US healthcare reform questions

Note to mods & admins, I wasn’t sure where to place this OP.

Reading this thread made me wonder about something. Now, it may be a silly or stupid question, but that’s never stopped me before :cool:.

Although a lot of things are in flux as to what the final bill will contain if and when it gets passed, two things seem certain:
[li]No more pre-existing conditions.[/li][li]No more dropping patients who are too sick or go to the doctor’s office or hospital too much.[/li][/ol]
But one thing I now wonder about happening, will insurance companies increase denials based on “you went outside our network” since this will be **about **the only way left to get out of paying claims?

Well, as it stands, you usually have to get a pre-authorization to go out of network. Obviously, there may be situations where that’s not possible–or the physician you want is not in your plan–but for most specialist visits, I don’t see how it would make a difference.

I’m thinking of cases where they’ll initially approve, and then try to back out of it later.

This is IMHO, but I don’t think that behavior will increase that much. For the vast majority of medical visits, whether the doctor is in-network or out of network is extremely obvious. Also, not every plan is based on network doctors. With more people having a choice of their health insurer, access to that type of insurance will probably increase.

On the other hand, I haven’t heard of anything in the proposed reforms that would discourage insurance companies from denying claims for being out of network to the extent they do now.

My bet is on more-or-less business as usual in terms of insurers denying claims based on networks.

Let me also add a plug for the Kaiser Family Foundation website for well-researched answers to questions about healthcare reform. This site provides good comparisons of the proposals:

Even if there are no pre-existing conditions, there will still be other “not our problem” denials.

Medical condition/injury due to a work related injury? “Not out problem - you need to file a workers’ compensation claim.”

Medical condition/injury due to an accident caused by the negligence of somebody else? “Not our problem - you need to file a PIP claim.”

Now, usually health insurers will cover this sort of care, then file a subrogation claim against whoever is supposed to be the first payor (like the insurer of the guy who ran you over, or whatever); but denials do happen on this basis.