United Health Care just sent me 3 - yes 3 - letters of denial for upcoming spinal surgery. But yesterday they notified me of a new document online: a letter of approval. When I called, it turned out that -- initially -- the surgeon had not given them full information. But really was it necessary to send me the denials until the physician had completed his process with them? It just feels like they do everything they can to keep people from utilizing their benefits....
5
Anthem is a bully. It's part of their business model to deny coverage, knowing that many, if not most people who are seriously ill won't have the energy and focus to fight them with appeals.
Within the last decade, I was denied coverage for some critical care but was lucky in that I lived in a state with a strong insurance commissioner and advocate who wrote letters on my behalf. Plus, as a stubborn writer and researcher, was able to discover cases similar to mine that ultimately won coverage, and on what grounds, using that as a stick to whack Anthem.
While happy that I 'won' my appeal, my heart goes out to all those too sick and too cowed by big business too fight for their survival. It happens all the time. It's obscene.
2
That's Anthem as usual
They tried to avoid pre-authorization for a life saving cardiac procedure just before my employer paid coverage was to expire. The ONE doctor who could override the denial could not be reached, did not respond to voice mails over two days. My physician and I were each disconnected at the end of business hours after waiting on hold for over an hour. Of course I had opted for Cobra and they immediately pre-authorized the procede the day it kicked in.
After the procedure was performed, they then refused to pay, saying they required further information to confirm that the procedure was necessary. I personally managed the delivery of my complete medical records they required from my cardiologist and the hospital where it was performed and had them to them within a week. 10 months later I still had a $270,000 EOB showing it unapproved and they were requesting records from my previous primary care physician! What next? My Vet?
Luckily, I live in a small state and constituent services are easy to get. I emailed both of my US Senators and Congressman. One Senator took the regulatory route. After going through three different state regulators, I discovered that Anthem was only administering "Self Insurance" for my former employer, so there was no regulatory oversight. I would have to go through the company. The other Senator simply did what I expected and wrote them a letter asking why the weren't paying. They couldn't pay fast enough after that arrived.
6
For more than five years Anthem would randomly deny claims for my son’s therapy (speech, occupational, vision). The therapy was supposed to be covered 90% in-network and 70% out of network. Every month I would send them everything they need to process the claim, I outlined it and wrote a note about who was supposed to get paid and put a total reimbursement required. They screwed it up every month, and I would be re-submitting claims that I originally sent in correctly more than five times. Sometimes I would not get paid for months at a time and they would owe me thousands of dollars in reimbursements. It got so bad operators would hang up when they recognized my voice, and once I got a call from what I can only guess to be ‘management’. This person tried to force me to say my problems stemmed from poor customer service, when I said no my problem was that my claims weren’t being processed correctly, they hung up on me. Their claims department have such poor quality control that they are screwing their customers out of a huge amount of money. I believe this is done on purpose. I’ve heard other moms say similar things but they don’t force their insurance companies to file their claims correctly because they’re too tired. I’ve contacted the BBB, my local Congress person, consumer affairs, but nothing has ever happened. Anthem made my life a living hell, something I don’t think I will ever get over. My child is doing great though.
6
I had chest pain while in Canada in October 2017. I went to the emergency room and was admitted. I ended up spending two days in the ICU. The doctor there recommended a heart catheterization, but Anthem declined. So I had two choices: pay for it myself or head home and have it done locally. I chose the second option. I got home and went to the hospital the next morning. They found a 97 percent blockage in an artery. Later that week, I got a letter from Anthem saying it wouldn't pay for one of my two days in the ICU because it "wasn't medically necessary." I'm still fighting with them to pay the bill, and I have no plans to stop fighting until it's paid.
8
I have seen, over the years that often in an E.R. Visit, in certain hospitals, patients who don’t have a potential emergency situation end up clogging the E.R., not only adding to the cost for healthcare but also taking away resources from doctors nurses and E.M.T. However the insurance companies can not expect the patients to determine when their symptoms constitute an emergency .This is the job of the triage nurse. She/he can determine who should go to ER and who should go to urgent care center right next door.The triage visit gets paid at a minimal rate . Non payment for care given tantamounts to fraud and in the long term, increased mortality rates
7
@Lipsych as an ER nurse, we are not allowed by law to send the sore throat, ear ache, sprained ankle, etc to our attached urgent care center. The hospital will be fined for turning the patient away. We have hugh signs outside stating what problems should go to the urgent center, yet many insist on an ER (ED) long wait.
