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Post by craftedbys on Apr 16, 2018 13:50:17 GMT
I didnt want to de-rail the thread ny destined2bmom so this is kind of a spin off/soapbox thread. My apologies for the epic length rant ahead. Hearing all she had been through it just pisses me off to no end that her doctor wanted to treat with IV antibiotics in the hospital, but insurance probably wouldn't pay it. In what universe is it right that some number cruncher sitting in a cubical who knows where gets to dictate how a patient is treated instead of the actual doctor of said patient?? We as Americans are being bled dry by greedy insurance companies that take our money hand over fist and then when we try to get treatment or make a claim they deny it and refuse to pay. A few weeks ago the nightly news ran a story about how in some states insurance companies are now allowed to reject emergency room claims if THEY deem it not to be enough of an emergency. They interviewed a family who are facing tens of thousands of dollars worth of hospital bills because the daughter, who has severe allergies, is away at school and sought treatment in the ER when she had severe allergic episodes. The insurance company decided they weren't severe enough and denies most of the claims. They have fought it and gotten a few thousand dollars taken off their bill, but still have a ton of bills left. We are not doctors, yet now the insurance companies want us to be able to diagnose and triage our illness or injuries and only go to the ER for "true" emergencies. I am just so disgusted by the whole insurance industry and the politicians that have given them more and more power over the last few decades. Stepping off my soapbox. |
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Post by mikklynn on Apr 16, 2018 13:55:25 GMT
I'm ashamed by our whole system. There was a news story recently about surgeons performing cataract surgery on elderly patients that could not afford the surgery. They do it annually.
So, if you are poor and can't afford the Medicare copay you go blind in AMERICA. Nice.
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moodyblue
Drama Llama
Posts: 6,175 
Location: Western Illinois
Site Supporter
Jun 26, 2014 21:07:23 GMT
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Post by moodyblue on Apr 16, 2018 13:56:24 GMT
I hear you. We have had to appeal some claims, including external appeals, for my husband's cancer treatments. And when a prescription dose was changed (twice a day instead of once), the insurance company wouldn't give him the 30 day supply - he could get 15 days at a time, but not 30 days unless he went 8 days without. He gets very irritated by the insurance company rejecting what his doctors prescribe.
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Post by littlemama on Apr 16, 2018 13:56:37 GMT
I didnt want to de-rail the thread ny destined2bmom so this is kind of a spin off/soapbox thread. My apologies for the epic length rant ahead. Hearing all she had been through it just pisses me off to no end that her doctor wanted to treat with IV antibiotics in the hospital, but insurance probably wouldn't pay it. In what universe is it right that some number cruncher sitting in a cubical who knows where gets to dictate how a patient is treated instead of the actual doctor of said patient?? We as Americans are being bled dry by greedy insurance companies that take our money hand over fist and then when we try to get treatment or make a claim they deny it and refuse to pay. A few weeks ago the nightly news ran a story about how in some states insurance companies are now allowed to reject emergency room claims if THEY deem it not to be enough of an emergency. They interviewed a family who are facing tens of thousands of dollars worth of hospital bills because the daughter, who has severe allergies, is away at school and sought treatment in the ER when she had severe allergic episodes. The insurance company decided they weren't severe enough and denies most of the claims. They have fought it and gotten a few thousand dollars taken off their bill, but still have a ton of bills left. We are not doctors, yet now the insurance companies want us to be able to diagnose and triage our illness or injuries and only go to the ER for "true" emergencies. I am just so disgusted by the whole insurance industry and the politicians that have given them more and more power over the last few decades. Stepping off my soapbox. If I read her post correctly, the doctor "thought" the insurance might not pay because she had 4-1/2 days of antibiotics left to pay. I would imagine if he followed through with the insurance company and stated that the antibiotics were not working, it could have been just fine.
As for the ER, my insurance will only cover an ER visit if you are admitted to the hospital. I'm sure that is because so many people go to the ER for non-emergency reasons and the cost is much higher for anything done through the ER.
