F'n Healthcare and Insurance

[al503]

For the record, I have very little experience with healthcare, period. I've seen a doctor 8 times since the 3rd grade (I'm 36 now). 4 'turn your head and coughs' for sports in high school , 3 not so annual checkups and once for alcohol poisoning as an undergrad.

My last annual was a couple of months ago and I'm starting to get the bills. For one office visit, which lasted about a hour and 45 minutes (5 minutes to check in, 40 minute wait, 10 minutes with the Dr., 5 minutes to draw blood, another 25 minute wait, then 10 minutes to do a chest x-ray) my bills seem to be totalling just under $1000 for about 30 minutes of actually productive time and lab fees.

Of course, my insurance company (that makes exhorbitant amounts of $ off of me because I never see the Dr./go to the hospital/don't take anything stronger than caffeine) claims that the majority of this is not covered and it'll have to come out of my f'n pocket. WTF????

I can't tell which of the 3 separate bills were for what because one of them has a line item with 'surgery' on it but it's only for about $45.

So now, I get to figure out if my bills are correct and go through all of my 'insurance' packets to see if my annual and the lab fees are actually covered and if so, to what extent, or if they're just trying to get out of paying my f'n bills.

I also took my mom to see an ear/nose/throat specialist because her sense of smell was very weak. Long story short, we wait for about 45 minutes, see the Dr. for literally less than 5 minutes and get a bill for $613. He says that there's nothing wrong and that her sense of smell will come back eventually. 4 months later and she still doesn't have her sense of smell back. I'd try to get another appointment but it took 2 appointments with 2 other 'regular' doctors before we could even get an appointment with the 'specialist.'

I hope this doesn't sound naive but WTF is going on?

[Overkill]

I've found there's sometimes 2 things at work here. One is the Dr's group takes the shotgun approach to billing.....send a bill to everybody (you AND the insurance company) and see who sends them money. So basically some of the stuff you're seeing bills for may ultimately be paid by the insurance co. This will usually fix itself if you do nothing. But do go to long or they'll send you to collections if its a real bill.

The other thing that happens is the insurance companies deny claims for minor technical issues, or perhaps no issue at all, just to see if you'll cough up for something that probably should be covered. Some times, like if you see another Dr besides your Primary Care Dr because he's not in and they bill under that Dr's name, or the group name, the Ins.Co will kick it back cause the treating physicians name doesnt match your PCP of record. Really, its any reason not to pay immediately on the off chance you'll pay.

The only way to get through this stuff is to start a file. Call your ins co and ask why they're not covering whatever, get the name of the person, date time....all that. If its a billing problem you'lll have to spend a bunch of time being the go between the dr's office and the Ins Co. The better records you keep and the more relentless your follow up is, the easier this will go.

[Round_Gun_Shooter]

I hope this doesn't sound naive but WTF is going on?

You obviously didn't bend over far enough.

I pay $1350 a month for my insurance. I pay nothing except my co pay until I see the refusal from the Insurance Company.

For many tests, you need a diagnosed reason. Chest X Ray=Former smoker or work in hazardous environment//Blood work-Symptomatic low levels of energy. and more a doctor can figure out.

In MA we now have a law coming in that requires everyone have health insurance. If you don't have it there are financial penalties. Now tell me where that makes sense. You can't afford health insurance so they fine for not having it

[raz-0]

Basically, the health care system as it exists requires you to make about a jillion phone calls. Hey, at least they don't require you to go and wait in line for most of their bureaucracy. However, I'm sure that's to prevent their employees from being assaulted rather than any altruism on their part. I know your pain, and the best I can do is share the strategies from my experiences.

It shouldn't have been so much work, but I've gone through most of the processes you ahve described having biling/insurance issues, and in the end all I got stuck with was a $90 x-ray bill that showed nothign was broken, but there was no way (i.e. the hospital didn't want to) to get the biling process fixed, so coverage was denied.

First up, the $45 surgery, any idea what it was,like did the doctor hack off a mole for you in the office just to be safe? If so, I suggest you just write a check for the $45 as it is a reasonable fee, and will avoid issues with the insurance company who wouldn't allow you to have it done that way. If not, call the doctor to find out what it is, and if it is one of those cash discounted non-insured procedures that sound reasonably priced, just pay it and don't bring it in to the process of dealing with the insurance company as it will needlessly complicate matters.

Second, while you have the doctors office on the phone, ask if they are legitimate bills, and if their office has submitted them to insurance. It may simply be that due to your lack of fimiliarity with current medical billing practices, you wound up in a situation where you are responsible for paying the bill and getting the cash out of your insurance company. I.e. you "volunteered" to do the footwork and be out the cash during billing/reimbursement overlap. Ask if they have been submitted and denied. If the insurance company has never seen it, and your doctor is nice, this can usually be made less painful.

