Health Insurance Degeneration Continues

[manualman]

We had our 3rd baby in July and I’m just now figuring out the last of the paperwork. I’ve got a pretty good PPO insurance plan at work. We followed the rules, picked an OBGYN on the PPO list, made sure the hospital was on the preferred list and asked the doctor to coordinate benefits prior to being admitted. So far, so good.

Trouble comes at the hospital. All the specialists aren’t hospital employees, they are outside practices with hospital contracts. Go have a baby and you will see the OBGYN, an anaesthesiologist, a pediatrician and possibly a contract doctor intern. You have no say on who the others will be, but if they happen to be NOT in your PPO network, you get stuck paying the out-of-network fees (which are large!).

I used to think a PPO was better than an HMO. Not anymore. The in-network hospital used to require their contract doctors to honor the PPO committments the hospital had made. Not anymore.

Somebody had better get busy with some reform ideas with real teeth or the socialists are going to be getting more and more traction on this issue all the time!

 

[whatevergirl]

We had our 3rd baby in July and I’m just now figuring out the last of the paperwork. I’ve got a pretty good PPO insurance plan at work. We followed the rules, picked an OBGYN on the PPO list, made sure the hospital was on the preferred list and asked the doctor to coordinate benefits prior to being admitted. So far, so good.

Trouble comes at the hospital. All the specialists aren’t hospital employees, they are outside practices with hospital contracts. Go have a baby and you will see the OBGYN, an anaesthesiologist, a pediatrician and possibly a contract doctor intern. You have no say on who the others will be, but if they happen to be NOT in your PPO network, you get stuck paying the out-of-network fees (which are large!).

I used to think a PPO was better than an HMO. Not anymore. The in-network hospital used to require their contract doctors to honor the PPO committments the hospital had made. Not anymore.

Somebody had better get busy with some reform ideas with real teeth or the socialists are going to be getting more and more traction on this issue all the time!

I’m in the PPO/HMO business, being on the commercial insurance side working at the broker level, and a large reason for this, is because hospitals do not want to take on the liability on their own insurance, so they make their docs have individual coverage. (or through the practice that they are with) That is the pits though–manualman! What will you have to do then? Are you going to be out of pocket for the balance? The thing is–you should have been told this up front by someone–either the hospital or the PPO.

 

[manualman]

I’m probably stuck. They probably did tell me. In 6 point print in one of the 18 forms I had to sign before seeing each new doctor while my wife was in labor (or bleeding profusely afterwards).

 

[texasags]

We had our 3rd baby in July and I’m just now figuring out the last of the paperwork. I’ve got a pretty good PPO insurance plan at work. We followed the rules, picked an OBGYN on the PPO list, made sure the hospital was on the preferred list and asked the doctor to coordinate benefits prior to being admitted. So far, so good.

Trouble comes at the hospital. All the specialists aren’t hospital employees, they are outside practices with hospital contracts. Go have a baby and you will see the OBGYN, an anaesthesiologist, a pediatrician and possibly a contract doctor intern. You have no say on who the others will be, but if they happen to be NOT in your PPO network, you get stuck paying the out-of-network fees (which are large!).

I used to think a PPO was better than an HMO. Not anymore. The in-network hospital used to require their contract doctors to honor the PPO committments the hospital had made. Not anymore.

Somebody had better get busy with some reform ideas with real teeth or the socialists are going to be getting more and more traction on this issue all the time!

I had a surgery in July and experienced the same problem with the anesthesiologist. I got the EOB stating lack of coverage due to “Out of Network”. Last month, it finally sorted itself out and was paid correctly. Apparently there was a “glitch” in the system (the hospital did just change ownership).

You are right about the socialists. I don’t understand how anyone would want the same government that runs the VA hospital system (Walter Reed, anyone??) and Medicare and Medicaid to be responsible for their health insurance.

 

[whatevergirl]

I am curious as to the socialist remark? Private insurance isn’t funded or underwritten by the government. It has to adhere to government guidelines, from the state insurance depts, and SEC, but the government doesn’t have a say in how HMO’s or PPO’s are managed. I might be missing what you are referring to, sorry.

