10 ms·

If you know how to "don't take no for an answer" I'll say optimistically, you'll be alright. My experience with my wife's health care (Aetna) has been that she

by yebyen 9y ago

If you know how to "don't take no for an answer" I'll say optimistically, you'll be alright. My experience with my wife's health care (Aetna) has been that she will call, try to get an issue resolved, be told "there is no resolution possible" enough times by enough different people that she is ready to give up. Then we call together, and suddenly the story changes. The particular issue we were dealing with, is not really important, but tl;dr I almost wound up with two health insurances because I tried to stay insured and cover my bases when I was changing jobs, and nobody needs two health insurances. They tried to tell us we couldn't cancel when I got a new job that came with better coverage for less. I thought that was a qualifying event! But, through some nonsense technicality we would not be allowed to cancel during the plan year, and even though I'd never made a claim and we were making quarterly payments, we'd be on the hook for the remainder of payments for the whole year. (This is illegal, I'm sure of it.) The best advice I can give you is, know your rights and how to assert them. Good luck with that though, health care in this country is byzantine and I had the benefit of people in my family that work in health care administration who could help me understand.

arkades 9y ago
1) know who to appeal to outside the company. This is the nuclear option. It's usually listed in fine print on every paper denial. 2) "My (partner) works in insurance. He does shit like this for a living. Please don't make me have to (goto 1)". 3) Feel free to cite the law where relevant, on paper, certified mail. The response is invariably "this is wrong, you misunderstand the law, but we will make an exception and (follow the fucking law this once.)" I was in health insurance, management level, before I went into medicine.
- LanceH 9y ago
  The number one rule is don't pay anything until it is resolved. The second you've made payment, nobody else cares to make any effort.
  - arkades 9y ago
    This is not something I'd recommend. Any lapse in payment will be used to suspend your policy in the future in the event you get flagged as a high-expense patient, backdated to the period you didn't pay your premiums on time. Pay on time, keep documentation you paid on time. Hell, turn on autopay and keep documentation on -that-. Don't ever think you can hold your premiums hostage. You'll only be screwing yourself. Edit: if you're referring to clinic bills, be sure you're in active communication with the practice manager so you don't get sent to collections. If it's a hospital, you'll be sent to collections anyway - they automate that process, once you're sufficiently late.
    - pinneycolton 9y ago
      I wonder if they meant that you shouldn't pay providers until things are sorted out. I agree that you need to pay your premiums, but doctors and hospitals will just send you to collections. Still not a great option, but it does keep the money in your pocket until things are sorted out. (Of course, I wouldn't do this unless I was very sure I was right, also, so that any collections issues would be an insurer/provider error.)
      - arkades 9y ago
        If you don't pay a bill, there's no error. The subsequent hit to interest rates on something like a mortgage outweighs most minor medical bills.
      - emodendroket 9y ago
        As far as your provider is concerned, whether your insurance should pay or not isn't really their problem. I have never been somewhere that did not make me sign a form saying that I agreed to be responsible for whatever my insurance did not pay.
        subway 9y ago
        Most providers understand the shit-show that is insurance, and will drastically adjust their behavior and prices based on who is paying.
danielvf 9y ago
Your advice is spot on. We had a very similar experience with Blue Cross for many years. I'd swear they have an RNG that randomly denies claims 80% of the time. You just had to fight each one on the phone. The people on the phone only had the apparent authority to "send the claim through the system again". About a month later you'd find out what happened. If denied again, we would just repeat until we eventually got lucky with the RNG. They did eventually pay everything they should have, but we'd average about two hours on the phone per doctor visit.
deleted 9y ago
[deleted]
X86BSD 9y ago
What floors me is how no one has disrupted this field yet. I have seen a few ground zero startups trying to disrupt healthcare. Make it more effecient, cut out fraud, etc but so far no one is making a dent. Why is it so hard for some smart young folks to come along and hammer out solutions to accomplish less fraud, easier, and faster to use systems etc? It seems like it's really REALLY hard to bust up this abortion we call healthcare in the US.
- paulmd 9y ago
  With specific exceptions (medical devices - those Rascal ads are there for a reason) there generally isn't a ton of fraud. What there is is a lot of middlemen each taking their own cut, which cumulatively adds up to a lot of overhead. It's the "efficiency" part that you mention. Efficiency is a tough nut to crack but there are organizations like Kaiser Permanente that have been very successful with a vertical integration model to cut this overhead. The problem is that it's a political fight every step of the way - doctors, hospitals, insurance companies, and drug makers each have their own extremely powerful lobbies who will spend lavishly to keep their cut of the profits flowing. Which is why we're actually moving in the opposite direction - the ACA moves away from this type of integrated care organization and towards a fee-for-service model. The idea is to have the consumer be the one choosing the cheapest MRI provider or whatever - but in practice the pricing is still entirely opaque and the public are more or less thrown to the wolves. The finest health-care plan the Heritage Foundation could devise... And of course everyone has their own idea of how to improve efficiency, all of which translates into a lot of paperwork and red tape. That is why your insurance denies claims after all - "efficiency" (airquotes). It creeps into every aspect of medical care, especially anything having to do with Federal dollars (Medicare/Medicaid). And to be fair a lot of it is justified, it is an uphill battle to get providers to adopt even basic best-practices like checklists during surgical procedures ("remove and count all 5 pieces of gauze before you close the patient"...). Another thing that doctors fight tooth and nail is clinical decision-support tools - even though these are a value-add for the physician in many cases (did you want to order that test with contrast or without? A family doctor may not know.) (disclosure: I worked on such a tool at my current employer) One little-addressed area of extreme waste is generic drugs. The idea is that once your patent expires (after decades of "patent evergreening" of course) anyone can make your drug - but in practice that's not how it works, one company just dumps product on the market at cost until everyone else leaves the market, at which point they are once again free to charge whatever they want. The overhead costs of starting drug production is quite high, and in practice it's more difficult for new drugs to claim bioequivalence because the drugs involve biological steps in their production. A company is not obligated to share the organisms used in their production process and if a competitor creates their own they must repeat FDA approval processes, which are inordinately expensive.