Third, if the doctor's office hasn't helped you out to the point you have a clear idea of what needs doing, call the insurance company and find out what they will and won't pay for and why.

If I had to guess, from your description and my experiences, I suspect this is what is going on.

1) Your basic physical exam was covered for a fixed dollar value. The doctor's rate for this may exceed it, in which case they will bill you for the balance. Most HMO-like entitites prohibit this, and you simply have to call the insurance company to find out what they pay, then call the doctors office and stand up for yourself. Around here, the standard rate is usually about $100, but the insureance rate is $50-70. However, the cash negotiated rate is usually about $60. I don't know why they choose to complicate things when they know the terms of the flat patient reimbursement form the HMO rquires they accept the negotiated price for a bsic office visit and exam.

2) For the blood tests (if for something like cholesterol screening, but not lead levels unless you have symptoms. Even if you work in an environment where you may be exposed to lead, the insurance company may deem that your employers responisbility to pay for), they likely draw at the office for patient convenience, and then ship them off ot a lab, but have the lab bill you. Every time I have gone through blood tests with this arrangement it has ALWAYS generated billing problems as the doctors office never seems to pass on the insurance info and it gets billed as a if uninsured. They may also incur issues with referrals not being issued properly. This is usually sorted out with about 4 or 5 phone calls once you get the hang of it.

3)For the x-ray, it may be more complicated. First off the x-ray has to be covered. Which can vary with insurer. There should always be a way to get an x-ray covered, but sometimes it requires your doctors office to go through the proper shenanigans to get it covered. If they did something like take one to see if you have spots on your lungs cause you smoke, then later sent it off for a real once over by a radiologist, or some other 3rd party, then you might once again be in a sistuation where referrals or billing/insurance info was not passed up the line correctly. In gneral, it is about the same as hashing out the blood tests, but more painful in my experience as the doctor incurred more expense taking the films, and the radiologists seem to be very reluctant to help sorting out billing unless the doctros office seems to be pissed.

4)Your mom's sense of smell... well, it is gone for good, or it isn't. There isn't much a doctor can do other than make reasonably sure it isn't a symptom of something treatable. The sense of smell and taste seems to fade in older people, especially women, and your primary care is going to refer it to a specialist to cover his ass, and then likely monitor it themselves long term. Specialists cost big bucks, which sucks, but is the way it is. If it is an uninsured visit, it almos always pays to ask them for cash terms for uninsured. They will usually cut you a better price as they don't have to deal with insurance BS that often pays them less than they bill. (i.e. they have to set the market price high so they can stay in business when HMOs will only pay 70% of market price, but if they are making a profit at $70 on every hundred billed, they will likely pass the same on to you and take the $30 "loss" on the books in their favor).

On the other hand, your doctor could be a total ass and wants your patient fee from the HMO and full rate for services. Kind of like dentists who bill a cleaning your teeth as a full mouth debridement because they get $250 more for it, and then don't do an actual full mouth debridement as well as screwing you over because your dental plan, if any, probaby only covers 4 quadrants over 4-5 years.

Even if you don't go to the doctor a lot, you should always try to get recomended a good one and get on baord as an existing patient. Then do your best to pick your insurance based on your good doctor.

Hope it all works out.

[al503]

First of all, thanks for taking the time and effort to reply, raz-0.

First up, the $45 surgery, any idea what it was,like did the doctor hack off a mole for you in the office just to be safe? If so, I suggest you just write a check for the $45 as it is a reasonable fee, and will avoid issues with the insurance company who wouldn't allow you to have it done that way.

No idea as there was nothing invasive with the exam.

Second, while you have the doctors office on the phone, ask if they are legitimate bills, and if their office has submitted them to insurance.

Of the 3 bills I've received, they all seem to have been submitted to my insurance company. I've gotten 'explanations of benefits' for each one with most of the stuff denied.

1) Your basic physical exam was covered for a fixed dollar value. The doctor's rate for this may exceed it, in which case they will bill you for the balance. Most HMO-like entitites prohibit this, and you simply have to call the insurance company to find out what they pay, then call the doctors office and stand up for yourself. Around here, the standard rate is usually about $100, but the insureance rate is $50-70. However, the cash negotiated rate is usually about $60. I don't know why they choose to complicate things when they know the terms of the flat patient reimbursement form the HMO rquires they accept the negotiated price for a bsic office visit and exam.

You're right on with this one. Seems like they picked up about 67% of the flat 'office visit 18-39 yrs.' One of the bills only lists the 'Office Visit.'

2) For the blood tests (if for something like cholesterol screening, but not lead levels unless you have symptoms. Even if you work in an environment where you may be exposed to lead, the insurance company may deem that your employers responisbility to pay for), they likely draw at the office for patient convenience, and then ship them off ot a lab, but have the lab bill you. Every time I have gone through blood tests with this arrangement it has ALWAYS generated billing problems as the doctors office never seems to pass on the insurance info and it gets billed as a if uninsured. They may also incur issues with referrals not being issued properly. This is usually sorted out with about 4 or 5 phone calls once you get the hang of it.