 

[Dale_M]

I don’t understand how anyone would want the same government that runs the VA hospital system (Walter Reed, anyone??)

This is a minor note: Walter Reed is a military hospital. It is run by the U.S. Army and not by the Veterans Administration (which is run by civilians). The DoD and the VA are totally separate departments, each with their own cabinet representative.

The care I have gotten through the VA has been very good. Although the initial wait at getting approved by the system was unconscionably long.

 

[manualman]

I am curious as to the socialist remark? Private insurance isn’t funded or underwritten by the government. It has to adhere to government guidelines, from the state insurance depts, and SEC, but the government doesn’t have a say in how HMO’s or PPO’s are managed. I might be missing what you are referring to, sorry.

What I meant was that the system keeps getting worse, more expensive and with more hidden loopholes to stick it to even consumers like me with full health insurance. Its just more canon fodder to those arguing for socialized health care. Americans are a sucker for a false dilemma: many will buy the fallacious argument that this is as good as private health insurance gets so therefore we need socialized medicine.

 

[LCMS_No_More]

This is a minor note: Walter Reed is a military hospital. It is run by the U.S. Army and not by the Veterans Administration (which is run by civilians). The DoD and the VA are totally separate departments, each with their own cabinet representative.

The care I have gotten through the VA has been very good. Although the initial wait at getting approved by the system was unconscionably long.

Hmmm…that’s probably due to underfunding.

 

[LCMS_No_More]

You are right about the socialists. I don’t understand how anyone would want the same government that runs the VA hospital system (Walter Reed, anyone??) and Medicare and Medicaid to be responsible for their health insurance.

Medicare operates with a rate 2% overhead and there’s little problem for people with Medicare getting the services they need. Private insurance runs at up to a 30% overhead (huge CEO salaries, dividends and advertising are SPENDY!) and do everything they can to keep from paying for services.

 

[whatevergirl]

Medicare operates with a rate 2% overhead and there’s little problem for people with Medicare getting the services they need. Private insurance runs at up to a 30% overhead (huge CEO salaries, dividends and advertising are SPENDY!) and do everything they can to keep from paying for services.

Many private insurers do not advertise. I work for the #3 global broker and we don’t advertise, however…salaries are high–not just for ceo’s. But, that is an erroneous statement to say that carriers (I’m on the broker side) try not to pay for services. They wouldn’t be a billion dollar business, or even in business at all, if they shirked their responsibilities to policy holders. People sometimes fail to read their policies, and then if something is not covered, they blame the carrier–but really, it’s in black and white what is covered and what isn’t, and it is our responsibility as insurance consumers to know what’s covered–auto, home, umbrella, health, etc. I sold personal lines for a long time and I would try my best to highlight the most important things on policies that were commonly asked, but it was not my job to read my clients’ entire policies to them. So, let’s not blanket statement and say insurance carriers do everything to not pay for services.

In the OP’s case, I feel terrible, because that is a loophole that just leaves the policy holder in the dark. I am sorry that happened to you, OP. That makes me mad…! It reminds me of taking my son to the oral surgeon last week…One can use his/her medical insurance to pay for oral surgery–most carriers. So, I submit it, and the office manager of the surgeon’s practice says…oh, i thought you said you have ‘xyz’ dental insurance. I said, no, i told you it was medical insurance. Luckily, I have a medical ‘fund’ that my employer supports, and the entire thing was covered out of that…do copay, nothing. So, I lucked out, but because they were out of network, same thing applied. I gave her the benefit of the doubt, but still…it made me mad that now my fund was used for that. I would rather hae my fund left open for like if I or a family member was rushed to the hospital.

 

[Joe_Kelley]

I have had some luck with the squeaky wheel approach. Generate enough paper work and they sometimes give in.

 

[whatevergirl]

What I meant was that the system keeps getting worse, more expensive and with more hidden loopholes to stick it to even consumers like me with full health insurance. Its just more canon fodder to those arguing for socialized health care. Americans are a sucker for a false dilemma: many will buy the fallacious argument that this is as good as private health insurance gets so therefore we need socialized medicine.

