NA Health insurance, are they scamming?

Let'sgoflying!

Let'sgoflying!

Touchdown! Greaser!
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Dave Taylor
I just finished a battle with an imaging provider billing office, and it struck me that the insurance co. was the true culprit; wanted to bounce it off people here, as many have interactions with the medical billing industry.

Before procedure, Med office says they need preapproval from ins (to see how much they will pay), after this, med office then tells me $900 is mine, and that is a final turnkey price (unless Dr orders more pics or complications of course...none of which happened in this case.
At check-in, I pay and re-establish this is my total responsibility for the procedure; 'yes that's it, you are paid in full'. Same discussion on check-out.

After 6 months, Med office is sending bills; you owe $900. I thought they must failed to record my payment, they can't really want to be paid twice, esp after our conversations.
I call, they say nope you really owe the same amount again as insurance did not pay that amount.
I recount the above story and we go back and forth a bunch before they finally capitulate and agree to write it off. (tip: didn't look like they would budge, but they did an about-face once I said I would be happy to share my story with the judge in small claims. {I said this very politely, but plainly})

At one point in the convo, they said the ins co originally said one thing to them and after my procedure, offered the Med facility another, lower payment. (how they can do that is mystifying)
Hearing this, I could not help but wonder if that is one of their (ins co's) tricks to pass on costs to the customer. Bait and switch. Then the customer is battling a fairly powerful med billing office which is desperate to recoup their costs because the ins. co is not living up to their earlier agreement. The med billing office finds patients a way easier target than the ins co so why not chase the patient instead? They already have patients sign a forms saying pt is ultimately responsible if the ins co reneges, so why not use that tool to ensure payment?
Conspiracy theory or onto something?
Feeling jacked around and tired of 'large company bullying & theft'.
 
The insurance industry, if by any other name, would be regulated into oblivion, or tossed in jail.

Those scumb bags have been raping the American people under the radar for ages.
 
Insurance is a game. Gotta know how to play if you don't wanna pay big.

Dealing is the name of that game. Never accept their offer, but counter offer, hit it hard and don't give up.

James, I take it you do not have health insurance?
 
Let'sgoflying! said:
I just finished a battle with an imaging provider billing office, and it struck me that the insurance co. was the true culprit; wanted to bounce it off people here, as many have interactions with the medical billing industry.

Before procedure, Med office says they need preapproval from ins (to see how much they will pay), after this, med office then tells me $900 is mine, and that is a final turnkey price (unless Dr orders more pics or complications of course...none of which happened in this case.
At check-in, I pay and re-establish this is my total responsibility for the procedure; 'yes that's it, you are paid in full'. Same discussion on check-out.

After 6 months, Med office is sending bills; you owe $900. I thought they must failed to record my payment, they can't really want to be paid twice, esp after our conversations.
I call, they say nope you really owe the same amount again as insurance did not pay that amount.
I recount the above story and we go back and forth a bunch before they finally capitulate and agree to write it off. (tip: didn't look like they would budge, but they did an about-face once I said I would be happy to share my story with the judge in small claims. {I said this very politely, but plainly})

At one point in the convo, they said the ins co originally said one thing to them and after my procedure, offered the Med facility another, lower payment. (how they can do that is mystifying)
Hearing this, I could not help but wonder if that is one of their (ins co's) tricks to pass on costs to the customer. Bait and switch. Then the customer is battling a fairly powerful med billing office which is desperate to recoup their costs because the ins. co is not living up to their earlier agreement. The med billing office finds patients a way easier target than the ins co so why not chase the patient instead? They already have patients sign a forms saying pt is ultimately responsible if the ins co reneges, so why not use that tool to ensure payment?
Conspiracy theory or onto something?
Feeling jacked around and tired of 'large company bullying & theft'.
Click to expand...

Sounds about right.

So the loser in this case wasn't the insurance company, or the hospital, or the patient. This time it was the provider. Even though insurance pre-approved the amount and procedure.

I am betting that in that stack of paperwork you signed in the consent/admission process, you signed an "assignment of benefits" allowing them to bill your insurance, have any payment from the insurance assigned to you, and most importantly have you "agreeing to pay any outstanding or remaining usual and customary charges" or words of similar intent.

You were going to be screwed, legally and technically, for the outstanding charge that the insurance company reviewed, and decided to modify their approval... But the ned office would have lost even more collecting on it after the first two hours of legal representation in court with your kind and veiled threat to sue, and they made a business decision that it was cheaper to write it off. And its bad business to put patients in collections for relatively small amounts. Everything is a business decision.

The hospital on the other hand, if you had owed a lot more, might have found it worthwhile to sell your debt to a collector or pursue it.
 