The second bill seems to have the blood/lab fees. This one has the 'surgery' along with about 8 lab fees, as well as the 'Radiology' fee. I'm thinking that the 'surgery' may have been sticking the needle in?

0% of these costs were covered and this is the bulk of my bills. How can you get an annual without blood tests?

3)For the x-ray, it may be more complicated. First off the x-ray has to be covered. Which can vary with insurer. There should always be a way to get an x-ray covered, but sometimes it requires your doctors office to go through the proper shenanigans to get it covered. If they did something like take one to see if you have spots on your lungs cause you smoke, then later sent it off for a real once over by a radiologist, or some other 3rd party, then you might once again be in a sistuation where referrals or billing/insurance info was not passed up the line correctly. In gneral, it is about the same as hashing out the blood tests, but more painful in my experience as the doctor incurred more expense taking the films, and the radiologists seem to be very reluctant to help sorting out billing unless the doctros office seems to be pissed.

The third statement has x-ray on it. The insurance covered about half of it but didn't seem to cover any of the 'radiology' fees on the second statement.

4)Your mom's sense of smell... well, it is gone for good, or it isn't. There isn't much a doctor can do other than make reasonably sure it isn't a symptom of something treatable. The sense of smell and taste seems to fade in older people, especially women, and your primary care is going to refer it to a specialist to cover his ass, and then likely monitor it themselves long term. Specialists cost big bucks, which sucks, but is the way it is.

Besides the wait, the visit went exactly like this:

1. 45 minute wait

2. Dr. comes in and introduces himself.

3. Dr asks how long my mom's sense of smell has been down

4. Dr. takes a look at my mom's nose for about 30 seconds

5. Dr. says it'll come back on it's own, not to worry about it, and have a good day.

I was being generous with the 5 minutes he spent

Looks like I'll have to start making some phone calls.

Again, thanks for your reply above.

[Rob Boudrie]

My best experience in this area was a dentist who charged an estimated deductible based on what my dental coverage paid ($660 bill). It turns out the "paid in full contract price" was $250, not $660. I sent the dentist a bill for "unauthorize charge in excess of contractually permitted copay" and she paid it.

It I didn't have insurance, I would have been hammered $660 for that visit, not simply paid the amount the insurance company paid. Another bill I got from an MD was "cash price $2400, insurance contract price paid in full $425."

[Bear23]

Typically with most insurances the doctor has a contracted rate that he gets paid, you are responsible for the copay, and deductible amount if it hasn't been met.

Be aware, you may have separate deductibles for labs, x-ray, oupatient surgery, other ancillary testing.

If the doctor has a contracted rate, he cannot go above and beyond that rate and 'bill' you for the remainder.

Your insurance may vary, as a patient it is up to you to understand your insurance and how it works.

[ipscbob]

Wow, that is unbelieveable! My wife and I are covered by Kaiser Permanente and we have a $20.00 copay for ALL regular visits regardless of the cause. We also have a $30.00 copay on ALL prescriptions, Period. No extras, no uncovered procedures or drugs in almost 15 years. I now appreciate my coverage a lot more.

[Overkill]

Kaiser has seemed like they've got their act together recently....but through the 90's I just hear a string of horror stories about crappy care at kaiser.

[Rob Boudrie]

Typically with most insurances the doctor has a contracted rate that he gets paid, you are responsible for the copay, and deductible amount if it hasn't been met.

And, typically, that "contract rate" is way less than walk in people are charged.

[Nik Habicht]

Typically with most insurances the doctor has a contracted rate that he gets paid, you are responsible for the copay, and deductible amount if it hasn't been met.

And, typically, that "contract rate" is way less than walk in people are charged.

And the theory there is that the insurance company deserves a discount for bringing in a bunch of customers.....

.....In the past, I've been uninsured, and I've managed to negotiate everything from straight out reductions to interest free financing. I'm still seeing most of the doctors who were willing to work with me....

[JSCHIEFEN]

AS A SURGEON I HAVE FACED THESE SAME PROBLEMS AS BOTH A PROVIDER AND A PATIENT. OUR SYSTEM IS IN A DEATH SPIRAL.

WE HAVE INSURANCE CEO'S MAKING SEVERAL MILLION PER YEAR PLUS BENEFITS AND HOSPITALS AND PHYSICIANS GOING BROKE

DAILY. WE HAVE ILLEGALS USING OUR HEALTH CARE SYSTEM EVERYDAY BY THE MILLIONS AND THEY DON'T PAY A DIME FOR THERE

CARE. YET, GOOD, UPSTANDING, HARD WORKING, HONEST, TAXPAYING AMERICANS CAN'T AFFORD TO SEE A DOCTOR AND CAN'T

GET OR CAN'T AFFORD INSURANCE (THAT MAY OR MAY NOT PAY ANYTHING FOR THEIR CARE).