Oh, I see–an indirect effect. Isn’t there anything you can do to explain this to your insurer? I mean, they should cover it. What, we need to halt the specialists as they walk into the hospital and say-oh I’m sorry, you’re not in my in network provider group. The hospital should not be allowed to have these nitty gritty stipulations. Usually, hospitals contract specialists, and the doctors/surgeons can have their own policies, and be on their own. (for med mal reasons) I think that if an anesthesiologist networks with a particular hospital that is in network, they should pay for it. But, I don’t make the laws. That’s what I mean by reform needing to take place.

 

[hasikelee]

Oh no, I think I have the same thing now that I am looking at mine.

Shucks. Maybe I’ll do the baby in the car on the way to the hospital thing AND not need any posthelp. (crosses fingers for a fast and safe delivery lol)

 

[JW10631]

I have worked in health insurance for longer than I care to admit.

I would like for someone who says that private health insurers spend 30% of their budget on operating costs to name them.
If we did that at my employer we would be taken over the the Pennsylvania Insurance Department before we reached insolvency.

Over 92 cents of every dollar is spent on benefits (not administration of or processing of benefits, just straight benefits).

United Health Care ran into some major issues not long ago relating to privacy and how they did their physician networks.

Insurance companies are tightly controlled by the state insurance departments where they are domiciled and where they do business. A big part of my job is in compliance with these regulations.

Nobody likes insurance companies and nobody likes being told they have to pay for things they think or expect are covered.

 

[DL82]

I live in the UK, where healthcare is free to all who need it. I have never had any difficulty getting the best treatment in the world. In fact, I used to work for the University linked with one of the biggest National Health Service hospital trusts in the UK, and they were leading the world in several areas of medical research.

It’s not a Stalinist style centrally controlled system, even in a small nation like Britain. Different regions are responsible for funding their own family doctors and small hospitals, while larger hospitals are Trusts, and have a board of trustees responsible for their funding. The General Medical Council, which is the professional association that represents doctors, have a big say in the way the NHS develops, as do research think-tanks responsible for approving new drugs for use.

Why is private healthcare in America so expensive?

1. There’s no alternative, so the hospitals and insurers can charge what they like. There are private doctors here in the UK too, but they can’t charge what they like. For example, I needed an ultrasound scan because of a cancer scare once, rather than waiting the 2 weeks for an NHS scan (I have a real health anxiety about the C word) I paid to go private so I could be seen the next day - £200. In America an uninsured person would probably be charged thousands of dollars, because there’s no alternative. If the options had been £2000 or wait 2 weeks, I’d have waited. Even a minimal safety-net state healthcare service would force the insurance companies back into market competitiveness.
2. Every time you go to see a doctor, you’re really seeing 2 doctors. Your specialist, who examines you, and decides what treatment you need, AND the insurance company’s claims consultant, who examines the paperwork your doctor has completed and decides what treatment you don’t need. You’re basically paying each time for somebody to sabotage your treatment plan!

 

[JW10631]

I be to differ with you about the alleged quality of health care in Britain. The NHS rations health care. Medicare in Canada does the dame thing. Americans will never accept this.

It is the American health care system that leads the world in research and development of new technologies, processes, equipment and medicines. Americans bear this burden for the rest of the world.

A smaller nation may make a government-run monopoly on health care services somewhat manageable, but it won’t work in the US.

We have over 300 million people. The cost of setting up an infrastructure (claims processing, etc) controlled by one government agency would be enormous, possibly in the trillions of dollars.

The US Government does not now process Medicare claims. It subcontracts this business out to private health insurance companies and then regulates the daylights out of them.
My employer does a significant business with this.

Part of the increase in the cost of American health care spending is the pressure put on it by an aging population. The first Baby Boomers begin to retire this year at age 62. In three years they are eligible for Medicare. The treatment of this aging population is expensive and will only increase.

Many hospitals in the Western and Southwestern US have closed their emergency rooms because of the unreimbursed treatment given to illegal aliens.

Many obstetricians have closed their practices because of the cost of medical malpractice insurance. This has happened in Southeastern Pennsylvania. Attorneys coupled with an increasing American notion of entitlement, have filed so many lawsuits that some malpractice insurers have gone bankrupt.

