5 ms·

Wife recently needed a CT scan of the chest. It was the correct imaging modality for the potential DX in question. An X-ray would be useless as it wouldn’t show

by erentz 7y ago

Wife recently needed a CT scan of the chest. It was the correct imaging modality for the potential DX in question. An X-ray would be useless as it wouldn’t show the suspected issue. First insurance denied saying we had to have an X-ray first and that X-ray needed to be abnormal in order to justify the CT. But this would just be a waste of time and money since the X-ray is useless for the suspected issue in question, and then it would also undoubtedly caused problems because they would deny the CT when the X-ray wasn’t abnormal. It took 3 hours of my time. About 3 hours of medical assistant time and about an hour of two different doctors time to get this simple 5 minute CT approved. This is all on top of the time of admins at the insurance company. The CT was done and low and behold did show an abnormality. The charge was around $2000 to insurance which was lowered to about $1150 by the negotiated rates. Of which we paid the $115 coinsurance (10%). We asked what the cash price would’ve been to avoid all this, $450. So our 10% coinsurance is actually more like 25% of the real price. And the insurance companies denial and absurd process could only possibly make sense over just always unquestionably paying the cash price if 1 in 3 CTs ordered by doctors in such a scheme was fraudulent. I seriously doubt that would ever be the case. And that’s still ignoring the personnel cost in this example. And the opportunity cost of those personnel not being able to spend that time on actual medical needs of other patients. The system is disgustingly broken in this country, we need to move to a single payer system and get these insurance companies out of the way.