by yebyen 9y ago

arkades 9y ago

1) know who to appeal to outside the company. This is the nuclear option. It's usually listed in fine print on every paper denial. 2) "My (partner) works in insurance. He does shit like this for a living. Please don't make me have to (goto 1)". 3) Feel free to cite the law where relevant, on paper, certified mail. The response is invariably "this is wrong, you misunderstand the law, but we will make an exception and (follow the fucking law this once.)" I was in health insurance, management level, before I went into medicine.

LanceH 9y ago
The number one rule is don't pay anything until it is resolved. The second you've made payment, nobody else cares to make any effort.
- arkades 9y ago
  This is not something I'd recommend. Any lapse in payment will be used to suspend your policy in the future in the event you get flagged as a high-expense patient, backdated to the period you didn't pay your premiums on time. Pay on time, keep documentation you paid on time. Hell, turn on autopay and keep documentation on -that-. Don't ever think you can hold your premiums hostage. You'll only be screwing yourself. Edit: if you're referring to clinic bills, be sure you're in active communication with the practice manager so you don't get sent to collections. If it's a hospital, you'll be sent to collections anyway - they automate that process, once you're sufficiently late.
  - pinneycolton 9y ago
    I wonder if they meant that you shouldn't pay providers until things are sorted out. I agree that you need to pay your premiums, but doctors and hospitals will just send you to collections. Still not a great option, but it does keep the money in your pocket until things are sorted out. (Of course, I wouldn't do this unless I was very sure I was right, also, so that any collections issues would be an insurer/provider error.)
    - arkades 9y ago
      If you don't pay a bill, there's no error. The subsequent hit to interest rates on something like a mortgage outweighs most minor medical bills.
    - emodendroket 9y ago
      As far as your provider is concerned, whether your insurance should pay or not isn't really their problem. I have never been somewhere that did not make me sign a form saying that I agreed to be responsible for whatever my insurance did not pay.
      - subway 9y ago
        Most providers understand the shit-show that is insurance, and will drastically adjust their behavior and prices based on who is paying.

danielvf 9y ago

Your advice is spot on. We had a very similar experience with Blue Cross for many years. I'd swear they have an RNG that randomly denies claims 80% of the time. You just had to fight each one on the phone. The people on the phone only had the apparent authority to "send the claim through the system again". About a month later you'd find out what happened. If denied again, we would just repeat until we eventually got lucky with the RNG. They did eventually pay everything they should have, but we'd average about two hours on the phone per doctor visit.

deleted 9y ago

[deleted]

X86BSD 9y ago

What floors me is how no one has disrupted this field yet. I have seen a few ground zero startups trying to disrupt healthcare. Make it more effecient, cut out fraud, etc but so far no one is making a dent. Why is it so hard for some smart young folks to come along and hammer out solutions to accomplish less fraud, easier, and faster to use systems etc? It seems like it's really REALLY hard to bust up this abortion we call healthcare in the US.

paulmd 9y ago
With specific exceptions (medical devices - those Rascal ads are there for a reason) there generally isn't a ton of fraud. What there is is a lot of middlemen each taking their own cut, which cumulatively adds up to a lot of overhead. It's the "efficiency" part that you mention. Efficiency is a tough nut to crack but there are organizations like Kaiser Permanente that have been very successful with a vertical integration model to cut this overhead. The problem is that it's a political fight every step of the way - doctors, hospitals, insurance companies, and drug makers each have their own extremely powerful lobbies who will spend lavishly to keep their cut of the profits flowing. Which is why we're actually moving in the opposite direction - the ACA moves away from this type of integrated care organization and towards a fee-for-service model. The idea is to have the consumer be the one choosing the cheapest MRI provider or whatever - but in practice the pricing is still entirely opaque and the public are more or less thrown to the wolves. The finest health-care plan the Heritage Foundation could devise... And of course everyone has their own idea of how to improve efficiency, all of which translates into a lot of paperwork and red tape. That is why your insurance denies claims after all - "efficiency" (airquotes). It creeps into every aspect of medical care, especially anything having to do with Federal dollars (Medicare/Medicaid). And to be fair a lot of it is justified, it is an uphill battle to get providers to adopt even basic best-practices like checklists during surgical procedures ("remove and count all 5 pieces of gauze before you close the patient"...). Another thing that doctors fight tooth and nail is clinical decision-support tools - even though these are a value-add for the physician in many cases (did you want to order that test with contrast or without? A family doctor may not know.) (disclosure: I worked on such a tool at my current employer) One little-addressed area of extreme waste is generic drugs. The idea is that once your patent expires (after decades of "patent evergreening" of course) anyone can make your drug - but in practice that's not how it works, one company just dumps product on the market at cost until everyone else leaves the market, at which point they are once again free to charge whatever they want. The overhead costs of starting drug production is quite high, and in practice it's more difficult for new drugs to claim bioequivalence because the drugs involve biological steps in their production. A company is not obligated to share the organisms used in their production process and if a competitor creates their own they must repeat FDA approval processes, which are inordinately expensive.