To say that there is no choice or no competition in the American health care industry is not just ludicrous, it’s crazy.

Every region in the US has a choice of insurance carriers, from Blue Cross Blue Shield, Aetna, United, Humana, Kaiser and many others. Each company offers many different coverage plans. You can get as much coverage as you want if you’re willing to pay for it.

Every major city and most smaller metro areas have a choice of hospitals. Some hospitals are teaching and research hospitals and thus charge higher reimbursement rates. Other handle high risk situations, such as the hospital where my wife is scheduled to give birth. They specialize in womens care and high risk pregnancies. They will certainly cost more than the average community hospital.

It starts with the consumer. The consumer is the person in charge of his or her own health care. Regular checkups and eating right, moderate to little drinking and no smoking are important. Knowing what is and is not covered is the responsibility of the consumer. Most health insurance in the US is primarily paid by an employer and the employer’s financial situation usually dictates the amount of coverage purchased.

 

[DL82]

I be to differ with you about the alleged quality of health care in Britain. The NHS rations health care. Medicare in Canada does the dame thing. Americans will never accept this.

It is the American health care system that leads the world in research and development of new technologies, processes, equipment and medicines. Americans bear this burden for the rest of the world.

A smaller nation may make a government-run monopoly on health care services somewhat manageable, but it won’t work in the US.

We have over 300 million people. The cost of setting up an infrastructure (claims processing, etc) controlled by one government agency would be enormous, possibly in the trillions of dollars.

To say the NHS rations care is simply to manipulate the word ‘ration’. The NHS treats anyone who needs treatment. The NHS does not pay for certain experimental or unnecessary treatments, such as Herceptin for cancer treatment or cosmetic surgery (though it will pay for plastic surgery for burns victims, etc.) but neither will the majority of US private insurance plans. You can always get those treatments privately in the UK, while also making use of the free healthcare available.

Nobody gets denied treatment that they need. It’s that simple. In fact, it is due to get better, with the new NHS Charter being drawn up by the Labour government, the emphasis will be much more on sickness prevention - genuine health care not just sick-care.

Bottom line, if a doctor examines you and thinks you need drug x, he will write a prescription, which you can then get for £6.60, regardless of the actual cost of the drug. Hospitals have budgets allocated to run on (as do hospitals run by insurance companies in the US) to make sure they don’t waste money, but it’s down to the trustees to make sure nobody is denied care as a result. If a hospital runs up a deficit due to a particular unforseen problem, like a local pandemic or staff strike, the government will under-write them to make sure nobody is turned away. Nobody rations individual treatment.

Yes, there are waiting lists, because we have 60m potential patients and only so many hospitals. The waiting lists are getting shorter though, and are done on the basis of need. Nobody dies of cancer while they’re on a waiting list for urgent surgery (this used to happen in the 1980s it’s true, but not anymore). Waiting lists in America are on the basis of how much you can afford to pay not how much you need the surgery. You might not get your surgery today, but only because there are no surgeons or operating theatres available, nobody will be turned away when there is a surplus of supply simply because they can’t pay and aren’t covered for a readily available treatment. No operating theatres here are taken up by rich old women having a tummy tuck while poor people need it for life-saving transplant surgery! If you want to skip the waiting list, you can pay to go private, and it costs a lot less here than in the USA, because private hospitals have to be competitive with the free NHS.

Just look at the catalogue of faults you’ve found yourself:

You say your country is too big to regulate a nationalized healthcare system. How does it manage with schools? The running of schools is left down to local boards of education, regulated by State level policies, with standardized testing to show if there are any problems in particular areas, and a few Federal policies to ensure nobody is discriminated against. You wouldn’t advocate privatizing the entire American public school system just because a few areas have poor schools would you?

I’m not saying America needs to adopt the British model. What you need, at the very least though, is a free alternative as a basic safety net for all to use. That way each individual can choose whether to get private healthcare insurance or whether to trust the free option. That keeps the private option competitively priced.

It comes down to this - is it ever right to turn somebody away from a hospital when they need life-saving treatment, which is readily available, simply because they cannot pay?

What you’ve described is a system regulated by rationing and fear.

What we have in the UK is a system regulated by trust and mutual advantage.