3
"Delay, deny, defend" had been a critical take on insurers' strategies against payment.
"Disinform" should now be prepended.
I don't sympathize with insurers, but I also don't envy their position. In the limit, they can only exit markets and then shut down entirely.
(Previous related comment under a different article:
Permalink: https://nyti.ms/2mzlhlL
)
1
Does the insurance company measure its "more bang for the buck" by the number of people that die because they did not go to the emergency room and thus are no longer covered by Anthem?
7
Pure fraud by Anthem. It’s officers deserve criminal investigation.
10
The Er should just be an admitting mechanism for the hospital. Use "docs in a box" and primary care otherwise. Frequent fliers are an immense cost. Use the placebo effect of announcing unpaid er visits? Sounds like real medicine to a problem, and a way to cut costs.
Private insurance companies hire two types of people. Sales to promote and sell policies and attorneys to defend refused coverage. My daughter had a job and health coverage through that employer. She had an issue, went to the doctor, the insurer refused to cover the procedure. The doctor wrote a letter...no response. An attorney wrote a letter...no response. Essentially they ignored communication, essentially saying, “if you want it, come and get it.”
4
My insurer, CIGNA, announced a similar policy this year, stating that they would apply a 40% deductible for non-life threatening ER visits.
When will someone sue Cigna? Please.. It's a variant of Anthem's cheat sheet, sure to result in more deaths, as policy holders with chest pain opt to stick it out at home, rather than risk paying thousands for an ER visit deductible.
It's egregious. Its greedy. And it should be illegal.
By the way, dont hold your breath waiting on that "really great health insurance" Trump promised. You might pass out and end up at the ER, then get a huge bill from Cigna.
19
Interesting story, and falls directly in line with why Anthem refuses to work with personalized advocacy companies — those hired by employers to represent their employees and their families in making good decisions about their healthcare. These tactics by Anthem are precisely why consumers need a healthcare advocate, because healthcare is littered with complexity and misinformation. Advocates help people understand if ER is the best path, identify these unwarranted denials from their carrier, fight for people and their health, and save them and their employers money — and aggravation — in the process. Anthem does not like advocacy providers and it’s pretty clear why.
2
I'm confused, you're suggesting that the health of the insured patient is more important than the wealth of the stockholder? Roberts court, time to right this wrong.
16
We contact the 24-7 nurse line which Anthem offers when we have something that feels urgent. After the usual Q and A with them they without fail say that a visit to doctor or ER is needed. Conveying this to the doctor often puts us at the front of the list for a quick appointment.
9
Smart cookie!
6
@KV Every time I have called an insurance company nurse advice line, I have been told to go to the ER.
3
Greatest country in the world can’t, or won’t, take care of its sick and dieing.
Laughable.
14
Corporate greed.
10
This is perverse and utterly unsurprising. From personal and professional experience, I can say that persistence — meaning hours spent following up, speaking to managers, submitting extra documentation, and otherwise being a squeaky wheel — pays off more than anything else, aside from flashing one’s own credentials (MD, JD, etc.). The same logic carries through many types of benefits denials, including SS disability.
So what does this mean? People with the privilege of resources, savvy and time fare better than most. And companies get richer and richer off people already exhausted and disadvantaged by a rigged system. This behavior may also lead to more challenges and closures for rural and safety net hospitals that serve places and people with few other options.
I would also point out that Anthem isn’t the only major insurer denying E.R. claims they should have paid. Other insurers, including those in the Medicaid and Medicare managed care business, are quietly doing the same in several states. Healthcare industry folks are definitely watching the legal and financial aspects of this issue closely with an eye towards increasing profits.
19
Does this surprise anyone? My experience with any insurance company in the recent past has included immediate denial until you fight with them, and demonstrate that you’re not going to give up. Go on their website to the “Investors” tab, find the office of the CEO, call the area code plus 555-1212, ask for the executive offices number and call them up.
