3 ms·

How often do health insurers says no to patients? No one knows

4 points by hhs 3y ago

NoZebra120vClip 3y ago
This "No Surprises" act that took effect a while ago is a laughable crock. Sure, your provider will let you get a fair price estimate on some service or another, but there's no guarantee that that is the service they will bill, or that they won't add on other services after the fact, so your "Good Faith Estimate" isn't worth the pixels it's displayed on. And so medical care in these United States is always a mystery and a surprise. Insurance plans are completely vague about what they cover, especially before you sign up. Good luck getting an idea of what plans cover while you're comparison shopping. There's always surprises in store after you've enrolled and plunked down your initial premium. Then the hits keep on coming. You can't know if something's covered, or if it will be denied, until after you've received that service and it's billed. Now, while I was on Medicaid I've had doctors who would frequently stop me and say that such-and-such a service won't be covered by insurance so they don't want to do it. And this is partly good ethics but also good business sense: since I am obviously an indigent patient, the doctor knows that the provider won't recover a significant sum from billing me if the insurance doesn't go through. It may be the case that Medicaid has protections that prohibit doctors from billing services that aren't covered. I'm not sure. But if you're on a self-pay basis, or private insurance, including the Exchange, watch out, because that's a license to print money for the providers. And so you have to become very canny when a doctor offers you a service, because you don't know its potential benefit nor its cost. This goes triple when you're hospitalized: if a nurse offers you a Tylenol, turn that down firmly, because that's a $50 pill right there. Now I've seldom had an insurance claim turned down on medical necessity grounds. But I've heard horror stories about appeals and red tape and all sorts of grief when someone has a condition that supposedly needs special treatment, and the insurance company doesn't see eye-to-eye with provider and patient. Thankfully, the really major stuff depends on pre-auth, so hopefully you aren't sitting with a bill while your appeals are in process, but neither is it enjoyable to be sitting with a life-threatening disease while the insurance company drags their heels. Doctors, in my experience, offer low-information and dire threats which often convince patients to jump into services and treatments out of ignorance and fear. Insurance companies should provide checks and balances so that patients are provided with transparency and a level-headed evaluation of medical necessity. Unfortunately, the insurance companies are covering for the providers and vice versa, rather than truly caring for patients.

4 points by hhs 3y ago

This "No Surprises" act that took effect a while ago is a laughable crock. Sure, your provider will let you get a fair price estimate on some service or another, but there's no guarantee that that is the service they will bill, or that they won't add on other services after the fact, so your "Good Faith Estimate" isn't worth the pixels it's displayed on. And so medical care in these United States is always a mystery and a surprise. Insurance plans are completely vague about what they cover, especially before you sign up. Good luck getting an idea of what plans cover while you're comparison shopping. There's always surprises in store after you've enrolled and plunked down your initial premium. Then the hits keep on coming. You can't know if something's covered, or if it will be denied, until after you've received that service and it's billed. Now, while I was on Medicaid I've had doctors who would frequently stop me and say that such-and-such a service won't be covered by insurance so they don't want to do it. And this is partly good ethics but also good business sense: since I am obviously an indigent patient, the doctor knows that the provider won't recover a significant sum from billing me if the insurance doesn't go through. It may be the case that Medicaid has protections that prohibit doctors from billing services that aren't covered. I'm not sure. But if you're on a self-pay basis, or private insurance, including the Exchange, watch out, because that's a license to print money for the providers. And so you have to become very canny when a doctor offers you a service, because you don't know its potential benefit nor its cost. This goes triple when you're hospitalized: if a nurse offers you a Tylenol, turn that down firmly, because that's a $50 pill right there. Now I've seldom had an insurance claim turned down on medical necessity grounds. But I've heard horror stories about appeals and red tape and all sorts of grief when someone has a condition that supposedly needs special treatment, and the insurance company doesn't see eye-to-eye with provider and patient. Thankfully, the really major stuff depends on pre-auth, so hopefully you aren't sitting with a bill while your appeals are in process, but neither is it enjoyable to be sitting with a life-threatening disease while the insurance company drags their heels. Doctors, in my experience, offer low-information and dire threats which often convince patients to jump into services and treatments out of ignorance and fear. Insurance companies should provide checks and balances so that patients are provided with transparency and a level-headed evaluation of medical necessity. Unfortunately, the insurance companies are covering for the providers and vice versa, rather than truly caring for patients.