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moodyblue
Drama Llama
Posts: 6,175
Location: Western Illinois
Site Supporter
Jun 26, 2014 21:07:23 GMT
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Post by moodyblue on Apr 16, 2018 14:01:12 GMT
I didnt want to de-rail the thread ny destined2bmom so this is kind of a spin off/soapbox thread. My apologies for the epic length rant ahead. Hearing all she had been through it just pisses me off to no end that her doctor wanted to treat with IV antibiotics in the hospital, but insurance probably wouldn't pay it. In what universe is it right that some number cruncher sitting in a cubical who knows where gets to dictate how a patient is treated instead of the actual doctor of said patient?? We as Americans are being bled dry by greedy insurance companies that take our money hand over fist and then when we try to get treatment or make a claim they deny it and refuse to pay. A few weeks ago the nightly news ran a story about how in some states insurance companies are now allowed to reject emergency room claims if THEY deem it not to be enough of an emergency. They interviewed a family who are facing tens of thousands of dollars worth of hospital bills because the daughter, who has severe allergies, is away at school and sought treatment in the ER when she had severe allergic episodes. The insurance company decided they weren't severe enough and denies most of the claims. They have fought it and gotten a few thousand dollars taken off their bill, but still have a ton of bills left. We are not doctors, yet now the insurance companies want us to be able to diagnose and triage our illness or injuries and only go to the ER for "true" emergencies. I am just so disgusted by the whole insurance industry and the politicians that have given them more and more power over the last few decades. Stepping off my soapbox. If I read her post correctly, the doctor "thought" the insurance might not pay because she had 4-1/2 days of antibiotics left to pay. I would imagine if he followed through with the insurance company and stated that the antibiotics were not working, it could have been just fine.
As for the ER, my insurance will only cover an ER visit if you are admitted to the hospital. I'm sure that is because so many people go to the ER for non-emergency reasons and the cost is much higher for anything done through the ER.
So if you go to the hospital with chest pain, thinking you might be having a heart attack, and it turns out to be something minor, you get no coverage for the blood work and EKG and so on that they do to rule out a heart problem? Yikes! And people are told "when in doubt, get it checked out." Someone could die while trying to decide if it's their heart or not and whether to go to the ER. |
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Post by destined2bmom on Apr 16, 2018 15:02:09 GMT
I completely agree with what everyone has said. This whole insurance industry making decisions on whether we should be hospitalized or sick enough to go to the ER really angers me.
The doctor (in the same office as mine and was treating me) was afraid that the insurance company wouldn’t pay because I had 4 1/2 days of antibiotics left.
Four days after I finished the antibiotics I saw my regular doctor who said that I was being admitted that day. But that I had to go through the ER because she had admitted someone two weeks before for cellulitis on the leg and they needed IV antibiotics and the insurance company refused to pay for them being in the hospital. But it wasn’t until they received the bill, that they found out. It makes me just shake my head. Because now it seems even doctors who have a medical licenses cannot just admit you.
And when I was seen by the ER doctor, she said that I was in a grey area for being admitted. But after talking to my doctor she could justify putting me in the hospital for observation. My copayment for the ER is $500.00. Since I was admitted I didn’t have to pay it. How crazy...
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Post by arielsmom on Apr 16, 2018 15:13:34 GMT
How about the big fancy, expensive buildings that house insurance companies? Around here there are many empty retail buildings. Why not renovate several of them into offices instead of the expense of brand new complexes? In this day of working online, people do not need to be housed in the same building anymore.
We could help insurance companies save a lot of money with overhead alone.
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Post by cannmom on Apr 16, 2018 15:16:21 GMT
I absolutely agree that our health care system in this country is broken, but you would not believe the number of people who use the ER for primary care. I understand insurance companies trying to stop that practice. Chest pain needs to be treated in the ER, lots of other issues do not.
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Post by Mel on Apr 16, 2018 15:25:15 GMT
I hate that someone with NO medical knowledge is the one that makes the decisions as to whether or not my drugs/treatments/doctor's visits are necessary. I mean, my DOCTOR (who has been to school for a million and seven years) says I am sick... PAY HIM!
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RosieKat
Drama Llama
PeaJect #12
Posts: 5,385
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Post by RosieKat on Apr 16, 2018 15:44:13 GMT
A few weeks ago the nightly news ran a story about how in some states insurance companies are now allowed to reject emergency room claims if THEY deem it not to be enough of an emergency. I don't think this is anything new. Around 25 years ago, I was in my first job and new to the area. In the middle of the night I began experiencing severe abdominal pain and vomiting. Per my insurance requirements, I called my primary care doctor's office, but only got an answering machine and no alternative number or answering service. I left a message. I then called the ER, who recommended I come in to be assessed for appendicitis. I drove myself to the nearest ER, where they informed me that they were not one of my in-network hospitals and I would have to cover 30% or something similar. As I was literally vomiting while I sat there, I said sure, we'll deal with it. Fast forward, it turned out I had a kidney stone. I paid my 30% without a peep, even though I had to borrow the money to pay for it. The insurance company didn't want to cover the part they were supposed to cover because it hadn't been a true emergency. I had to fight it for over a year, with the rationale listed above - I can't diagnose myself, my doctor didn't respond, and ER said to come in. I finally won, but it was a huge struggle. I'm in NO WAY saying this was OK, just saying I don't think it's new. |
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Post by stampinbetsy on Apr 16, 2018 16:14:45 GMT
I totally get it. When DS was younger, his endocrinologist wanted to put him on growth hormones (which is, of course, mega expensive). Insurance denied it, and the office refiled. It was denied again, and the letter came from a doctor who may not have even been an endocrinologist.