You Americans are so scared of eachother!

 

[LCMS_No_More]

Waiting lists in America are on the basis of how much you can afford to pay not how much you need the surgery. You might not get your surgery today, but only because there are no surgeons or operating theatres available, nobody will be turned away when there is a surplus of supply simply because they can’t pay and aren’t covered for a readily available treatment. No operating theatres here are taken up by rich old women having a tummy tuck while poor people need it for life-saving transplant surgery! If you want to skip the waiting list, you can pay to go private, and it costs a lot less here than in the USA, because private hospitals have to be competitive with the free NHS.

This is important. People love to say, “Americans won’t accept rationing of health care” but they already DO. If you can’t pay, you don’t get the care. That’s rationing based on ability to pay.

Just look at the catalogue of faults you’ve found yourself:

You say your country is too big to regulate a nationalized healthcare system. How does it manage with schools? The running of schools is left down to local boards of education, regulated by State level policies, with standardized testing to show if there are any problems in particular areas, and a few Federal policies to ensure nobody is discriminated against. You wouldn’t advocate privatizing the entire American public school system just because a few areas have poor schools would you?

Actually, there’s a whole movement out there who advocates just that!

I’m not saying America needs to adopt the British model. What you need, at the very least though, is a free alternative as a basic safety net for all to use. That way each individual can choose whether to get private healthcare insurance or whether to trust the free option. That keeps the private option competitively priced.

Well said!

It comes down to this - is it ever right to turn somebody away from a hospital when they need life-saving treatment, which is readily available, simply because they cannot pay?

I would say absolutely NOT!

But I’m a left-wing, anti-American, pinko commie-lib because I opposed absolute, unregulated, laissez-faire capitalism and believe that there should be some regulation and government services.

(That was sarcasm, folks)

What you’ve described is a system regulated by rationing and fear.

What we have in the UK is a system regulated by trust and mutual advantage.

You Americans are so scared of eachother!

Fear has become the great motivator in the US. It’s sad when we go from “we have nothing to fear but fear itself” to the constant noise of yellow alert, orange alert, terrah, terrah, terrah! Did you know that one of the most popular genre of movies in the US is horror (some of which seem to be inspired by hell!)? Sickening!

Now, let’s think about this…is God the author of fear or is someone else?

 

[vern_humphrey]

When my wife had knee replacement surgery, a very pleasant lady came by and chatted with us. She later submitted an enormous bill.

So we tried to challenge it. It turned out there was a “service” which handled billing for hundreds of doctors, and they had no idea how we could contact her or challenge the bill.

We simply sent the “service” a letter saying we challenged the bill and demanded further documentation of the “treatment” provided, together with a copy of a signed document where either of us authorized such “treatment.”

That was two years ago, and we haven’t heard from them since.

 

[JW10631]

Just what do you mean that we Americans are so afraid of each other?
I am of the opinion that you don’t know what you are talking about.

Hospitals are NOT run by insurance companies. I don’t know where you ever got that idea. There are some hospital systems that own their own insurance companies. University Hospitals in Cleveland and the UPMC Health System in Pittsburgh are both hospital systems that own their own insurance companies.

Our education system is a huge local/state/federal government controlled money-hungry monster that always falls for the latest fad and is accountable to no one. Private schools have to produce results or the students are disenrolled and the schools close.

Waiting lists in the US are primarily for organ transplants, not for needed procedures. My mother had to wait five days for open heart surgery because the hospital she was admitted to had no immediate openings for the surgery she needed.

Certain private hospitals reserve the right to turn away patients who do not pay. Hospitals owned by states, cities or counties must treat all who need care. Catholic hospitals do not turn away the needy.
Just because someone does not have health insurance does not mean that someone can not receive health care.
Twice in my life I went for a year with no health insurance. If I needed to be hospitalized I would have worked out a payment plan with the hospital and that would have been it.

The Canadian government run health care system works so well that Canadian snowbirds buy American health insurance in order to get treatment they have to wait months for in Canada. Dr. Walter Williams wrote a book about the issues of Canadian health care - where a dog can get an MRI faster than its owner.

BTW, there is no free health care. Somebody, somewhere, pays for it.