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ObamaCare Discuss The Real Problem With America's Healthcare System at the General Forum; Originally Posted by saltwn read up on what countries' citizens pay for health care. While you are at it, also ...

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Old 04-08-2020, 06:59 AM
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Default Re: The Real Problem With America's Healthcare System

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Originally Posted by saltwn View Post
read up on what countries' citizens pay for health care.
While you are at it, also read up on regulation of care, wait time for care, coverage for optional services and surgeries, quality of drugs, tax cost, and all the parts of it you are sweeping under the rug.
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Old 04-08-2020, 10:30 AM
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Default Re: The Real Problem With America's Healthcare System

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While you are at it, also read up on regulation of care, wait time for care, coverage for optional services and surgeries, quality of drugs, tax cost, and all the parts of it you are sweeping under the rug.
Also, one that is forgotten until it is in need, is the development of life saving drugs and vaccines that are developed by pharmaceutical companies in the United States, more so than in any other country.
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Old 04-08-2020, 01:46 PM
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Default Re: The Real Problem With America's Healthcare System

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Originally Posted by loboloco View Post
Originally, health insurance paid to the individual, not the healthcare provider.
To make this clear, I go to doctor and get bill for $300.00. I am responsible to the doctor for the bill. I send a copy to the insurance company and they reimburse me for the part they cover. This is still a third party pay, but the consumer feels the bite first and has incentive to keep the pocketbook pain level down.
But is there any write-off (a.k.a. "adjustment") this way?

Or would the consumer simply pay the full submitted charges (minus what the healthcare insurer reimbursed him--or her)?
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Old 04-08-2020, 03:45 PM
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But is there any write-off (a.k.a. "adjustment") this way?

Or would the consumer simply pay the full submitted charges (minus what the healthcare insurer reimbursed him--or her)?
The fees charged were massively lower than what they are now, realistic prices. Not these overinflated prices that are submitted to the insurance that are then knocked down to real market prices, and that's what they call 'adjusted'.
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Old 04-08-2020, 04:11 PM
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Default Re: The Real Problem With America's Healthcare System

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But is there any write-off (a.k.a. "adjustment") this way?

Or would the consumer simply pay the full submitted charges (minus what the healthcare insurer reimbursed him--or her)?
Since it was mostly 'pay as you go', the prices were kept down because the doctors and the patients both had an incentive to do so. As is still the case, insurance payments were made after the fact and at the insurance companies leisure.
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Old 04-08-2020, 06:30 PM
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Default Re: The Real Problem With America's Healthcare System

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The fees charged were massively lower than what they are now, realistic prices. Not these overinflated prices that are submitted to the insurance that are then knocked down to real market prices, and that's what they call 'adjusted'.
That is a good point.

But it still begs the question: Were those "massively lower" prices merely due to a change because of inflation?
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Old 04-09-2020, 08:57 AM
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Default Re: The Real Problem With America's Healthcare System

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That is a good point.

But it still begs the question: Were those "massively lower" prices merely due to a change because of inflation?
When a medical office didn't have to hire a person to do nothing but file claims, and follow up on those claims, correct the claims, argue the medical necessity with a faceless bureaucrat, and follow up on payment, the office saved money.

When a medical office doesn't have to wait up to 60 days for payment for services rendered, but instead receives payment immediately, it saves them money.

A small amount could be attributed to inflation, some to the litigious nature of people, and the rest, I lay at insurance companies feet.
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Old 04-09-2020, 03:02 PM
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Default Re: The Real Problem With America's Healthcare System

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When a medical office didn't have to hire a person to do nothing but file claims, and follow up on those claims, correct the claims, argue the medical necessity with a faceless bureaucrat, and follow up on payment, the office saved money.
That does make sense.

But why would there need to be someone "argu[ing] the medical necessity" of a procedure?

My own insurance sometimes strikes a procedure entirely--meaning that the insurance company will not pay toward it, and I am not to feel compelled to pay toward it, either--and there is simply no arguing the point.

What the insurance company says is the final word on the matter.
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Old 04-10-2020, 07:48 AM
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Default Re: The Real Problem With America's Healthcare System

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That does make sense.

But why would there need to be someone "argu[ing] the medical necessity" of a procedure?

My own insurance sometimes strikes a procedure entirely--meaning that the insurance company will not pay toward it, and I am not to feel compelled to pay toward it, either--and there is simply no arguing the point.

What the insurance company says is the final word on the matter.
Alright, let me use a anecdote.

I had a 'planter's wart' between my big toe and next toe, large enough that it was causing problems with how I walked (from annoying low level pain) This was MANY years ago.

Doc felt it should be removed, and let's say it would cost $100. Since I was on my parents insurance at the time, it was submitted to them for pre-authorization. They came back as 'not medically necessary' and declined to pay for it. My parents felt it was necessary, so they paid cash for it.

When you submit a claim to insurance, and they put it under not medically necessary, that means if you have already had the procedure, it is your responsibility to pay for it. If not already had it, then you need to decide if you really need or want it, and then you would pay for it.

The 'adjustment' or striking something off as you call it, is a deal between the doctor and insurance company, and if the doctor miscoded something when submitting a claim, they would change or correct it, and resubmit it.

Some people will blindly accept the insurance company's response, and with all due respect, that's pretty much what the insurance company wants to happen. If they don't have to pay for it, that's more for them. Contesting things will some times force the insurance company to reconsider their decision, especially when the doc can validate with medical necessity details.

No, the insurance company doesn't have 'final word' if you can have something done, they can only have 'final word' about paying for it. Insurance is just a method of payment.
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Old 04-10-2020, 09:23 AM
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Default Re: The Real Problem With America's Healthcare System

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Originally Posted by GottaGo View Post
Alright, let me use a anecdote.

I had a 'planter's wart' between my big toe and next toe, large enough that it was causing problems with how I walked (from annoying low level pain) This was MANY years ago.

Doc felt it should be removed, and let's say it would cost $100. Since I was on my parents insurance at the time, it was submitted to them for pre-authorization. They came back as 'not medically necessary' and declined to pay for it. My parents felt it was necessary, so they paid cash for it.

When you submit a claim to insurance, and they put it under not medically necessary, that means if you have already had the procedure, it is your responsibility to pay for it. If not already had it, then you need to decide if you really need or want it, and then you would pay for it.

The 'adjustment' or striking something off as you call it, is a deal between the doctor and insurance company, and if the doctor miscoded something when submitting a claim, they would change or correct it, and resubmit it.

Some people will blindly accept the insurance company's response, and with all due respect, that's pretty much what the insurance company wants to happen. If they don't have to pay for it, that's more for them. Contesting things will some times force the insurance company to reconsider their decision, especially when the doc can validate with medical necessity details.

No, the insurance company doesn't have 'final word' if you can have something done, they can only have 'final word' about paying for it. Insurance is just a method of payment.
Medical care insurance like all insurance is governed by the terms and conditions of the policy, contract. It's not an all you care to eat buffet, at least for most policies.

Mean old insurance companies underwrite policies based on risk and coverage. They don't have the luxury of being backed by the US Treasury like Medicare or Medicaid. Even so, government health insurance restricts coverage to recognized procedures and reimburses health care providers at a discounted rate insufficient to allow health care providers to continue operating with supplemental payments by patients or other insurance.

Fraud estimates for Medicare claims alone amount to $52 billion per year. Private insurance companies do a much better job policing claims than the government out of necessity.
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