What health insurance reform?

Wonder if this will lead corporations to re-negotiate their health care benefit prices?

I hope you all choke on your commie Muslim obama medicine.

'Merca! !!

We switched to Blue Cross Blue Shield last year and they screwed us.

Our daughter's insulin pumps (Omnipod) were listed as durable medical and covered at 100% with our previous provider. BCBS said the same and directed us to their durable medical supplier for the pumps. Two six month shipments later, their supplier sent us a bill for $7000 stating that they hadn't been paid by our insurer.

We called BCBS, and the person on the phone said they were sure the pumps were durable medical. Then they actually looked up our plan and stated that, in fact, they are not. We should've been getting them through another provider as medical supplies and paying a 20% co-pay.

BCBS refuses to pay for their mistake. Their supplier (rightfully) has us on the hook for $7000 we're unable to pay, but is gracefully still supplying us with durable medical we do need from them. Every time we call BCBS we have to go through the same "Wait, those should be durable medical. *looks it up* Oh they're not under your plan." with another person.

Here's the kicker:
For everyone we know who has a 20% co-pay on durable medical, these pumps are classified under their BCBS plan as durable medical.
For everyone we know who has zero co-pay on durable medical (like us), these pumps are classified under their BCBS plan as supplies.

Either way they get their co-pay. Nice.

Here's the kicker:
For everyone we know who has a 20% co-pay on durable medical, these pumps are classified under their BCBS plan as durable medical.
For everyone we know who has zero co-pay on durable medical (like us), these pumps are classified under their BCBS plan as supplies.

Either way they get their co-pay. Nice.

Also... highly illegal? Different classifications of home medical equipment based on something non-health related (your insurance) is a little ridiculous. Especially as they told you they could cover it and directed you to a place to purchase... at that point, their mistake is not your fault. I'd almost suggest consulting an attorney on that, especially if they kept record of their own mistake (though I wouldn't inform them that you're planning on doing that).

One thing to note about Blue Cross Blue Shield (BCBS) companies is that sometimes they are essentially different entities just using the name. For example, BCBS of Illinois is a different entity that BCBS of North Dakota (and sometimes they are just "Blue Cross of [STATE]" without the "Shield"). Plus with different state regulations you can end up with very different experiences. My experience is mostly with their IT systems which are usually completely different making it fun to exchange information with them. Sometimes they have outsourced some of their operations to the same third party though, which is only good if the third party is competent.

Coverage wise I've had good experiences with BCBS of IL (not perfect by any means). Compared to UnitedHealthCare that I have had in the past, and Regence BCBS of Oregon that my wife has had, BCBS of IL wins.

Demosthenes wrote:
Here's the kicker:
For everyone we know who has a 20% co-pay on durable medical, these pumps are classified under their BCBS plan as durable medical.
For everyone we know who has zero co-pay on durable medical (like us), these pumps are classified under their BCBS plan as supplies.

Either way they get their co-pay. Nice.

Also... highly illegal? Different classifications of home medical equipment based on something non-health related (your insurance) is a little ridiculous. Especially as they told you they could cover it and directed you to a place to purchase... at that point, their mistake is not your fault. I'd almost suggest consulting an attorney on that, especially if they kept record of their own mistake (though I wouldn't inform them that you're planning on doing that).

Not illegal at all. Different plans are different products which can classify grey-area things like Omnipod pumps (insulin pump, which is usually durable medical... but replaced every 3 days, which is usually a supply) any way they wish. It's shady and they suck, but it's not illegal.

As far as hiring an attorney to fight a battle where BCBS blames the supplier (who has to verify insurance and marked it as verified on their bills) and the supplier blames BCBS (who pointed us to them), our out-of-pocket cost for that would be far beyond the $7000 we already owe. In Wake County, cases against medical insurance companies lean very heavily toward the defendant. No attorney would pick up such a case on contingency, and there would be no punitive award or recovery of attorney's fees. (Yes... we looked into all of that last October when all of this came to light.)

Write Obama or your congressman or the chairman of the health committee and explain your situation. This seems like it could have legs politically. It is amazing how putting something in the public eye can cause change. I believe that is the way trickle down is supposed to work =P

I mentioned this in the "Random thing I loathe" thread.

