Drs, Insurance, etc | Arthritis Information

 

  I think wanttobefree, wanted her thread closed.. i AGREE..

BUMPhi bumpy .. i wonderd what is bipolar..

bumping Boney    when my kids went to their pediatrician - they were always given a hearing test as part of their physical. Whether or not it was paid for by insurance, I don't know, nor do I care.  My childrens health is more important than arguing over a bill that I had to pay.  If money is such an issue, I would have checked.

I agree that not all dr's are Gods.  That is why I said that everyone should check everyone, not to be suspicious, but to know what is going on.  Everyone can make mistakes.

As for the hearing test, I was trying to get her to check into a little further.  BECAUSE, I *highly* doubt a hearing test done by an audiologist would be .00.  Additionally, I *highly* doubt that a specialist could see him the same day.  Something just stinks about this somewhere.  Maybe there was a coding issue at the dr's office? 

As for everyone coming down on her, I'm not touching that with a 10 ft pole.

I'm of the opinion, that if the dr thinks I need it and it is reasonable, then what difference does it make if it costs me something out of pocket.  I guess everyone differs on health first, money second.You're right Phats, a specialist would be a lot more money, and it would be a while to get in.  My boys doctors did eye and hearing tests, if there were issues he'd send them to a specialist.  This happened with their eyes; I still had to pay for his test, but went for further testing to a specialist. some of the most stressed, and consequently least patient and rudest folks in a medical office, are the billing staff.  i do not envy their jobs.  there are so many different health plans: private plans, of which there are group and individual; medicare; supplements to medicare; medicaid; schips;  each with ever changing rules and procedures.  its confusing for the medical provider and the patient and thats why we all have to sign that form saying we'll pick up the cost of anything an insurer won't pay.  hi guys i am lucky here in the uk and pay no costs. but being unable
to work and not much cash to play whith  i would have to queery the
bill.. but experienses have taught me not to get to stressed about
some issues..as it can make a person more ill. and the person who
sent out the bill or whatever.. just carries on whith life..
so to sum up.. queery the bill ..if you gotta pay.. dont get overstressed

Bumbling Boney
The place I usually get a surprise is at the pharmacy!   Usually it is sticker shock when I fill my Rx and they say "oh, this isn't covered by your ins anymore".  So, the pharmacy has to call and get another med from the dr and then run it.  It stinks~!I would investigate the coding issue. That is what caused my son's lead test to be charged. After I investigated it we discovered the problem and it was then covered.   Still, we all know that things slip through the cracks.

I really didn't realize that prescriptions and visits cost large amounts of money until I went to college. I grew up on military bases-everything was covered. We joke that I was the most expensive child in my family since I was 7 weeks early. I cost .97. My parents kept the receipt just so I knew what I was "worth". Anyway, I broke my ankle in a rugby game and went to the er-not on a base. That was fine cause they would file later. But, when I went to fill a prescription I was totally shocked. I honestly didn't even take my checkbook to the pharmacy. My friend footed the bill and thought I was nuts. Granted, my parents were reimbursed after things were filed but it was still crazy. This is also a case of an adult, granted very young adult, not knowing how it all worked. I didn't know to call ahead to the insurance to get treated at a civilian facility. They could have denied the claims but didn't. I guess it was considered a true emergency so they didn't question it but I was very lucky.

All in all, this is just another chapter in our health care system. No matter what, we will never know how it all works.






Crazy.[QUOTE=rocckyd]

All in all, this is just another chapter in our health care system. No matter what, we will never know how it all works.
[/QUOTE]

 

And why should we accept that?  In a previous post I mention all the different insurance coverages there are in the US, private group employer based insurance, individual private insurance(of which there are comprehensive, basic and catastrophic plans), HMOs, PPOs, Medicare - Part A, Part B, Part D, Medicare Advantage plans, Medicare supplements, Medicaid (which varies from state to state, in California its call MediCal) SCHIPS -- I forgot the military system for military and their families, and the Veteran's Administration health care system for vets.  Each insurer with different requirements, different rules, different forms, different drug plan and formularies, different reimbursement plans.

 

I use to think major reform of our health care system wasnot possible because of the influence of the stakeholders on our political system, especially insurance companies and drug companies, if we build on our current system, mandating every one have insurance, we still have insurance companies eating up a lot of health care dollars for their administrative costs, over 20%, a single payer system, which would do away with insurance companies would bring administration costs down to single digit, i believe around 3%.  So, during this time of discussion of the future of health care in the US, people should also consider the dollars savings and efficiency in a single payer system.

 

Below is a link that discusses a single payer system:

 

http://www.pnhp.org/facts/single_payer_resources.php

 

 

Joie2008-05-12 12:33:17Apparently I haven't read the original post that spawned this one yet but I see both sides of the insurance issue.  I work for a small optometrists office and part of my job is the billing.  I do my very best to call each persons insurance company and find out what their benefits are and try to maximize what they can get but ultimately, no matter how complicated, an insurance policy is between the patient and the insurance company and you should know your benefits.  You would be surprised at how silly people can be when it comes to this. I ALWAYS ask when someone schedules their appt, do you have any optical coverage.  Seems like a simple question but believe me, its not.  I would say a good percentage of people that say yes they do, actually do not.  My all time favorite is the answer of yes, I have insurance, um, ok, what insurance do you have, well, I don't know, I work for local mom and pop company, don't you know what I have???  I have actually had to argue with people explaining to them that I can not bill for their services if they can not even tell me who there insurance is with!! 