Fortunately, we had a second level review, and it turns out that DH's company is self-funded, and his company made the insurance company cover it, subject to regular review.
Buy I find it very irritating that doctors can't do what needs to be done because of Insurance companies.
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Post by littlemama on Apr 16, 2018 16:28:29 GMT
If I read her post correctly, the doctor "thought" the insurance might not pay because she had 4-1/2 days of antibiotics left to pay. I would imagine if he followed through with the insurance company and stated that the antibiotics were not working, it could have been just fine.
As for the ER, my insurance will only cover an ER visit if you are admitted to the hospital. I'm sure that is because so many people go to the ER for non-emergency reasons and the cost is much higher for anything done through the ER.
So if you go to the hospital with chest pain, thinking you might be having a heart attack, and it turns out to be something minor, you get no coverage for the blood work and EKG and so on that they do to rule out a heart problem? Yikes! And people are told "when in doubt, get it checked out." Someone could die while trying to decide if it's their heart or not and whether to go to the ER. No, it is the copay that I am talking about. The testing would be covered as usual, but the $250 copay would be my responsibility.
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Post by destined2bmom on Apr 16, 2018 18:29:44 GMT
I absolutely agree that our health care system in this country is broken, but you would not believe the number of people who use the ER for primary care. I understand insurance companies trying to stop that practice. Chest pain needs to be treated in the ER, lots of other issues do not. I completely agree and understand your comments. I saw quite a few people in the waiting room that day who looked perfectly healthy and I wondered what they were doing there. And in the past I’ve seen that happen at other hospitals. But I think that maybe if there could be a note in their files that stated that they did not have a primary care doctor; then maybe the insurance companies would charge those individuals. Then again, maybe they don’t have insurance and so they need to use the ER as their doctor office. But people who have primary care doctors and who get sent to the ER or people who think that they are having an extreme medical issue should not be charged by the insurance companies. |
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Post by littlemama on Apr 16, 2018 18:41:37 GMT
The "funny" thing is that your doctor cannot prescribe medication to you without seeing you first, but someone with no knowledge of you or your medical history can overrule your doctor.
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mimima
Drama Llama
Stay Gold, Ponyboy
Posts: 5,019
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Post by mimima on Apr 16, 2018 18:52:20 GMT
The US has allowed us to have a shameful medical system for far too long. I wish our leaders would get the political will to actually move towards universal, single payer health care, but I am not holding my breath.
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Post by Jennifer C on Apr 16, 2018 18:55:38 GMT
I agree that our healthcare system needs to be totally reworked, and the first place it needs to be reworked at is the ER. People believe or want to go to the ER for the smallest things. My daughter slipped in our kitchen and banged her head on the corner of the counter. She passed out and only woke up when the EMT's were with her. They took her to the hospital and she had to stay in a bed in the hall way in the ER. The peds rooms were full because it was cold/flu season. Lots of kids were brought into the ER either because they didn't have a primary dr. or they were on Medicaid. I even heard a Mom refuse to leave the ER and demand that her daughter get a bed that night because she didn't want to take care of her at home. We finally were just transferred upstairs and they admitted my dd there.
Jennifer
I reread what I wrote and wanted to add...The child whose Mom wanted her admitted had a severe sinus infection or cold and the Mom couldn't get it cleared with OTC meds. My daughter had a level 3 concussion and still to today, she has some short term memory loss and still can't remember that day or the next.