14
Even if you don’t support Medicare for All, we can all agree that for-profit insurance companies are always going to be much worse. That’s why I disliked Obamacare, because even if you have a good plan, a gold plan, insurance companies deny medical, medication, and just about everything else. Will Medicare for All be a perfect system? No. Will be be a better and more humane system than letting corporate bureaucrats make life and death decisions? Yes. Corporations are private tyrannies with no accountable. At least public policy values democracy, no matter how imperfect. For-profit companies make making by denying as much care as possible. If people die well too bad. Profits before people, the worst of all possible worlds.
12
Imagine being seriously ill or seriously injured and only having to worry about physical recovery and not personal bankruptcy.
Imagine not having to create GoFundMe accounts, or beg for clemency from the hospital, or hire billing specialists, or deal with debt collection agencies.
Imagine not having to worry about losing access to healthcare as a result of losing your job.
Imagine not having to worry that despite good insurance you pay high premiums for, you are still liable for hefty bills because your in-network hospital has an out-of-network ER.
Imagine not have to beg people not to call an ambulance because you can’t afford it, instead taking an Uber ride to the ER, bleeding all over their seats.
That’s what it’s like to live in a country with socialized healthcare.
24
As we all know in our hearts, healthcare should not be a profit making enterprise. It is obscene.
Healthcare is require for the pursuit of happiness and it should be provided to ALL.
18
Kaiser did the exact same thing to me, but not for ER visits. Instead they denied a referral by their own doctor for therapy for my autistic son. The denial didn’t even make grammatical sense and of course it was reversed upon appeal. But I was so angry that they made me go through that whole appeal process, because it took more than a year and most moms don’t have time to file all that paperwork. Now that they were caught trying to deny everyone’s claims, they stopped doing this practice. But it came at the cost of my son’s chance of benefiting from the treatment, which only works within an age group he’s since outgrown. Too late to reverse an appeal for him!
13
@Janet D And they also play the float on your money.
2
Insurance companies (I worked for one ) have a standard practice of denying claims they know they are responsible with the hope to get the insurer to just pay the bill.
They figure if 20% of people don’t question it, then it’s cost effective.
Watch, Republicans next bill will be to pass that the insurance companies no longer need to disclose reasons for ER denials.
I’m sure it will pass through with flying colors. Maybe they can get 20% to pay and 20% to die. What a bonus year that will be to buy more Republicans.
16
Years ago I had a similar experience with United Healthcare. My psychiatrist opted out of the preferred provider system and began charging $180 a visit. UHC continued to reimburse me at 50% of $150. I called a center in Albany and a dismissive agent told me, "We're doing the right thing." I asked for the CEOs name and address, which he refused to give me. So I found it on line and wrote William McGuire about the issue with a CC to Attorney General Eliot Spitzer. 6 weeks later I got a call from someone at UHC. She said she had trouble finding my 'phone number so I told her about Switchboard.com. In the end I received a check for about $2000. How many people get frustrated by this maze and give up? Another profit center for these crooks. Let's not forget that McGuire had to give up 400 million dollars of gains from questionable stock options.
16
The insurance companies have for all practical purposes been given carte blanche. They are concerned with profits, not health. We need to return to the mission of health care. Universal health care is inevitable. Time for the Congress to get it going. #November
11
Sixty percent of Americans with employer-sponsored health insurance are in self-insured plans, meaning that it's the employer NOT the insurance company that has the liability for claims. The insurance company merely administers the benefit on behalf of the employer, who pays all the bills. We have to recognize that excess health care spending is a big drag on the economy and stop simply blaming insurance companies. If your employer didn't have to spend so much on needles ER visits, wages and other benefits might be higher. We're all in this together.
5
@fooddoc
It makes no difference whether the employer self insures (that is, pays into a contingency fund with a reinsurer backup) or pays premiums to an insurance company. The issue is who/when determines if an emergency room visit is necessary. Every doctor's office has limited hours of operation and every doctor's office has an announcement before you reach the receptionist stating "if this is an emergency hang up and call 911 or proceed to the nearest emergency room".
Nobody I know, with reasonable health coverage, would opt for the crowded emergency room to wait for hours among the uninsured to seek care if there were no other option. Yes, healthcare is expensive and we would all like to make more money but if were are all in this together, then let's make healthcare more affordable and more efficient some other way than having to second guess whether to go to the emergency room or not.
12
Insurance companies do have skin in the game. Insurance companies write the criteria for payment, not the companies that hire them.
