6 ms·

On paper it may seem to insure you against catastrophic loss, that is, if the insurance company can't find a way to deny your claim for one reason or another. Y

On paper it may seem to insure you against catastrophic loss, that is, if the insurance company can't find a way to deny your claim for one reason or another. You can surely bet they will be trying.

Someone1234 6y ago
"You didn't check that the second doctor in your surgery, who came in while you were unconscious was in-networking? Well, too bad, you should have done your due diligence more carefully!" When we had a kid, it was $10K out-of-pocket, and we had a bunch of "out-of-networking" bingo due to mostly lab tests or a doctor out of network at an in-network ER. Since then kid themselves also had an ambulance ride (seizure), and that too was "out of networking" in spite of being the only ambulance provider available within 15+ minutes.
- lotsofpulp 6y ago
  The involuntary treatment by out of network providers and them being able to charge you whatever they feel like definitely needs to be outlawed.
  - deleted 6y ago
    [deleted]
- learc83 6y ago
  What you're describing is completely illegal now. Under the Affordable Care Act, which applies nationwide, insurers are required to cover out-of-network emergency care as if it was in-network care, which means your deductible and coinsurance can't be higher than the regular in-network amounts.
  - lotsofpulp 6y ago
    As far as I understand, the out of network provider can still come after you for whatever the insurance doesn’t pay them. In the US, you basically provide your healthcare provider with a blank check.
  - Someone1234 6y ago
    Everything I said happened under the ACA. It was "only" $10K because of the ACA's out-of-pocket maximums. A quick google suggests this is common: > It's important to understand, however, that the out-of-network emergency room does not have a contract with your insurer, and is not obligated to accept their payment as payment in full. If the insurer pays less than the out-of-network emergency room bills, the emergency room can send you a balance bill for the difference, over and above the deductible and coinsurance amounts you pay.
    - learc83 6y ago
      You said >Since then kid themselves also had an ambulance ride (seizure), and that too was "out of networking" in spite of being the only ambulance provider available within 15+ minutes. That's the illegal part.
      - Someone1234 6y ago
        If you say so. The $1,500+ ambulance bill still existed, I still paid it, and my kid wasn't even born until five+ years after the ACA came into force. The insurance company was "nice" enough to let me count it towards my kid's deductible for that year, but I paid every cent.
        learc83 6y ago
        People will gladly collect money they aren't legally owed. In this case, unless there is more to the story, you shouldn't have paid it.
        HarryHirsch 6y ago
        In normal countries you don't have that kind of criminogenic environment. Also, do stop the victim blaming.
        learc83 6y ago
        >In normal countries you don't have that kind of criminogenic environment. Also, do stop the victim blaming. Stop using "victim blaming" as a way to shut down discourse. In every country in the world people run scams. Universal healthcare would make these particular kinds of scams a lot harder, but I guarantee you, you could still find this kind of anecdotal evidence of criminal behavior relating to healthcare.
- WarOnPrivacy 6y ago
  sidebar: In 1991 we birthed a child at home and the absolute total was around $3500. It was all out of pocket. At the time, insurance would not cover midwives, nevertheless a home birth.
  - lostapathy 6y ago
    My neighbor did that 3 times. Didn’t work out so hot for the third kid. I would never consider asking if they regret that choice, but I cannot imagine the grief from losing your child in a home birth scenario.
    - WarOnPrivacy 6y ago
      There's a lot of factors that go into the decision making. I don't want to speculate on their birth team - our midwives only accepted the lowest risk mothers. For our first birth, a hospital would have been a terrible, terrible option. By the time of our 4th birth (10y later, twins), hospital birthing environments had vastly improved. Our OB/GYNs practice was 100% women w/ midwives on staff. The only thing we missed was having a doula.
lotsofpulp 6y ago
They do not deny claims for reasons of just saving money. They employ teams of doctors and pharmacists who double check prescribing doctors’ and whether or not treatment plans are supported by evidence. If people think multi billion dollar insurance companies are trying to nickel and dime them for medically supported treatments, then I don’t know what to tell them other than it’s simply not in their interest to risk so much for so little.
- jschwartzi 6y ago