Absurddoctor works for a small company, with about 20 employees. Our health insurance is a NYC small-business version of Aetna. It was fine, when we were in Brooklyn. Now that we're 50 miles away, we're encountering issues.

A few months ago, I researched pediatricians for AbsurdBaby. I found one that was listed on Aetna's website, interviewed the practice, liked them, and they started seeing AbsurdBaby within a few minutes of his birth. He's been to their office twice since, and everything's gravy.

Until we tried to sign him up for insurance. When HR filed the paperwork, she was first told that the doctor doesn't participate in the plan. We sent the HR lady a screenshot of the website where it clearly shows that he does. She then said that he was considered a specialist instead of a primary doctor, so we needed a referral. I sent a screenshot that showed he was listed as a PCP.

We end up having a conference call with HR, the insurance broker, and Aetna. It turns out that I was supposed to ignore the list of plans the doctor accepts, and only search for doctors while not logged in, to see some special row that mentions whether the doctor is a "NYC Community Plan preferred provider." The pediatrician is not. In fact, with the exception of a few doctors that have multiple offices, there are no doctors outside the five boroughs in this plan. It would have been nice to know that months ago, when I had called Aetna to research pediatricians, etc.

Even though this pediatrician accepts Aetna, since he's not considered a preferred provider, I have a $5,000 deductible, instead of a $30 co-pay.

I then started to wonder if the hospital where I gave birth is considered a preferred provider. I started freaking out, since a cesarean delivery and everything that goes with it goes for around $23k, instead of the $900 co-pay I was expecting. I was crying so hard on the phone that the broker had to hang up and call back later.

Mind you, when I checked my claims on Aetna.com, imagine my surprise when I saw that all of the pediatrician visits were paid in full.

The hospital claim is still pending.

This is totally not the kind of crap new parents should have to deal with. I'm starting to wonder how many cases of post-partum depression are triggered by surprise medical bills...

Norway is looking better and better every day.

I was crying so hard on the phone that the broker had to hang up and call back later.

Customer service failure, click here to retry the mission? Seriously, he hung up on you because you were crying about a concern his company created with a completely ass-backwards search tool? *facepalm*

Demosthenes wrote:
I was crying so hard on the phone that the broker had to hang up and call back later.

Customer service failure, click here to retry the mission? Seriously, he hung up on you because you were crying about a concern his company created with a completely ass-backwards search tool? *facepalm*

No, it wasn't Aetna who hung up, it was the insurance broker. The same broker who told me last year that this very plan had no deductibles.... only for the insurance to tell me that I had a $5,000 deductible for mental health.

sometimesdee wrote:

This is totally not the kind of crap new parents should have to deal with. I'm starting to wonder how many cases of post-partum depression are triggered by surprise medical bills...

As a new parent I feel you. Unrelated to the new parent thing I had to get a $3k procedure pre-approved from BCBS IL or the specialist was going to charge me up front. They supposedly approved it and I had the procedure and did not pay front. Two weeks later I get a CC letter from my insurance asking my specialist for more information. I called the insurance company and asked why they needed more info if they pre-approved and the very nice call center rep said they had no record of a pre-approval.

I asked the specialist for a copy of the pre-approval letter and they said they have a third party do it and don't have it. All they gave me was a form that the specialist's office uses where someone had checked a box stating it was insurance pre-approved. Also, BCBS IL sent the letter asking for information to the billing PO Box and not to the actual specialist office so I had to call BCBS and have them send another copy to the correct address.

So now I am hoping that the specialist will get the info to BCBS and/or dig up the pre-approval letter from their 3rd party or I guess I have a $3k bill coming my way.

So yeah, Norway...

Confusopolies really are the best kind of industries, aren't they?

Also, I've never had encounter with an insurance broker that where they got everything right.

Mixolyde wrote:

Confusopolies really are the best kind of industries, aren't they?

Also, I've never had encounter with an insurance broker that where they got anything right.

FTFY

Mixolyde wrote:

Confusopolies really are the best kind of industries, aren't they?

