Health insurance help please

[kthompson]

So a provider has chimed in and now a health insurance agent who's wife is also a provider is chiming in.

First you need to always be sure what you bought. There are many plans sold out there today that are VERY VERY LIMITED in coverage. Most people realize if they bought say $25,000 liability coverage on their car when it hits that they are out of there and it is all you. The same is true with many plans being sold today. These are often sold on line, by fax, toll free number or by agents who can only sell for that company.

Find an agent if possibly by referral. Some of the most ignorant ones I know work for "A" company. They often only know what they have been told and never ever compare products or read for them self.

Price more than one company. If one is a lot less than another why? Yet most people will try to buy only off of price. Big mistake.

Before you decide on a company call your doctors and see if they accept it.

But you are past here and so lets look at what your options are;

As have been stated READ your policy. Have the agent go over it with you and ask them to help you understand the claims.

There are some things you have said happened that does not make sense based upon the limited info: in one way it sounds like you have a policy that has a list or network of providers and then in another (the offer made and hospital accepting) it does not sound that way.

If it was a life threating emergency which it sounds as it would fall into that class you should be OK going to a non network provider if required due to distance or time required to reach one or if the ambulance took you there (unless you told them to over another hospital as close but in network) often that will make the network issue mute.

Lab test and xrays done in hospital are always higher than out patient ones so the difference is not odd but they should be paying higher rate for inpatient test.

If you find the insurance company is not paying as you believe they should or you find out your coverage is not what you were told by agent (if you bought off line or over the phone sorry Charlie) and you have a witness file a complaint with your States Dept of Insurance. You probably can do this on line. They want facts and facts only. Ours does a great job. If the insurance company is wrong will get them straight if the insured is wrong will tell them so.

Please note I am not trying to define a company or agent. Sadly there are plenty of both that are as any other industry even medical providers don't care. It is next to impossible for an agent to report a dishonest agent as they think it is due to competition. Often I have had people tell me what they had in coverage to find out....and you have no such coverage.

There are many out there today doing a great job making you think they are selling insurance when in real life it is just a maybe discount on your next claim.

It is true with insurance, cars, tractors and yes medical providers; buyer beware.

My guess it no elected official will be any help on such.

Oh, almost forgot, go on line and do a search for your insurance company's name with such as troubles or scams also. Also your State dept of ins normally have a place on their web site to let you know of complaints file against any company licenses in their state. Be careful on for they normally don't give you a market share with it. Expect a company that has 25% of the business to have more claims than a company who has only 1% of business. Hard for the consumer to know the business figures. But a quick call to your Dept of Ins can help decide on a company before you buy. You might have to be listening very carefully to what they say over the phone but listen to tone of voice as you ask them about a certain company.

I am sorry for the mess you are in and hope you well with it. Also trust you have a great recovery.

 

[deere755]

One thing I should have mentioned is I have my health insurance through my employer. I am kind of limited on what they have to offer. I could I guess try and get it on my own but I would never have been able to have gotten it as cheap as I do through them. Now it would probably be impossible to get health insurance on my own with a heart condition

 

[Cat_Driver]

All this back and forth is a shell game between doctors and insurance companies.

Hospitals charge $25.00 for an aspirin or a band aid, and then bargain down to $5.00. Same as doctors they charge 50K and settle for 10K - it's all a game.

Whoever you have to pay just give them a low ball offer make them sign a note on that when they accept, or simply say you are going bankrupt and they won't get a dime.

 

[The Dougster]

Someone mentioned the rediculous billing system used by hospitals and I find that amazing... My wife is fighting Renal Cell carcinoma and we have been making monthly trips to MD Anderson hospital in Houston for well over a year now.... MDA is one of the finest, if not the finest, cancer treatment hospitals in the world... extremely high tech and efficient, excellent doctors, etc, but their billing system is one screwed up mess... There have been times when we'd drop by their billing office with questions and even their office staff are confused.
Now, I don't know much about billing systems but I am astounded that this has been a continuing problem for all hospitals. Perhaps they need someone "less expert" to review the procedure... someone with some common sense?