No "bait and switch"...payment for many codes is based on diagnosis (preventive vs diagnostic). Many variables can impact amount paid including if your policy recently renewed your deductible could have reset back to 0 at renewal or the CSR may have given incorrect information, at my company if the claim is appealed based on incorrect info given by CSR the claim will be paid based on the error. If the provider is in-network they have a contracted rate so if they called they were most likely calling to see how much of your deductible you had already accumulated in order to let you know what your responsibility would be. I'm assuming since your share was $900 you have a high deductible plan?
 
Zeldman said:
Insurance is a game. Gotta know how to play if you don't wanna pay big.

Dealing is the name of that game. Never accept their offer, but counter offer, hit it hard and don't give up.

James, I take it you do not have health insurance?
Click to expand...

Buuuuuut, Berry said we all are covered lol


No, I don't, I don't gamble unless I know I'm going to win, and my risk vs what I'd pay, not worth it.

Also the reason health costs are SOO high that people feel they NEED insurance is, as we all know, because what insurance has done to the health industry.
 
@NHWannabe this was a cut and dried procedure with no surprises. Deductible resets Jan1. In network is what they told me. Yes, high deductible.
Next time I will run a recorder on all conversations. Legal in Texas.
 
Every carrier records every call...that's why my company will pull the call and if quoted incorrectly will pay based on what was communicated during the call. And fyi it's in every contract a provider who is in-network cannot bill you.
 
I would honestly rather have a plan that didn't cover anything up to say $5,000... and I don't mean the deductible I mean it doesn't pay for ANYTHING- no drugs, no visits, no checkups, etc below that amount and have the tax laws changed so all out of pocket medical costs are tax deductible. Then of course get the correspondingly lower premiums.

Anything you could afford to pay for out of pocket costs more through insurance, that's just how it works. You're paying whether it's through your premium or directly. At least directly the insurance company doesn't get a cut.
 
James331 said:
Buuuuuut, Berry said we all are covered lol


No, I don't, I don't gamble unless I know I'm going to win, and my risk vs what I'd pay, not worth it.

Also the reason health costs are SOO high that people feel they NEED insurance is, as we all know, because what insurance has done to the health industry.
Click to expand...


Amen to that, and it's a two-way-street. The industry has milked the insurance for all it's worth.
 
People think they need health insurance because they know they get sick. Some people get very sick, and even if costs were a fraction of what they are today, many people wouldn't be able to cover those costs. Insurance mitigates that risk for the consumer.

I've had policies with most of the big national insurers and one or two smaller ones over the years. In almost all cases, the billing issues I've experienced were the fault of the provider, not the insurance company. I've found many providers to be either incompetent or unethical when it comes to insurance claims, and have received bills for covered services or bills that were higher than the negotiated amount. When it is the fault of the insurance company, an escalation usually results in a prompt resolution.

I think there is merit to the claim that the proliferation in the availability of health insurance drives prices higher, in the same way that the increased availability of student loans (and the idea that everyone has to go to college) has pushed up the cost of tuition. Where a pool of money is available, someone will find away to access it.


JKG
 
The single biggest problem is the majority of health care is paid for with other peoples money. And the second is it's essentially impossible to compare costs ahead of time. There is almost no ability to shop and practically no incentive to do so. And that's works the same whether it's private insurance or a single payer system.

John
 
I had a health insurance plan that I liked. they said I could keep it if I liked it. Someone lied.
 
Health care for profit..... need I say more.
 
172andyou said:
So why are single payer systems half or less what the US system costs?
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Because they provide less services than the partially private US healthcare system. I have the opportunity to watch the british, german and spanish public system at work and it's not pretty.
 
weilke said:
Because they provide less services than the partially private US healthcare system. I have the opportunity to watch the british, german and spanish public system at work and it's not pretty.
Click to expand...

I've seen the first two, plus Austria and Japan. All have been better than my experience in the US. Their outcomes are better also, both in terms of effectiveness and satisfaction (the british system, which is also the one most like the US, has the worst satisfaction - perhaps even worse than ours). Which isn't what one would expect if your assertions were true.
 
172andyou said:
So why are single payer systems half or less what the US system costs?
Click to expand...

It's still other peoples money. And there's no comparison shopping. That's all I said.
 
172andyou said:
So why are single payer systems half or less what the US system costs?
Click to expand...

Because they dont take the Burger King approach. You dont have it your way.

Consumer driven medicine has some of the highest costs associated with less than highest outcomes.