Also, I've never had encounter with an insurance broker that where they got everything right.

Love that word.

I would much rather have confusopoly in the dictionary than a lot of the more recent inclusions.

DSGamer wrote:
Mixolyde wrote:

Confusopolies really are the best kind of industries, aren't they?

Also, I've never had encounter with an insurance broker that where they got everything right.

Love that word.

I can't claim originality, Scott Adams coined it in The Dilbert Future:

In the future, all barriers to entry will go away and companies will be forced to form what I call “confusopolies”.
Confusopoly: A group of companies with similar products who intentionally confuse customers instead of competing on price.

And listed as examples:

Telephone service.
Insurance.
Mortgage loans.
Banking.
Financial services.

Some types of insurance are better than others, but health is, by far, the worst. I should re-read that, just to see how amazingly prescient it was.

Mixolyde wrote:
DSGamer wrote:
Mixolyde wrote:

Confusopolies really are the best kind of industries, aren't they?

Also, I've never had encounter with an insurance broker that where they got everything right.

Love that word.

I can't claim originality, Scott Adams coined it in The Dilbert Future:

In the future, all barriers to entry will go away and companies will be forced to form what I call “confusopolies”.
Confusopoly: A group of companies with similar products who intentionally confuse customers instead of competing on price.

And listed as examples:

Telephone service.
Insurance.
Mortgage loans.
Banking.
Financial services.

Some types of insurance are better than others, but health is, by far, the worst. I should re-read that, just to see how amazingly prescient it was.

Pretty close on a lot of the light humor, not so much on the ridiculously crazy just for the hell of it.

Here's yet another example of why we need to get rid of this fee-for-procedure mentality: Cancer doctor gave needless chemo in $35M fraud.

If doctors were on salary, there would be no motivation to do this type of crap.

Yet the GOP likes to think that it's the (non-existent) "welfare queens" who are gaming the system. I have yet to hear of a Medicare recipient stealing 35 million dollars worth of... anything.

sometimesdee wrote:

Yet the GOP likes to think that it's the (non-existent) "welfare queens" who are gaming the system. I have yet to hear of a Medicare recipient stealing 35 million dollars worth of... anything.

Actually, everyone gets in on the action - doctors, patients, pharmacists, equipment makers, everyone. And it costs taxpayers $60 billion a year.

Going by that article, the patients who are stealing are only doing so because they're getting paid off by the providers. It comes right back down to the providers.

An outside estimate as of 2012 put *fraud*, as opposed to waste and abuse or improper payments, at 3% to 10% of Medicare spending, or probably about 6% as a median. In 2012, Medicare paid out $565B in benefits, so that would be about $17B on the low end, $34B at the median, or as much $56B on the high end. (Unlike the posted article, 2011 estimates of Medicare fraud costs were about $48B.)

The rolling average improper payment rate for 2010-2012 as reported by DHHS was 7.1%; the average for 2011 was 8.1% (page 66, para 3). The rate for the three year period ending in 2010 was 9.4%. That's a pretty clear downward trend of about 25% in just two years, a reflection of the emphasis put onto these programs, and that they have moved from primarily research and proof of concept to production. That reports has a wealth of information on how the fraud waste and abuse programs in DHHS are constituted and paid for, and it's required to be updated each year. No matter which monetary amount you buy into, that reduction is good news.

Bear in mind, fraud schemes don't just target the government providers, so it's unlikely that private insurance is doing any better.

Disclaimer - in my job, I have direct contact with the administrative and technical teams at CMS who perform this kind of work, and have had for the last decade or so.

My understanding is that patient health insurance fraud is generally limited to kickbacks to people recruited to a scheme. The vast majority of health care fraud is done on a massive scale in a short time frame by a registered provider, then repeated at intervals with new companies, possibly in new states, with the intent of closing out the scheme as quickly as possible to avoid tracing of the principals. It's really, really hard to spot all of it; the smart ones will run with perfectly normal patient statistics that turn out to be imaginary procedures and visits over a plausible period of time, usually to imaginary premises (although Google Street View is helpful with that, believe it or not). The days of "John Smith" having 600 teeth removed in an afternoon are generally gone, or at least, introduce the provider to the FBI in short order.

