered, and which providers are in network. But even that is no guarantee.
Every insurance provider should have a list of doctors and hospitals that are in network. Only go to providers that are in your network. Easy, peasy, lemon sqeezy.
I hesitate to suggest this, but travel quickly to a European or Australasian country with whatever travel insurance you can get and then mysteriously become tragically ill. You will be treated without question and it will be assumed your insurance will pay something.
Yeah, but it happens occasionally that for some reason the in network hospital where you went to have surgery with your in network surgeon but the anesthesiologist, who you don’t get to pick, is not in network.
This is a very interesting question. As I watched the battle over health care being fought, I was always struck by those on the opposed side who seemed remarkably sure THEY had rock solid coverage.
While everyday another sad story comes out of someone denied coverage after years of paying in. Or discovering not everything is covered. Or being blindsided by denial of coverage of Dr ordered care, over one technicality or other. Or still receiving bankrupting bills due to out of network issues!
Reading such stories definitely leaves me thinking there really isn’t any way to avoid it because so very much seems unknowable, unpredictable, or ever changing. I would find it a scary system to be in at any strata, I think.
(I have no first hand experience with such a system so I can only go on what I read and General impressions!)
This exact situation has happened to my family several times. In every case, the insurance company ended up paying the anesthesiologist as if they were in network. The first time (BCBS) I had to enlist the help of the State Insurance Commisioner’s office, the other times a call to the insurance comapny was all it took.
For those of you saying things like read your policy, that is not a failsafe.
What if out-of network people work on you without your knowledge or consent? You can’t plan for that always.
As far as admissions I thought obamacare covered both outpatient and inpatient care as part of their ten points. Is the advice the healthcare guy gave me out of date?
Also here is something I’m confused by. If I get medical care not covered by my insurance like bariatric care my insurance will not cover complications. So if I get a lap band, but five years later I need a reoperation I pay the bills. Why isn’t that considered a pre existing condition and covered? If in pay for a surgery, why isn’t the a surgery a pre existing condition if I have complications?
Also the people in charge of health insurance don’t always know either. I’ve gotten several ‘I don’t know’ answers and wrong answer from the people in charge of my health policy.
Even if you have enough money to pay your deductable, you need to beware of the copay (typically 10-20%) which you are still on the hook for even after you meeet the deductable.
Oh yeah, and about that deductable: there are probably rules in your insurance policy which, in effect, mean that only part of your out-of-pocket expenses actually go to meeting your deductable. I’ve recently found this out the hard way. Due a major medical issue in my family, I had to pay a few thousand dollars before I met my $1250 deductable :mad:
Obamacare has good intentions, but it’s like a bunch of first graders trying to outsmart their teacher. The insurance industry will always find a way to game the system.
The general lack of transparency is the most infuriating thing surrounding medical billing for me.
Awhile ago I was at a doctor’s office for a physical and inquired about getting a small wart on my finger frozen off. Since I had a high deductible plan and this procedure would be paid out of my pocket, I was interested in the cost. I asked if it would be $10… $100… $1000? They couldn’t answer. They couldn’t say within an order of magnitude what the procedure would cost. The best they could do was offer to submit the question to the Bureau of Medical Billing Great Black Box, or wherever such queries go, and get back to me in 10 days. I could then decide if I wanted to go ahead with it (and pay another couple hundred dollars for another office visit, of course). :smack:
Even there, in an emergency, if you get taken to an out-of-net ER, your insurance will only cover you enough to be made stable enough that you can be transported to another in-net facility.
Remember the movie Sicko ? One of the infamous incidents documented there (although it had been in the news before, IIRC) was the time the HMO demanded that the patient be moved from the out-of-net ER to their HMO-run ER, before the patient was really stable. The patient then died en route.
I wish that were true but its not. Many specialty physicians are considered contractors and are not covered by insurance. Cardiologists, anesthesiologists, etc. I even asked my health insurance company can I sign a document saying I refuse all care from any practitioner who is not in network and not covered by my insurance. She told me no, but she has been wrong about other stuff. If the person whose job it is to explain insurance is wrong or confused what chance does a patient have?
Medicare isn’t available on the insurance exchanges, you can only get it by being 65 or by having end stage renal disease (maybe a few other conditions).
For people who get insurance via work, I don’t think they can get on the exchanges. I don’t know.
Many exchange plans do not cover out of network costs.
The ACA did almost nothing to stop balance billing, narrow networks, etc. If anything it probably made them worse.
You can also qualify for Medicare by being on SSA disability for 25 consecutive months. And re the balance billing; what a lot of people don’t realize is that even if the insurance company agrees to pay an OON provider at the INN rate it doesn’t mean the provider actually has to accept that rate, usually they can still go after the patient for the difference.
I wonder if there is an equivalent of the Laffer curve for health insurance. If health insurance covers too many services, then people can’t afford it and nobody buys health insurance. If it covers too few services, then people realize ‘what is the point of buying insurance’ and nobody buys it since they will go bankrupt once they get cancer anyway. Why not save your money and go on medicaid if you get sick. I’ve heard several people talk about the latter, how they went w/o insurance for years, saved endless tens of thousands of dollars by not paying premiums and when they got truly sick they went on a public plan while their friends who paid into insurance for years ended up bankrupt because insurance didn’t cover everything and eventually went on a public plan. Same outcome, but person A saved thousands in the process.
The US seems to be moving further and further into the latter category. The only way to make insurance ‘affordable’ is to create narrower and narrower networks, and cover fewer and fewer things. All these things leave patients with insurance that either won’t let them get treated, or that hands them the bill after treatment is over. Balance billing, drive by doctoring, narrow networks, etc. are going to get worse and worse. Plus as insurance tries to cut down costs by cutting DR reimbursements, that will increase DR incentive to engage in OON charges. Why work on an in network or medicaid or medicare patient for $30 when you can spend 5 minutes with a patient who is OON and charge them $200 for it?
The entire system in the US is unsustainable, the question is when/how will it collapse and be reformed?