 

[dave1949]

Dougster,

I worked in commercial IT business systems for many years. You would not believe the crap that is out there in all business segments. It isn't always the billing folks fault, sometimes they have the worst tools imaginable to do their job with.

Some organizations will never grasp the strategic (and profitable) importance of leveraging IT. Some try, and end up with consultants who miss the mark, some have incredibly dense internal tech. development procedures that make building anything about impossible.

And I must say, IT development has it's share of prima donna's that have sky high egos. They will fight over stuff to the death.

Good luck to your wife, sorry to hear about that.
Dave.

 

[dmccarty]

<snip>
Now, I don't know much about billing systems but I am astounded that this has been a continuing problem for all hospitals. Perhaps they need someone "less expert" to review the procedure... someone with some common sense?

Dougster,

I think you were talking about my comments.

MOST of our billing issues are with one hospital/Doctors office. We do quite a bit of business with them but even that does not explain the mistakes they have made over the years. But the doctors are excellent so putting up with the billing problems is worth it.

We have constant doctor appointments. There have been at least two this week. That is about average. Maybe a low average.

Given the amount of bills we receive the number of mistakes is quite low. Except for the one office which has improved over the last year or so. Most of the time it just a matter of not paying a bill twice. Every once in awhile we have to contact the insurance company to make sure a procedure is covered and most of the time it has been. I can only think of one bill that resulted in a back in forth between us, the hospital and the insurance company. But to be fair it was not something the insurance company would get many claims about so their questioning the bill/procedure was reasonable.

The only other time I think we had a problem with insurance was when one of our kids almost died on vacation. Long Long Long story. We ended up taking both kids to the doctor that treated one of the kids in the ER. The visit was a check up for the ER visit and to look at our other child. Since he was out of network the insurance company was not happy. Given the circumstances it was a who cares but I think they ended paying after they heard the circumstances.

Later,
Dan

 

[tanglefoot]

I thought the problems with billing that have been described in this thread were confined to my area doctors and hospitals. I have found that some of the best doctors in my area have office staffs that are careless or incompetent. I think that is a shame, but I don't know how to deal with it effectively. Between that problem and an insurance company that does not want to pay anything it can find a reason not to(the insurance company won't take my word for any correction), we usually have problems when we need treatment.
Butch

 

[tallyho8]

I received a bill after taking my wife to an emergency room and everything was double billed, 2 charges for x-rays, 2 charges for antibiotics. etc.

I went to the billing department to try to get it corrected. They said they would have an accountant sit down and go over the bill with me for $50 an hour.

 

[The Dougster]

My complaint isn't with the doctors or even the insurance companies... in fact, both have been incredibly kind to us. We spend an entire day at MDA having a wide assortment of tests done, brain scans, bone scans, CT, MRI, etc and we see the doctor the next day... Now, I confess that I don't know much about billing systems but why not use a simple column system... tests run in one column, price of the tests in a separate column, amount paid by insurance in another column and a simple balance due in yet another column... why not keep it plain and simple? These data can be derived from other data within a hospitals billing system and not be lost. It's pretty sad when we show the bill to the hospitals accounting staff and even they can't interpret it? <megasigh>

 

[DocHeb]

Butch,
Replying to you, but in general to all the comments on the complexity of health care billing. In general, I stay out of these health care discussions but feel compelled to write.

The hospitals and doctors did not think up this system. This system has been invented and regulated by the federal government. It is then spread out to commercial insurances. Federal health billing regulations are an abomination, are notoriously vague - but are enforced based on individual regulator's interpretations, are so complicated that they require personel with specialized training to do, and place the physicians and health care facilities at the risk of "FRAUD" if their interpretaiton of the rules doesn't mesh with the regulator's interpretations of the rules.

There is also massive amounts of disinformation (dare not say lies) on both sides of the issue. Our President stated that surgeons "would rather cut off a diabetic's foot and earn $30,000 to $50,000 for the procedure, rather than take care of the diabetic chronically". Well, the actual payment to the surgeon for an amputation is $700-1400, and includes all hospital care post-op and follow-up visits. You can talk about doctor/insurance conspiracies all you want, but if there was a conspiracy it would suggest that the doctors would be happy. Let me assure you, they're not.