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Post by destined2bmom on Apr 16, 2018 19:16:10 GMT
I agree that our healthcare system needs to be totally reworked, and the first place it needs to be reworked at is the ER. People believe or want to go to the ER for the smallest things. My daughter slipped in our kitchen and banged her head on the corner of the counter. She passed out and only woke up when the EMT's were with her. They took her to the hospital and she had to stay in a bed in the hall way in the ER. The peds rooms were full because it was cold/flu season. Lots of kids were brought into the ER either because they didn't have a primary dr. or they were on Medicaid. I even heard a Mom refuse to leave the ER and demand that her daughter get a bed that night because she didn't want to take care of her at home. We finally were just transferred upstairs and they admitted my dd there. Jennifer I reread what I wrote and wanted to add...The child whose Mom wanted her admitted had a severe sinus infection or cold and the Mom couldn't get it cleared with OTC meds. My daughter had a level 3 concussion and still to today, she has some short term memory loss and still can't remember that day or the next. I am really sorry that your daughter still has issues today from that fall. Did they actually admit that child whose mom was throwing a fit? |
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Post by LuvAgoodPaddle on Apr 16, 2018 19:40:40 GMT
I am not a fan of ACA, but this is not new. Back in the early 90's I remember having to fight an ER visit getting paid because insurance denied it. It took a lot of fighting but it did get paid! My husband sliced through is finger. Luckily I was right there, covered it with a towel and drove him immediately to the ER. There was a lot of blood, so we knew it was really bad even though it was tough to actually see. I certainly did not want to take the time to clean it to figure it out with all the blood. When we got to the ER, it was bad enough that the nurse asked right away if we brought the finger with us! I freaked out...thinking I would have to go home and actually search for it.  Dr came in and after examining it closer, decided he could stitch it back together even though he would have a funny shaped fingertip. So my husband has a strange, pointy index finger, but thankfully I didn't have to search for the missing piece. Insurance denied paying his visit because they said it wasn't an emergency. I guess I was supposed to have the knowledge of a triage nurse and know that?? Took a lot of fighting with insurance to get them to cover it. |
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smartypants71
Drama Llama
Posts: 5,706
Location: Houston, TX
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Post by smartypants71 on Apr 16, 2018 20:18:02 GMT
I was home sick for the majority of last week, so I spent a lot of time on the couch watching tv. Literally every other commercial was a prescription commercial. Why are they spending all this money on advertising to regular people? Between pharmaceutical companies and insurance companies, i just...ugh!
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mlana
Pearl Clutcher
Posts: 2,523
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Post by mlana on Apr 16, 2018 22:19:24 GMT
We have had Kaiser since 2002 and they have been great for care, but the premiums have been higher and higher. We were first insured thru our small business, but went on ACA subsidized coverage after DH had his stroke and our premiums rose to $2500/ month for the two of us. This year we expected to net very little as we expect DH to go on dialysis at some point, though maybe not as early as we had previously been told. Because of this, we are on a very heavily subsidized plan, which has been great.
So, mixed blessing here, DH starts his first job for someone other than our company in almost 30 years. The pay is good, but the insurance won’t be thru Kaiser. He is at a delicate point in his health, with very frequent testing of his kidneys and biweekly Procrit injections to keep his iron up. Now I have to find him all new doctors, who will not be connected and who will all have to brought up to date on where he is in his disease. I know each one will want/have to prove why they’re ordering what they’re ordering for him, which will mean an excessive number of blood draws for someone who is needle phobic. Add in that some of those draws will be by office nurses rather than by phlebotomists who truly excel at sticks and you have the makings of a tragedy.
Why don’t we just stick with Kaiser and pay our premiums out of pocket? The $1660/month premiums? For a total of almost $20k/year? It’s ridiculous that we have to change his entire health care system because he changed jobs.
Marcy
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sassyangel
Drama Llama
Posts: 7,456
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Post by sassyangel on Apr 16, 2018 23:07:38 GMT
Every single group health plan I code, including self-funded, has Emergency wording of the exact same variation "XX after deductible/deductible waived after $XX copay, copay waived if confined, non-emergency not covered" This is pretty standard.
While I agree with your bone of contention, that emergent care decisions should likely be the decision of a doctor, the amount of people who treat the ER as their PCP would be out of control if plans weren't worded like this.