THE SYSTEM IS SO COMPLEX THAT NO ONE CAN UNDERSTAND IT LET ALONE MAKE IT WORK TO GET CARE FOR THE PATIENT.

TRUST ME, DOCTORS DON'T LIKE IT ANY MORE THAN THE PATIENT DOES! WITH THE COST TO TRAIN A SURGEON NOW WELL OVER

A MILLION DOLLARS AND THE FACT THEY ARE LEAVING THE PROFESSION AT A RATE 3X's AS FAST AS WE ARE REPLACING THEM, WE

ARE IN SERIOUS TROUBLE IN OUR HEALTH CARE SYSTEM.

AFTER NEARLY 30 YRS IN THIS PROFESSION, ALL I WANT IS FOR MY PATIENTS TO GET WHAT THEY NEED FOR CARE AND TO BE AS HEALTHY

AS THEY CAN BE FOR THE REST OF THEIR LIFE. WE HAVE A SYSTEM THAT WAS THE BEST IN THE WORLD. BUT NOW IT IS VERY SICK AND

ABOUT TO DIE, AND PATIENTS ARE SUFFERING AS NEVER BEFORE IN THIS COUNTRY.

I'M NOT SURE THERE IS ANY HOPE FOR US OR OUR COUNTRY UNLESS WE BAND TOGETHER TO FIX THIS ILL AND SO MANY OTHERS

THAT ATTACK OUR FREEDOM AND WAY OF LIFE.

DOC SCHIEFEN

[ipscbob]

Kaiser has seemed like they've got their act together recently....but through the 90's I just hear a string of horror stories about crappy care at kaiser.

If you listen to those really in the know, you will hear a string of stories about bad care at ALL hospitals. Most of my family are independant physicians and they are in the know. Our local Kaiser hospital is rated number two in our county for quality of care. Kaiser has the best preventive care policy in the industry. Keeping me healthy keeps them profitable.

[Hank Ellis]

My wife used to work for insurance companies but she wanted to work for people that had some morals. So she went to work for lawyers.

In the aeromedical side we bill knowing that we will recieve only 60% of what we bill. When someone gets busted up in a motor vehicle accident (MVA), whether they have insurance or not, are illegal or not, is not of concern. If they need the care they will be transported. Once the charges are written off from insurance companies that will not pay and those that cannot pay, we get the 60%. That 60% pays for the aircraft at $3.5 mil a pop, the pilot, flight nurse, mechanic, and the support to get it in the air. Making a profit in aeromedical is not easy.

[dajarrel]

Typically with most insurances the doctor has a contracted rate that he gets paid, you are responsible for the copay, and deductible amount if it hasn't been met.

And, typically, that "contract rate" is way less than walk in people are charged.

This is another reason why you cannot afford not to have insurance, no matter how bad it is. IMHO, those without insurance subsidize those who have insurance by paying the "full cost"

FWIW

dj

Edited to add that although I "see" a problem, I have no idea how to "fix" the problem.

Edited May 25, 2007 by dajarrel

[Middle Man]

Edited to add that although I "see" a problem, I have no idea how to "fix" the problem.

Remove the ridiculous government bureaucracy and open medicine to the most basic free market principles...

Private insurance providers really do not do much more that parrot the policies regarding rates for payments to physicians and what procedures will be covered as set forth by Medicare/Medicaid programs. It's not fun to get tripped up in the red tape and fine print, that's something all sides of the equation hates.

Edited May 25, 2007 by Middle Man

[vluc]

Part of the reason some costs may not be covered would be related to the diagnosis chosen by the provider.

If he /she used one that is not associated with certain lab tests, it will be denied - example a "routine" code is used and the related blood test is "medical" in nature. A call to the doctor's office requesting it be recoded usually works.

Offices don't know the ins and outs of every insurance plan. Your Highmark Direct Blue and my Highmark Direct Blue may not be the same plans when it comes to coverage, co-pay, deductible, etc.

The key it to be educated on your plan, speak up and be vocal about it.

[Bear23]

Typically with most insurances the doctor has a contracted rate that he gets paid, you are responsible for the copay, and deductible amount if it hasn't been met.

And, typically, that "contract rate" is way less than walk in people are charged.

Walk-ins pay my full price for an office visit or consult, plus x-ray and if they have surgical procedures. Nothing wrong with that, this is after all America. I do give those patients with low incomes, payment plans and reduced rates. If I see you drive up in an Escalade or CL600, and you have a problem with the amount.....I may wonder...WTF?