Now, granted, usually like dental, your vision coverage is usually through a different carrier than your medical insurance but come on people, I am willing to do some leg work to help you but you have to give me a clue!  LOL!!!  I have no problems once so ever when someone calls and says I have such and such insurance, can you help me figure out what my benefits are?  Yes, I can.  I need the basic info, which again, a lot of people don't have, such as contract numbers, and I will call and see if I can find out.  I work for a small office and don't mind helping people out.  I can understand that some offices are just too busy to help people with this stuff and thats a shame.

Another issue that arises when I try to help someone is people with small carriers.  I will call them, get the benefits and ask them if they will pay me (the provider) directly and they say sure.  Ok, explain to the patient, I have never heard of your insurance but I called them and they said they will pay X and send me the check.  If they pay you please know that you need to forward that check to us.  Never fails, patient gets the check, I track it down and get Oh gee well um, I didn't know......I hate helping people only to have them turn around and screw me for it!

When it comes time to being on the patient end of things, I always try to anticipate as much as possible.  For example, when I found out that I was going to do remicade, I called the doctors office to ask for the procedure and diagnoses codes and called my insurance company to find out what my copay was.  YIKES, it was a lot.  After a few days of panicking and a few more phone calls and such, I found out that I have a cap on my out of pocket expenses, whew!

We as patients can not always anticipate things like that but we do need to spend some time and try to learn as much as possible.  I have heard everyone (not just people here) complain about how difficult the medicare plans are to figure out.  See if there is a patient advocate at your local hospital who can help or if you are a senior, check at the local senior center.  I have blue cross and we get a "at a glance" benefit summary which helps a lot for the majority of routine things.  But, whenever in doubt, I call the insurance company myself and find out, this usually requires some billing codes but your doctors office should be able to provide those for you.

I agree, the US needs some major changes to its system.  I do not pretend to know what the answer is but until then, we have to be responsible for knowing our coverage.  I recently had my yearly "womanly" appt and than got a bill for a copay a few weeks later.  I KNOW that I have no copay for this particular service so I called them up and nicely explained that my policy waves the copay and after a few minutes of checking they said I was correct and they would take care of it.

I ALWAYS read and save my EOB's.  Explanation of benefit statements.  That way if the doctors office tries to charge me for something they shouldn't, I just have to show them that.  I can also catch some errors, like if they say something isn't covered it usually states why and then I can call the doctors office and let them know they made a mistake and need to rebill.

I understand that sometimes we don't have control over things.  My hubby recently had a cavity filled and even though it was sort of in the back, the dentist used the white filling instead of the old silver ones.  Hubby was mad when we got a bill because our benefits only pay for the old type filling and not the new white ones and the dentist didn't give him a choice.  Who's at fault there?  Hard to say I guess but personally I believe the old fillings aren't as healthy for us as the newer ones so I didn't have an issue with the bill.

Ok, I am just rambling now. Sorry.  Not really sure what my point of this post was, I just see the issues of billing from both sides and while my health is more important than money, I also do not have very much money and need to know what my benefits are so I don't get that surprise bill in the mail. Even with my best diligence, I still occasionally get that surprise now and than!  LOL!
Hi Michele, First of all let me clarify, when I was speaking of billing people I was referring to my personal experiences with billing staff in doctors offices.  My experiences with my eye doctors and dentists have always been very good, but i think that is in part because those type of insurance plans are not as complicated as health insurance plans.

 

Look over your post, look at how many times you have had to do leg work to figure out what your plan covered.  You are knowledgeable about billing practices, know about billing codes, seem smart and articulate, but what about the average person, the older person?  What if you are sick and trying to manage your health care, scheduling appts, tests, labwork -- and on top of that you have to decipher insurance coverage.   My bil has a doctorate, and would have headaches figuring out payment of his mother's medical bills as she had 3 different plans with different coverage and reimbursement rates.  I worked in an office w/a legislative consultant, he was handling his mother's bills, and had the entire table covered with paperwork as he was trying to deal with paying her medical expenses.

 

I agree people need to be responsible and understand what their plans cover, but its seems to get more and more complicated, and we are paying more for our health care.  So can't we do better, wouldn't a simpler system be not only more cost effective but free up money to be spent on health care delivery? 

 

There was an interesting program "Sick Around the World"  the countries discussed in the program spend 8-11.6% of their economy on health care (we spend 16%) they cover everyone, we leave out 47 million.  here's a link to a brief description of how these countries health care systems work:

 

 http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/

   

Joie2008-05-12 13:16:09I definitely agree that changes need to be made.  That too much of our health care dollar is spent on bureaucratic BS and not enough on our actual health care.  I don't know how to solve the problem.  My concern is this, I have sarcoidosis-its not a well understood disease nor is it a highly researched disease.  The FDA technically has no medication approved to treat it.  Steroids are the first line, most medically accepted treatment.  I have taken them, took them for over a year, took all the dmards, took enbrel, humira and mtx.  This was all before I even had the correct dx but they are still medications that some sarcoidosis doctors use. 

