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ObamaCare Discuss The Real Problem With America's Healthcare System at the General Forum; Originally Posted by AZRWinger Medical care insurance like all insurance is governed by the terms and conditions of the policy, ...

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  #31 (permalink)  
Old 04-10-2020, 09:52 AM
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Default Re: The Real Problem With America's Healthcare System

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Originally Posted by AZRWinger View Post
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.
Insurance companies will push the line in grey areas of 'medically necessary'. It is to their benefit.

Other things they like to do is limit the need for certain things, unless, once again, the doctor can prove medical necessity. I am a Type 1 diabetic, and I check my blood glucose up to 10 times a day. Most insurance plans have a 'standard' of up to 5 times, so in order to be covered for the number of test strips I need, the doctor has to submit 'medically necessary' every time my prescription renews.
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  #32 (permalink)  
Old 04-10-2020, 12:53 PM
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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.
I am indeed sorry that you had this problem.

But wouldn't you have profited more if (1) the medical procedure had occurred; (2) the insurance had declined to pay for it; and (3) you did not owe the doctor, either--since the insurance company stated as much?

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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.
Actually, I make a distinction between the two.

An adjustment (or write-off, as it is sometimes called) is simply the lowering of the submitted charges (usually by quite a bit).

To strike something off--and this is often the case, according to the EOBs that I receive--is effectively to say, "We the insurance company) do not plan to pay anything toward this charge; and you (the insured) should not feel obligated to pay anything toward it, either. We consider it to be a bogus (or unnecessary) charge."

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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.
Well, you may call it "blindly accept[ing]," if you wish. But I have never paid anything that my insurance (through its EOBs) said that I do not owe.

And I never shall, either.

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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.
It has the final word about whether or not I owe something. (See above.)
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  #33 (permalink)  
Old 04-10-2020, 02:34 PM
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Default Re: The Real Problem With America's Healthcare System

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I am indeed sorry that you had this problem.
Thanks but no worries... I think I was 17 at the time.

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But wouldn't you have profited more if (1) the medical procedure had occurred; (2) the insurance had declined to pay for it; and (3) you did not owe the doctor, either--since the insurance company stated as much?
Actually, I make a distinction between the two.

An adjustment (or write-off, as it is sometimes called) is simply the lowering of the submitted charges (usually by quite a bit).

To strike something off--and this is often the case, according to the EOBs that I receive--is effectively to say, "We the insurance company) do not plan to pay anything toward this charge; and you (the insured) should not feel obligated to pay anything toward it, either. We consider it to be a bogus (or unnecessary) charge."
Just because the insurance company declines to pay something does NOT mean I do not owe it to the provider. Reducing (or adjusting) a charge is usually by contract these days. Back in the day it was more based on R&C (Regular and Customary) which was based on the common charges for a particular area. The Drs office submits $XX for a particular item to the insurance. The insurance company says they will only pay $X, based on the contract, and the Dr accepts that payment. That is an adjustment.

A 'strike through' or denial means that the insurance company, likely by contract, isn't considering the item for payment at all. It then becomes your responsibility to pay for it. You may discuss it with your provide, and if they take the charge off your bill, that's up to them, but if they don't it IS your responsibility to pay it. Also, if coinsurance is applied, the insurance company will only pay % of the allowed expense, the rest is on you. Third type is when the charge is allowed, at the reduced rate, but falls under the deductible of your plan, and you are still liable for the charge to the provider.

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Well, you may call it "blindly accept[ing]," if you wish. But I have never paid anything that my insurance (through its EOBs) said that I do not owe.

And I never shall, either.

It has the final word about whether or not I owe something. (See above.)
We shall have to disagree, but let me put this example forward: Let's say you had an infection in your foot that was painful, and the Dr felt a topical anesthesia would be best for you during the procedure to drain the infection.

The insurance company declines to pay for the anesthesia. You received it, you feel it's justified to not pay for something you've received?
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Old 04-10-2020, 09:20 PM
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Default Re: The Real Problem With America's Healthcare System

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Originally Posted by GottaGo View Post
Insurance companies will push the line in grey areas of 'medically necessary'. It is to their benefit.

Other things they like to do is limit the need for certain things, unless, once again, the doctor can prove medical necessity. I am a Type 1 diabetic, and I check my blood glucose up to 10 times a day. Most insurance plans have a 'standard' of up to 5 times, so in order to be covered for the number of test strips I need, the doctor has to submit 'medically necessary' every time my prescription renews.
You are overlooking the benefit to the premium payers of insurance companies. Yes, insurance companies benefit from not paying for medical care or supplies not covered by policies, but so do their policyholders.

Certification of medical necessity is not the same as denial of care.
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Old 04-11-2020, 02:57 PM
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Default Re: The Real Problem With America's Healthcare System

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Reducing (or adjusting) a charge is usually by contract these days.
That is certainly correct.

Quote:
Originally Posted by GottaGo View Post
A 'strike through' or denial means that the insurance company, likely by contract, isn't considering the item for payment at all. It then becomes your responsibility to pay for it. You may discuss it with your provide, and if they take the charge off your bill, that's up to them, but if they don't it IS your responsibility to pay it.
Let me give you an example (from 8/8/2019):

"MEDICAL CARE" (caps in original) was listed no fewer than nine times on the EOB I received. But under "You Owe the Provider, there was nothing listed there--as in, zero dollars and zero cents--as my responsibility.

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Originally Posted by GottaGo View Post
We shall have to agree to disagree, but let me put this example forward: Let's say you had an infection in your foot that was painful, and the Dr felt a topical anesthesia would be best for you during the procedure to drain the infection.

The insurance company declines to pay for the anesthesia. You received it, you feel it's justified to not pay for something you've received?
In the example that you have created it would be difficult for me not to feel a moral obligation there.

But that is not what typically happens.

The insurance company generally strikes a procedure that it considers either bogus or unnecessary (as I noted previously)--which, obviously, anesthesia is usually not (whether local or general).
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  #36 (permalink)  
Old 04-11-2020, 03:29 PM
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Default Re: The Real Problem With America's Healthcare System

Quote:
Originally Posted by pjohns View Post
That is certainly correct.



Let me give you an example (from 8/8/2019):

"MEDICAL CARE" (caps in original) was listed no fewer than nine times on the EOB I received. But under "You Owe the Provider, there was nothing listed there--as in, zero dollars and zero cents--as my responsibility.



In the example that you have created it would be difficult for me not to feel a moral obligation there.

But that is not what typically happens.

The insurance company generally strikes a procedure that it considers either bogus or unnecessary (as I noted previously)--which, obviously, anesthesia is usually not (whether local or general).
It could be the insurance company has received the claim but hasn't determined what they are going to pay. So, they leave the patient responsibility blank.
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Old 04-12-2020, 06:56 PM
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Default Re: The Real Problem With America's Healthcare System

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You are overlooking the benefit to the premium payers of insurance companies. Yes, insurance companies benefit from not paying for medical care or supplies not covered by policies, but so do their policyholders.

Certification of medical necessity is not the same as denial of care.
An insurance company cannot deny you care. They can deny paying for it.
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Old 04-13-2020, 10:22 AM
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Default Re: The Real Problem With America's Healthcare System

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An insurance company cannot deny you care. They can deny paying for it.
According to Democrats a lack of insurance coverage is responsible for 40K in preventable deaths annually.
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