  Explain to me what you mean by "supported by evidence?" Is it some kind of cost-benefit analysis? Because if so that's certainly denying a claim on the basis of saving money.
  - lotsofpulp 6y ago
    Supported by science experiments conducted by scientists showing efficacy or causation. It is doctors and pharmacists that deny and approve, and they don’t have information about how much the company is saving if they deny. The most common denial reason is for doctors ordering brand name drugs that cost 10x more than a generic, but have no data to show they are any better. Or drugs that aren’t shown to have any effect, but doctors just want to appease the patient or experiment.
    - reificator 6y ago
      > The most common denial reason is for doctors ordering brand name drugs that cost 10x more than a generic, but have no data to show they are any better. Or drugs that aren’t shown to have any effect, but doctors just want to appease the patient or experiment. My diabetic friend has documented bad reactions to the expensive name brand insulin and a couple of others, but not a specific cheap (relatively speaking) one. His insurance mandates that he use the name brand exclusively and will categorically deny any other form of insulin. Now, maybe this doctor is just prescribing insulin to a fucking diabetic to appease the patient, but for some reason I doubt that's the case.
    - 6y ago
learc83 6y ago
>On paper it may seem to insure you against catastrophic loss, that is, if the insurance company can't find a way to deny your claim for one reason or another. You can surely bet they will be trying. The most common method of denying claims was that it was a preexisting condition, something that ACA prevents them from doing. The vast majority of people who have health insurance will be covered in event of a catastrophic illness. It's definitely more than just "on paper".
adanto6840 6y ago
I'm "self-employed", ie employed by the company that I own, and so I have to shoulder the entirety of health insurance cost for my family of 4. Because I'm the only FT employee, we aren't eligible for "business/small group" health plans; which means we either have to buy private health insurance (often not meeting ACA Essential Coverage requirements) and/or purchase health insurance from the 'health exchange' marketplace administered by our state. The first year, we could actually purchase decent coverage and while it was expensive, it was a solid PPO plan. The past two years however, there isn't even a single PPO plan offered on the exchange in my state -- not one -- I don't even think there were any "Platinum" coverages offered. The end result is that we pay essentially a mortgage-size payment each month and in exchange we get relatively abysmal coverage. Worse yet? It seems they categorically deny ~75% of claims, which generally means we have to appeal & fight them on it (our success rate is high but it's time-consuming); if it's testing/labs that need done, we also have to front the cash out of pocket to avoid delaying diagnosis & any potentially needed treatment. Often that means $800+ out of pocket PLUS a 4-8 hour time investment over a 3-4 month span in order to try to recoup that money -- all the while, we're of course paying the absurd premiums each month. Insurance & the financial aspect of healthcare is so completely broken in the US that it's sickening. I believe the problem is so severe that it's really hurting our country's economy and is incredibly stifling for individuals & small businesses. I wish I knew how to fix it. :(
- CuriouslyC 6y ago
  Unfortunately not so much an option for a bit, but medical tourism is the best answer. You can take a vacation and get treatment for less than you're paying just for insurance.
  - heavyset_go 6y ago
    Finding a good doctor is tough to do even domestically, how do you vet foreign doctors? Referrals from doctors you already trust?
- throwaway31338 6y ago
  I abandoned my business of 15 years last year because of worry about availability of health insurance. It looks like I was in a similar situation to you. My business was going well. I was making equivalent income of a bit more than a high-end salary for my skill set in my area. I was fine (grudgingly) paying the premiums. The problem was that there was absolutely no assurance insurance that would actually cover anything would be available in the future. We had "marketplace" plans for a number of years. Eventually there were no "silver" marketplace plans available in my locale (and "bronze", with 20% "co-insurance", means I'm going bankrupt if I have any significant events anyway, so I might as well just have no coverage). I gave up and took a job. I couldn't expose my family to the risk of not having any insurance available. It was crushing. I took the route of not having employees and was unable to qualify for "business" plans. I guess I wasn't "successful" after all, since I didn't aspire to grow the business beyond what would support my family.