glennvtx 7y ago
No we do not. The government has screwed the system up enough, giving this government even more control is a terrible idea. Just stop enforcing monopolies, Force providers to have a clear pricing structure and let market forces deal with it.
- wmeredith 7y ago
  The market forces did deal with it and created entities large enough to perform regulatory capture and here we are.
  - cheaprentalyeti 7y ago
    The government created these entities by giving the insurance companies a priveliged position in their regulatory structure starting in WW2, and increasing this with every promised legislative "fix" including the creation of the HMO in the 70's with the HMO Act of 1973, all the way through Obamacare, which was considered to be the best thing since Sliced Bread, right up until "We can't handle any of this Capitalism shit, we need Single Payer!"
- ezoe 7y ago
  From my Non-American view, this is a classic case for the need of regulation. The government define a set of medical treatments that were scientifically proved, don't allow the insurance companies to deny the request of medical treatments from the doctor. The only problems we face is some malicious doctors requests unnecessary treatments, or malicious doctor and patient working together to request the money for treatments that didn't happen. But these are trivial fraud techniques and it happens anyway regardless of context so it can be dealt with usual criminal law system.
  - wincy 7y ago
    The Affordable Care Act (Obamacare) included mandatory insurance funding for homeopathy, chiropractors, acupuncture, and naturopaths. My wife worked at a chiropractors office who got paid by Medicare to shock elderly diabetics legs while they chowed down on candy bars. Homeopathy is one of the dumbest scams known to man, and I don’t really know about the other two but I wouldn’t call them “medicine”. The more government there is around to fund things, the more dumb bloat there is and we’ll get more glorified massage therapists cutting children’s “tongue ties” and selling amber teething necklaces for $40. Let people waste their own money on this stuff.
- ramblerman 7y ago
  Not everything magically works well under free market forces. Two examples are healthcare and prison management. Because you incentivize either people being sick, or in prison. It's really as simple as that.
ezoe 7y ago
>It took 3 hours of my time. About 3 hours of medical assistant time and about an hour of two different doctors time to get this simple 5 minute CT approved. This is all on top of the time of admins at the insurance company. At this rate, most of the costs are human wages, not the medical equipment and its operating cost. If we can cut all these unnecessary middle men whose job is just confirm/deny the requests, the cost will be a lot cheaper. That's UK. Why the insurance companies has a privilege to deny a medical test when fully-qualified doctor said it's necessary in the first place? If the government regulation set the standard medical procedures and its price, insurance companies has no privilege to deny the requests, only the fully-qualified doctor decide the treatments, it can also cut some costs and more importantly, it's fair. That's Japan.
- lotsofpulp 7y ago
  > Why the insurance companies has a privilege to deny a medical test They aren’t denying the test, they’re denying payment for it from the insurance company. Also, many times, the insurance company is not making its rules, but they are implementing them per the payer’s instruction. The payer can be the government, who outsourced Medicare and Medicaid administration, it could be employers that self fund employee’s insurance, etc.
  - ezoe 7y ago
    That's denying, or more like denying the the whole purpose of insurance. Also, it's bad design of incentive. The insurance companies has an incentive to deny the payment, because it does reduce the cost and increase the profit. For profit companies try to increase the profit that's not wrong, but in this context , it's morally bad. So the better incentive design is not to allow the insurance company to deny the payment. Take a look at my country(Japan) and my insurance company for example. They offer a free cancer test. Why? The treatment of later stage cancer costs so much money. Since they can't deny the payment, it's better to find the cancer as early as possible. That will reduce their cost, increase their profit. It also lead to healthier people as a bonus.
    - 7y ago
ars 7y ago
> we need to move to a single payer system The only reason you say that is that you haven't actually experienced Medicare. It's much much much worse than what you experienced with your insurance company. The only type that is even remotely sane is Medicare Advantage which is administered by private insurance companies. What you have described is a huge problem, I 100% agree, but it will not be solved by single-payer.
- csnover 7y ago
  > The only reason you say that is that you haven't actually experienced Medicare. I have experienced Medicare (along with pre- and post-ACA Gold level individual marketplace plans, small group plans, premium employer-sponsored plans, and Medicaid). The only system I’ve experienced which is better than Medicare was my state’s Medicaid system. Every private insurance plan I’ve had has been significantly worse in every metric—more expensive, less coverage, super stressful (imaging having a kidney stone and having to decide whether to spend $300 + coinsurance to go to the emergency room on a Sunday night or wait in excruciating pain until you can get an appointment for a $10 office visit instead the next day). On Original Medicare with a Medigap plan I pay $377/mo in premiums and have 100% coverage for hospitals, doctors, surgeries, ambulances. There are no provider restrictions. The “coverage area” is the whole country. Outpatient services in hospitals is fine. There’s no arguing over billing, no copays, no coinsurances, no hassle. Drug coverage is a whole different thing, but it sucks about as much as it did with private insurance—which it would, since Part D is just a marketplace of private insurers! Notably, though, any drugs I get in a clinic, like super expensive biologics, are covered under Original Medicare for that $377 premium. What is your experience that makes you think so differently?
  - ars 7y ago
    I completely agree that Medicaid is the best one of all. But I need to point out that (at least in my state) Medicaid is simply contracted out to local insurers, it is not run by the government. It's the fact that you need to buy a medigap plan that is exactly the problem. Those plans are not available to everyone. And you have to buy private insurance to fix what the government doesn't do right. Medicare Advantage is the same exact thing: you have to buy private insurance and the one the government offers is terrible. So basically your experience exactly confirms what I said. Medicare for all is not a good plan. Medicare Advantage for all however is a good plan. And Medicare Advantage is simply private insurance companies that are paid by the government. And personally I think that's the best option. Leave it as private insurers, but let the government give every family an allowance to help pay for it or even pay for it entirely.

by erentz 7y ago

glennvtx 7y ago

No we do not. The government has screwed the system up enough, giving this government even more control is a terrible idea. Just stop enforcing monopolies, Force providers to have a clear pricing structure and let market forces deal with it.

wmeredith 7y ago
The market forces did deal with it and created entities large enough to perform regulatory capture and here we are.
- cheaprentalyeti 7y ago
  The government created these entities by giving the insurance companies a priveliged position in their regulatory structure starting in WW2, and increasing this with every promised legislative "fix" including the creation of the HMO in the 70's with the HMO Act of 1973, all the way through Obamacare, which was considered to be the best thing since Sliced Bread, right up until "We can't handle any of this Capitalism shit, we need Single Payer!"
ezoe 7y ago
From my Non-American view, this is a classic case for the need of regulation. The government define a set of medical treatments that were scientifically proved, don't allow the insurance companies to deny the request of medical treatments from the doctor. The only problems we face is some malicious doctors requests unnecessary treatments, or malicious doctor and patient working together to request the money for treatments that didn't happen. But these are trivial fraud techniques and it happens anyway regardless of context so it can be dealt with usual criminal law system.
- wincy 7y ago
  The Affordable Care Act (Obamacare) included mandatory insurance funding for homeopathy, chiropractors, acupuncture, and naturopaths. My wife worked at a chiropractors office who got paid by Medicare to shock elderly diabetics legs while they chowed down on candy bars. Homeopathy is one of the dumbest scams known to man, and I don’t really know about the other two but I wouldn’t call them “medicine”. The more government there is around to fund things, the more dumb bloat there is and we’ll get more glorified massage therapists cutting children’s “tongue ties” and selling amber teething necklaces for $40. Let people waste their own money on this stuff.
ramblerman 7y ago
Not everything magically works well under free market forces. Two examples are healthcare and prison management. Because you incentivize either people being sick, or in prison. It's really as simple as that.