None of them helped.  I am now using remicade treatments.  Remicade has just recently been found to help some sarcoidosis patients but it is not fda approved for this use and still is not used often for this disease.  They are very expensive and before I found out about the cap I have, which is 00 just on out of pocket expenses for hospital, procedures and blood work (does not include rx's or other copays) I tried calling all sorts of agencies to try and get help for the expensive copay.  But, because remicade is not approved for sarcoidosis, no agency would help me.  What would happen if we went to a national or single payer or social medicine plan.  I am sure I would never be allowed to even try this drug because of the cost and the fact that it is not yet approved for sarc and it will probably be many years before it is.

I am afraid that if our medical needs don't fit nicely into some pre-approved box, that a lot of us will not get the medications or treatments that we need.  Many of you here are sero negative, what if "THEY" decide you have to have a positive rf before they will pay for medications? 

I know my mother has pulled out her hair trying to help my grandma decipher her medical bills, I understand your point very well and agree that changes need to be made.  As I suggested, some hospitals have patient advocates who can help with these matters.  I was talking to a patient at my office about these same sorts of things and she said that she takes her neighbor lady to the senior center and they have someone there that helps old people figure this stuff out.  It certainly isn't easy.  Its not easy for me and as you said, I have knowledge into this. 

I know that our monthly insurance premium is 6 a month, thats just the premium!!  Thats almost as much as my mortgage!!!  Now add in my 00 cap, plus my office visits and medications that do not fall under the cap, overages in dental costs, etc and I really can not afford to be sick!  LOL!!

Yes, I would hope that our country could do better.  My hubby and I work hard but do not make a lot of money.  We are THAT household you hear about on TV that are one financial crisis or illness away from financial ruin.  I have even taken food over to my grandmother so she can still eat and pay for her doctors and medications.  Something definitely needs to change but the changes have to be well thought out.
Don't ask me how, but we keep getting REFUNDS from providers.  When my daughter was going through a lot of procedures, we thought it was because we paid something before insurance had been settled, but now that things have slowed down, I have no idea what the deal is.

Example:  Went to children's hosp. for exam in January.  Paid copay.  No labs, no xrays that day.  Just an office visit.  Last month, we received a .47 refund check from them.  No explanation.  Dated in January.

I guess it cost me more to park that day than to see a physician.
Michele, thanks for taking the time to continue this discussion, its a complex issue that many in their frustration and lack of confidence in reform, want to ignore, but health care costs are growing (double by 2016 if no changes) and its no longer an issue just for the uninsured but also for insured, working people like yourself, that are paying more in insurance premiums, copays and out of pocket expenses.

 

I understand your doubts about what "reform" would entail, but I believe we must move in that direction.  You mention your concern about access to meds not fda approved for your condition.  I don't know much about off-label use (i think thats what its called) but that would have to be addressed in a "new system."  But you mention, cost, which is the key problem.  With our current system, insurance companies, pharmacy benefit managers (mail order pharmacies like Medco, etc.) and drug companies eat into health care dollars to pay their admin costs, marketing, shareholders dividends, ceos salaries.  Some say that 30% of health care monies go for these purposes, not patient care.

 

I'm fortunate in that currently my copay for enbrel is a month.  Amazing, as its 00 a month.  For others, their insurance may have a larger copay or share of cost, while other insurance plans may not cover it all, and of course, those w/no insurance go without.  There has been a trend to group "specialty drugs" like some biologics into a Tier 4 group, which would mean rather than a copay, the cost to patient would be 20 to 30% of the drug cost, or in the case of enbrel, 0 to 0.  So, my point is while I understand your concern of the uncertainty of reform, one thing for certain, is that as health care costs increase,  employers and insurers will push more of the cost of premiums and medical costs onto the individual.

 

Right now, with our current system and for profit insurance companies, if someone loses their job, and has a prexisting condition, and has a break in coverage, they mostly likely would not be able to purchase a health insurance plan.  But if we had universal health care, a plan that would cover everyone, that would not occur.

 

In the program "Sick Around the World" the 5 democratic, capitalistic countries deliver health care to all their citizens for less than the US spends.  If they can do it, why can't we?  We don't have to copy these systems, of the 5 countries, they all are different, so why not have a look at them, see what works, incorporate those things into a new US system.  Interestingly, in these 5 countries, insurance companies are nonprofit and drug prices are negotiated, resulting in keeping health care costs affordable.  No one in these countries goes bankrupt cuz of medical expenses and no one with a preexisting condition is denied insurance.

 

I don't know what the answer is either, but there are many good proposals being discussed, there is also billions of dollars spent in lobbying efforts to protect stakeholders(insurers, drug companies) interests, so we patients/consumers/taxpayers/voters need to get up to speed on this issue and demand health care reform, and not fall victim to the scare tactics and misinformation perpetuated by groups representing the status quo.     

 

     

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