On paper it may seem to insure you against catastrophic loss, that is, if the insurance company can't find a way to deny your claim for one reason or another. You can surely bet they will be trying.

Someone1234 6y ago

"You didn't check that the second doctor in your surgery, who came in while you were unconscious was in-networking? Well, too bad, you should have done your due diligence more carefully!" When we had a kid, it was $10K out-of-pocket, and we had a bunch of "out-of-networking" bingo due to mostly lab tests or a doctor out of network at an in-network ER. Since then kid themselves also had an ambulance ride (seizure), and that too was "out of networking" in spite of being the only ambulance provider available within 15+ minutes.

lotsofpulp 6y ago
The involuntary treatment by out of network providers and them being able to charge you whatever they feel like definitely needs to be outlawed.
- deleted 6y ago
  [deleted]
learc83 6y ago
What you're describing is completely illegal now. Under the Affordable Care Act, which applies nationwide, insurers are required to cover out-of-network emergency care as if it was in-network care, which means your deductible and coinsurance can't be higher than the regular in-network amounts.
- lotsofpulp 6y ago
  As far as I understand, the out of network provider can still come after you for whatever the insurance doesn’t pay them. In the US, you basically provide your healthcare provider with a blank check.
- Someone1234 6y ago
  Everything I said happened under the ACA. It was "only" $10K because of the ACA's out-of-pocket maximums. A quick google suggests this is common: > It's important to understand, however, that the out-of-network emergency room does not have a contract with your insurer, and is not obligated to accept their payment as payment in full. If the insurer pays less than the out-of-network emergency room bills, the emergency room can send you a balance bill for the difference, over and above the deductible and coinsurance amounts you pay.
  - learc83 6y ago
    You said >Since then kid themselves also had an ambulance ride (seizure), and that too was "out of networking" in spite of being the only ambulance provider available within 15+ minutes. That's the illegal part.
    - Someone1234 6y ago
      If you say so. The $1,500+ ambulance bill still existed, I still paid it, and my kid wasn't even born until five+ years after the ACA came into force. The insurance company was "nice" enough to let me count it towards my kid's deductible for that year, but I paid every cent.
      - learc83 6y ago
        People will gladly collect money they aren't legally owed. In this case, unless there is more to the story, you shouldn't have paid it.
        HarryHirsch 6y ago
        In normal countries you don't have that kind of criminogenic environment. Also, do stop the victim blaming.
        learc83 6y ago
        >In normal countries you don't have that kind of criminogenic environment. Also, do stop the victim blaming. Stop using "victim blaming" as a way to shut down discourse. In every country in the world people run scams. Universal healthcare would make these particular kinds of scams a lot harder, but I guarantee you, you could still find this kind of anecdotal evidence of criminal behavior relating to healthcare.
WarOnPrivacy 6y ago
sidebar: In 1991 we birthed a child at home and the absolute total was around $3500. It was all out of pocket. At the time, insurance would not cover midwives, nevertheless a home birth.
- lostapathy 6y ago
  My neighbor did that 3 times. Didn’t work out so hot for the third kid. I would never consider asking if they regret that choice, but I cannot imagine the grief from losing your child in a home birth scenario.
  - WarOnPrivacy 6y ago
    There's a lot of factors that go into the decision making. I don't want to speculate on their birth team - our midwives only accepted the lowest risk mothers. For our first birth, a hospital would have been a terrible, terrible option. By the time of our 4th birth (10y later, twins), hospital birthing environments had vastly improved. Our OB/GYNs practice was 100% women w/ midwives on staff. The only thing we missed was having a doula.

lotsofpulp 6y ago

They do not deny claims for reasons of just saving money. They employ teams of doctors and pharmacists who double check prescribing doctors’ and whether or not treatment plans are supported by evidence. If people think multi billion dollar insurance companies are trying to nickel and dime them for medically supported treatments, then I don’t know what to tell them other than it’s simply not in their interest to risk so much for so little.