ezoe 7y ago

>It took 3 hours of my time. About 3 hours of medical assistant time and about an hour of two different doctors time to get this simple 5 minute CT approved. This is all on top of the time of admins at the insurance company. At this rate, most of the costs are human wages, not the medical equipment and its operating cost. If we can cut all these unnecessary middle men whose job is just confirm/deny the requests, the cost will be a lot cheaper. That's UK. Why the insurance companies has a privilege to deny a medical test when fully-qualified doctor said it's necessary in the first place? If the government regulation set the standard medical procedures and its price, insurance companies has no privilege to deny the requests, only the fully-qualified doctor decide the treatments, it can also cut some costs and more importantly, it's fair. That's Japan.

lotsofpulp 7y ago
> Why the insurance companies has a privilege to deny a medical test They aren’t denying the test, they’re denying payment for it from the insurance company. Also, many times, the insurance company is not making its rules, but they are implementing them per the payer’s instruction. The payer can be the government, who outsourced Medicare and Medicaid administration, it could be employers that self fund employee’s insurance, etc.
- ezoe 7y ago
  That's denying, or more like denying the the whole purpose of insurance. Also, it's bad design of incentive. The insurance companies has an incentive to deny the payment, because it does reduce the cost and increase the profit. For profit companies try to increase the profit that's not wrong, but in this context , it's morally bad. So the better incentive design is not to allow the insurance company to deny the payment. Take a look at my country(Japan) and my insurance company for example. They offer a free cancer test. Why? The treatment of later stage cancer costs so much money. Since they can't deny the payment, it's better to find the cancer as early as possible. That will reduce their cost, increase their profit. It also lead to healthier people as a bonus.
  - 7y ago

ars 7y ago

> we need to move to a single payer system The only reason you say that is that you haven't actually experienced Medicare. It's much much much worse than what you experienced with your insurance company. The only type that is even remotely sane is Medicare Advantage which is administered by private insurance companies. What you have described is a huge problem, I 100% agree, but it will not be solved by single-payer.

csnover 7y ago
> The only reason you say that is that you haven't actually experienced Medicare. I have experienced Medicare (along with pre- and post-ACA Gold level individual marketplace plans, small group plans, premium employer-sponsored plans, and Medicaid). The only system I’ve experienced which is better than Medicare was my state’s Medicaid system. Every private insurance plan I’ve had has been significantly worse in every metric—more expensive, less coverage, super stressful (imaging having a kidney stone and having to decide whether to spend $300 + coinsurance to go to the emergency room on a Sunday night or wait in excruciating pain until you can get an appointment for a $10 office visit instead the next day). On Original Medicare with a Medigap plan I pay $377/mo in premiums and have 100% coverage for hospitals, doctors, surgeries, ambulances. There are no provider restrictions. The “coverage area” is the whole country. Outpatient services in hospitals is fine. There’s no arguing over billing, no copays, no coinsurances, no hassle. Drug coverage is a whole different thing, but it sucks about as much as it did with private insurance—which it would, since Part D is just a marketplace of private insurers! Notably, though, any drugs I get in a clinic, like super expensive biologics, are covered under Original Medicare for that $377 premium. What is your experience that makes you think so differently?
- ars 7y ago
  I completely agree that Medicaid is the best one of all. But I need to point out that (at least in my state) Medicaid is simply contracted out to local insurers, it is not run by the government. It's the fact that you need to buy a medigap plan that is exactly the problem. Those plans are not available to everyone. And you have to buy private insurance to fix what the government doesn't do right. Medicare Advantage is the same exact thing: you have to buy private insurance and the one the government offers is terrible. So basically your experience exactly confirms what I said. Medicare for all is not a good plan. Medicare Advantage for all however is a good plan. And Medicare Advantage is simply private insurance companies that are paid by the government. And personally I think that's the best option. Leave it as private insurers, but let the government give every family an allowance to help pay for it or even pay for it entirely.