There's a *ton* of focus on identifying the people behind serial fraud schemes, and it's starting to meet with success. You guys would be proud.

Robear wrote:

There's a *ton* of focus on identifying the people behind serial fraud schemes, and it's starting to meet with success. You guys would be proud.

Psst. I don't know if you guys know, but the Governor of Florida is one of those people. Please arrest and prosecute him.

OG_slinger wrote:
Robear wrote:

There's a *ton* of focus on identifying the people behind serial fraud schemes, and it's starting to meet with success. You guys would be proud.

Psst. I don't know if you guys know, but the Governor of Florida is one of those people. Please arrest and prosecute him.

Amen!

Since this thread is about health insurance reform, I thought I would opine about what Obamacare has meant for me. It has radically altered my health care and almost all for the good.

First, because of the medical loss ratio portion of the ACA, this will be the second year in a row that I will be getting a "premium holiday" for a full month. My health insurance company did not meet the 80/20 rule and issued a very large check to my employer. Instead of spending money on issuing checks, they are having a "premium holiday" in October.

Also for the second year in a row, my premiums have gone down and my coverage has increased.

However, my recent medical woes have really brought the provisions of the ACA front and center to my life. When I was taken to the ER three weeks ago, the two closest ERs were St. Joseph's Hospital and Barrows Neurological. Barrows is a subsidiary of St. Joseph's, but, as the name implies, they are exceptionally specialized. When I was being treated by the paramedics at work, they asked me where I wanted to go and I said that since I was already dealing with neurological issues, I prefered to go to Barrows, and off I went. Under the old rules, my HI company could have restricted my choices of ER and told me that I had to go to St. Joseph's instead of Barrows (the two distinct ERs are on opposite sides of the campus). I can't be charged more than my current ER co-pay simply because I chose a specialized ER.

Next, I have been keeping a running tab of everything related to my neurological problems starting with my the visit to Urgent Care where the attending physician realized that I had been to Urgent Care six times in the prior 14 months for problems with my right ear, which lead to the MRI that indicated the problems I was having was neurological. Right now, we are at about $60,000 of billed claims related to my condition. It is illegal for my HI to cancel my insurance even if that amount doubles or triples (which is not completely out of the question). I don't have to worry about my HI company trying to find some mistake somewhere that I made as a reason to cancel my coverage nor do I have to worry about hitting a "lifetime cap" on medical care. If there is a future time when I may have to have neurological surgery, that could have easily started me on the road to great worry about hitting that cap and being denied future coverage.

Also, this round of medical issues cannot be used as a reason not to provide me coverage in the future, i.e. the pre-existing conditions clause under the new law. Once they have this problem figured out and treated, it is ancient history and no insurance company can bring it up as a reason to deny me coverage.

So, at least at this point, I am a fan of Obamacare.

I'm personally looking forward to the start of 2014, when my HI provider will no longer have the option to decide to stop covering me because I have a pre-existing condition of being trans. (I don't think they're likely to do this, but it's very much happened to other people. "Flu? Must be trans flu." ffs.) The PP part of the PPACA is [em]important[/em].

I had a sponsored tweet show up on my twitter TL the other day... it was FUD about how the PPACA might actually be costing more money, despite all the evidence to the contrary! It really, really pissed me off.

Anyone else see that Forbes used the logo of a Furry Convention in an article about the ACA?

IMAGE(http://img.gawkerassets.com/img/18x7hvk9x1c0ijpg/ku-xlarge.jpg)

The amount of love I have for that lack of fact checking cannot be expressed in this paltry written form.

I approve of Chief Barry's plan to extend health care to all the catgirls, trans and cis.

Hypatian wrote:

... decide to stop covering me because I have a pre-existing condition of being trans.

WTF? How in god's name do they justify that as a "condition" which has a direct impact on potential future medical exposures outside of the norm? Mind you, I'm saying this as an insurance guy so it's not the standard knee-jerk "all insurance companies are evil and want to steal everyone's money" mindset.