jschwartzi 6y ago
Explain to me what you mean by "supported by evidence?" Is it some kind of cost-benefit analysis? Because if so that's certainly denying a claim on the basis of saving money.
- lotsofpulp 6y ago
  Supported by science experiments conducted by scientists showing efficacy or causation. It is doctors and pharmacists that deny and approve, and they don’t have information about how much the company is saving if they deny. The most common denial reason is for doctors ordering brand name drugs that cost 10x more than a generic, but have no data to show they are any better. Or drugs that aren’t shown to have any effect, but doctors just want to appease the patient or experiment.
  - reificator 6y ago
    > The most common denial reason is for doctors ordering brand name drugs that cost 10x more than a generic, but have no data to show they are any better. Or drugs that aren’t shown to have any effect, but doctors just want to appease the patient or experiment. My diabetic friend has documented bad reactions to the expensive name brand insulin and a couple of others, but not a specific cheap (relatively speaking) one. His insurance mandates that he use the name brand exclusively and will categorically deny any other form of insulin. Now, maybe this doctor is just prescribing insulin to a fucking diabetic to appease the patient, but for some reason I doubt that's the case.
  - 6y ago

learc83 6y ago

>On paper it may seem to insure you against catastrophic loss, that is, if the insurance company can't find a way to deny your claim for one reason or another. You can surely bet they will be trying. The most common method of denying claims was that it was a preexisting condition, something that ACA prevents them from doing. The vast majority of people who have health insurance will be covered in event of a catastrophic illness. It's definitely more than just "on paper".

adanto6840 6y ago

I'm "self-employed", ie employed by the company that I own, and so I have to shoulder the entirety of health insurance cost for my family of 4. Because I'm the only FT employee, we aren't eligible for "business/small group" health plans; which means we either have to buy private health insurance (often not meeting ACA Essential Coverage requirements) and/or purchase health insurance from the 'health exchange' marketplace administered by our state. The first year, we could actually purchase decent coverage and while it was expensive, it was a solid PPO plan. The past two years however, there isn't even a single PPO plan offered on the exchange in my state -- not one -- I don't even think there were any "Platinum" coverages offered. The end result is that we pay essentially a mortgage-size payment each month and in exchange we get relatively abysmal coverage. Worse yet? It seems they categorically deny ~75% of claims, which generally means we have to appeal & fight them on it (our success rate is high but it's time-consuming); if it's testing/labs that need done, we also have to front the cash out of pocket to avoid delaying diagnosis & any potentially needed treatment. Often that means $800+ out of pocket PLUS a 4-8 hour time investment over a 3-4 month span in order to try to recoup that money -- all the while, we're of course paying the absurd premiums each month. Insurance & the financial aspect of healthcare is so completely broken in the US that it's sickening. I believe the problem is so severe that it's really hurting our country's economy and is incredibly stifling for individuals & small businesses. I wish I knew how to fix it. :(

CuriouslyC 6y ago
Unfortunately not so much an option for a bit, but medical tourism is the best answer. You can take a vacation and get treatment for less than you're paying just for insurance.
- heavyset_go 6y ago
  Finding a good doctor is tough to do even domestically, how do you vet foreign doctors? Referrals from doctors you already trust?
throwaway31338 6y ago
I abandoned my business of 15 years last year because of worry about availability of health insurance. It looks like I was in a similar situation to you. My business was going well. I was making equivalent income of a bit more than a high-end salary for my skill set in my area. I was fine (grudgingly) paying the premiums. The problem was that there was absolutely no assurance insurance that would actually cover anything would be available in the future. We had "marketplace" plans for a number of years. Eventually there were no "silver" marketplace plans available in my locale (and "bronze", with 20% "co-insurance", means I'm going bankrupt if I have any significant events anyway, so I might as well just have no coverage). I gave up and took a job. I couldn't expose my family to the risk of not having any insurance available. It was crushing. I took the route of not having employees and was unable to qualify for "business" plans. I guess I wasn't "successful" after all, since I didn't aspire to grow the business beyond what would support my family.