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Post by Jennifer C on Apr 17, 2018 13:09:21 GMT
I agree that our healthcare system needs to be totally reworked, and the first place it needs to be reworked at is the ER. People believe or want to go to the ER for the smallest things. My daughter slipped in our kitchen and banged her head on the corner of the counter. She passed out and only woke up when the EMT's were with her. They took her to the hospital and she had to stay in a bed in the hall way in the ER. The peds rooms were full because it was cold/flu season. Lots of kids were brought into the ER either because they didn't have a primary dr. or they were on Medicaid. I even heard a Mom refuse to leave the ER and demand that her daughter get a bed that night because she didn't want to take care of her at home. We finally were just transferred upstairs and they admitted my dd there. Jennifer I reread what I wrote and wanted to add...The child whose Mom wanted her admitted had a severe sinus infection or cold and the Mom couldn't get it cleared with OTC meds. My daughter had a level 3 concussion and still to today, she has some short term memory loss and still can't remember that day or the next. I am really sorry that your daughter still has issues today from that fall. Did they actually admit that child whose mom was throwing a fit? I'm not sure if they admitted the child. She didn't seem very ill to me, bouncing around and enjoying her Mom's phone. My daughter was taken care of pretty fast and went up with my Mom. I stayed behind and as soon as her Dad got there we went up. Jennifer |
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Post by stormycat on Apr 17, 2018 15:04:09 GMT
Funny I should read this today. I was just looking at the claims for my son's new mobility stroller (not quite a wheelchair as he is 20 months). My insurance (my primary insurance) broke down the different parts of the mobility stroller, main frame, foot rests, etc.
Total bill 2073.32, they covered 48.69 of it. They paid for the stroller straps. That's it, the rest of all the components, they paid 0.00.
I am still not sure why they only paid that, and nothing else.
Right now his CT Scan is pending, that bill is 8,994.69, curious to see how much they will pay of that.
His weekly OT therapy is billed at 482.00 for the hour. Plus he has multiple specialists and tests that still are coming through.
Thankfully, since I adopted him as special needs (he had a Traumatic Brain Injury, Cerebral Palsy, CVI-vision impairment, and epilepsy) he also has a secondary state medicaid plan until he is 18, that covers everything my primary doesn't.
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Post by craftedbys on Apr 17, 2018 17:07:59 GMT
Sorry I didnt get a chance to come back to the thread yesterday, didn't mean to post and run, but my Dad hasn't been feeling well and I was taking care if him. He still feels poorly this morning, his dizziness hasn't subsided and he fell this morning, so I have brought him to the ER to get him checked out. Of course DH is out of town again today and my brothers both live out of town (although only 1 bothers to help me with Dad) so I am doing this on my own.
It is heartbreaking to hear everyone's stories as well as infuriating. I don't understand how other countries can manage to offer healthcare and here in the USA there are so many people who have to choose between healthcare and food or shelter.
And the amount of waste with Medicare is astounding. Don't get me wrong, I am so thankful that my parents have been covered, but it made me crazy to see the statements of what was paid. Medicare over pays for so much--do they even look at the bills? I know that it paid $200 for an item that I could have gotten at Wal-Mart for $50. The EXACT same item. And that was just 1 item. Multiply that by all the people on Medicare and I'm sure it adds up quickly.
Again, I am very thankful for Medicare, I was able to get him seen and I am not sitting here worried about what the bill is going to be and where I would come up with the money.
Any prayers and positive thoughts for my Dad's quick recovery would be appreciated.
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Post by mikklynn on Apr 17, 2018 18:00:28 GMT
craftedbys I am sending my prayers that your dad improves quickly.
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Post by destined2bmom on Apr 17, 2018 18:03:51 GMT
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Post by malibou on Apr 17, 2018 18:15:34 GMT
Hoping your dad is on the mend soon.
As far as the topic, insurance companies suck.
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Post by cannes on Apr 17, 2018 22:01:05 GMT
I completely agree.
On that same token, though, we also need to be seeking appropriate treatment for illness and injury and a great many consumers do not. The ER's and Urgent Care facilities across the country are stuffed with people who have conditions that are neither urgent or emergent. This taxes an already broken system in many different ways.
I am all for demanding change to how we handle medical care in this country, but it's a multifaceted issue that needs reforms in many areas: insurance, pharmaceutical and patient.
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Post by Zee on Apr 17, 2018 22:19:40 GMT
The other side of the coin is the ridiculous amounts of money charged by hospitals, doctors, and drug companies. Insurance companies have to limit costs somehow. Yes, they go too far, but the whole system is a mess.
Once upon a time it was enough for your doctor to say you needed something and you paid for it. Then insurance companies got involved and it's been an escalating price war ever since.
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Dr came in and after examining it closer, decided he could stitch it back together even though he would have a funny shaped fingertip. So my husband has a strange, pointy index finger, but thankfully I didn't have to search for the missing piece.