Something that might seem ironic, but in the past few years, healthcare reimbursement has been tied to patient satisfaction. On its surface that sounds like a great idea. The reality is the places with the highest satisfaction scores are having some of the poorest outcomes (emergencies from overmedication for pain, for instance)

If you want to see what single payor for all will look like, look at what medicare, and military/VA medicine does. The formulary is straight forward and simple. By and large, if the old drugs work fine, they aren't paying for the new drugs that are not generic. There would be one statin. One ACE inhibitor. One Beta blocker. One anticoagulant. One antiplatelet drug. Expensive drugs get rigorous review, and generally require appeal to get funded, and only after the old standby's have been proven to fail for that particular patient.

Reimbursement for/performance of procedures is also pretty regulated. The best outcomes come from proceduralists who do lots of them, so its better for patient outcomes to limit the number of proceduralists/centers and keep their annual volumes high. There might be a wait if you aren't urgently ill. There might be a group of people who say "this hasn't shown benefit, we aren't approving it" or "survival with or without the procedure is unchanged, we aren't approving it". Those "death panels" that the government was accused of forming, which essentially already existed in private insurance, would be just as present in a single payor system.

A big part of our cost here in healthcare is that so much of our population is unfunded, yet requires emergency/catastrophic care. And sadly, much of our healthcare expense is in what we call "last mile" healthcare. The last 6 months of the average elderly american's life is overwhelmingly expensive, and many of the things we do in that last mile do not improve survival, nor quality of life, or truly ease suffering.

That care is passed on to the private insurers and the self pay patients at huge markup. If ALL were covered by single payor, with some sort of tax funding, the cost per patient would go down, and those who wanted to do something "not covered" would likely be able to afford it if they wanted (and there will always be providers who take cash or work for cash only. In the meantime, 3 taxes that I'd like to see at the federal level, that would have positive health impacts - even more of a tobacco tax, add a sugar tax on ready-to-consume sugary foods and drinks (like Berkeley California just did) and even more of an alcohol tax. Those three substances are major contributors to the epidemic levels of obesity, diabetes, alcoholism, liver disease, cardiovascular disease and lung disease, not to mention cancer. With those taxes, you'd both drop the impact of those substances and raise funds for the treatment of their impact.

Canada and Britain both have a single payor setup, but not all docs participate in their national health services. And those who are haves, will always be able to afford concierge or cash care that the have-nots cant. Or come buy it in the USA.
 
172andyou said:
I've seen the first two, plus Austria and Japan. All have been better than my experience in the US. Their outcomes are better also, both in terms of effectiveness and satisfaction (the british system, which is also the one most like the US, has the worst satisfaction - perhaps even worse than ours). Which isn't what one would expect if your assertions were true.
Click to expand...

None of the colossal ****-ups I have seen in those health systems would show up in any of the 'outcome' measures used by organizations like WHO or OECD.
 
denverpilot said:
$500 EpiPen anyone?
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Those are ridiculous. Epi is dirt cheap, only pennies a dose. We get epi in various trays and throw it away when not used. It is the delivery device they are (over)charging for.
 
I wonder what the army pays for atropine auto-injectors.

Found it. $33 each.
 
weilke said:
Because they provide less services than the partially private US healthcare system. I have the opportunity to watch the british, german and spanish public system at work and it's not pretty.
Click to expand...

Having lived in the US, Netherlands, and UK I couldn't disagree with you more. The US system is a monumental disaster compared to anything else I've experienced. Quality of care is comparable, cost is absurd.
 
weilke said:
Because they provide less services than the partially private US healthcare system. I have the opportunity to watch the british, german and spanish public system at work and it's not pretty.
Click to expand...

The Brit system is still crap if you're poor, or so my buddies over there have said.

Canada is crap for poor folks, if you can afford your own private insurance, you'll have private insurance.

Scrabo said:
Health care for profit..... need I say more.
Click to expand...

"We're from the government and we're here to help"

Need I say more.

Just like a drug dealer, get you dependent, kill off all competition and make all your thug buddies rich, at least dealers don't masquerade about what they are all about.
 
jsstevens said:
The single biggest problem is the majority of health care is paid for with other peoples money.
Click to expand...
Amen to that.
The problem then manifests itself on both ends: the insurance companies and the human victims.
And as in any business, lost of profit is made by not paying and seeing who will actually raise their voice. And the ratio of how much an insurance company ends up paying after then refuse to pay initially is staggering.
The medical business here (yes, it is business, not healthcare) is not curing people but about selling cure to everybody, whether they need it or not.
I am always afraid of getting sick.
 
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Katamarino said:
Having lived in the US, Netherlands, and UK I couldn't disagree with you more. The US system is a monumental disaster compared to anything else I've experienced. Quality of care is comparable, cost is absurd.
Click to expand...

Have you ever been sick, like major cancer or multisystem trauma kind of sick in those systems?
 
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