It is in the best interests of the insurance company to keep healthcare costs down, if they want that contract renewed. And it is all about dollars.
Remember please that we are discussing health care insurance and not medical
care.
6
The worst thing about self-insured plans administered by the insurance companies is that there is none of the oversight or regulation that applies to plans sold by health insurance companies. This makes for even greater incentives for denying coverage because the insurance companies are not liable for denying coverage provided by the employer. If you have an issue, you take it up with HR.
"Corporations are people", isn't that what the Supreme Court said? Looks like insurance companies are not human, never have been.
16
@Jacquie
No. That's not what it said. It said they are "persons" under law, separate legally recognized entities with a host of legal rights and obligations conferred by law. And few peoole, if they really thought about it, would have it any other way.
3
@Wine Country Dude It took a right-wing, activist Supreme Court to hold that corporations have a right to unlimited political contributions and religious rights. Not only that, but corporations are "persons" entitled to a single Federal Income Tax rate of 21%, while real people have a variable tax rate that goes up to 37%? Big corporations benefit more from those tax breaks (along with the loopholes affecting their taxes), so they have even more rights that real people or small corporations. Here's an interesting article that shows how the ridiculous notion that corporations are "persons" within the meaning of the 14th Amendment became the law of the land in another time when big corporations were running the country:
https://www.theatlantic.com/business/archive/2018/03/corporations-people...
2
@Wine Country Dude
Few people, if they really thought about it, would enthusiastically promote the metastacized version of corporate "persons" that you seem to be doing here. Happily, those corporate "persons" you're so comfortable with cannot think, as actual persons can. We should all out-think them back down to the limited size & scope they merit.
When a patient calls a doctor’s office after hours as well as during office hours the first thing they often hear on the answering machine is to hang up and call 911 if they have a medical emergency or what they think is a medical emergency. The patient cannot wait the usual six weeks it takes to make an appointment. The doctor will not drop what they are doing to see the patient who may be having a heart attack or slashed their finger off so the ER is where you go especially if you do as directed and call 911. These visits keep ER’s in business and often result in life saving results . Patients will die and hospitals will loose business with this stance on the part of insurance companies
12
The medical industrial complex is an unspeakably evil institution supported by the US government.
We are not a free country. We are intimidated by medical bills, and college debt.
Ashamed to be an American and have to share space with the Stepford wives and husbands who have yielded like sheep.
As for me, off to Canada where care is not free, it's paid for by all citizens thru taxes which is nearly half what we pay here through premiums.
When victims don't resist they deserve to be victims. Bye bye you all.
Am going to a country where mass shootings are extremely rare and the election of a Trump like figure is inconceivable. Also they don't kidnap Hispanic or any other children, separating them from parents and putting them in cages. In the US the response has been muted. I don't want to live with those people. I hold them in contempt.
24
Georgia’s insurance commissioner Ralph Hudgens is bought and paid for by the Insurance company. He has not fought any insurance company rate increases. Does nothing for consumers. He is so bad his Deputy and who he supported didn’t make it out of the R primary. We need a Blue wave starting in the Insurance commissioner Office in Ga.
10
This does not surprise me. A favorite trick of my former insurer, Blue Cross, was to send out denials claiming that my children were not listed on my policy, and when challenged, claim that it had been a mistake because “their name had been spelled incorrectly”. There are really no depths to which these people will not sink.
23
@Global Charm
A good way to think of them, is, "Lower than whale dung", which is quite low !!!
7
Organized harassment by insurance companies are not a new thing. I had gone through this when a carrier would reject our submittals by separating the claim from the doctor's Bill and the mailing both pieces of documentation in separate envelopes with a statement in the returned documentation that said "we cannot process your claim because the Bill and/ or claim was not attached. The returned paperwork had the staple holes from being attached to each other. It was not until we filed a complaint with the state insurance agency did this nonsense stop, and the claims paid.
18
Years ago, I was an Insurance agent, selling whole-life policies, term life, auto and home, commercial lines, and of course the thing we here in America call Healthcare Insurance, the greatest misnomer ever used, an evil product that is designed to collect outrageous premiums, have unreasonable deductibles, and whose order of the day, is "Deny, deny again, deny a third time, and if an oversight agency gets involved, try to prove the denial ploy, and pay up only if all else fails.
See here's the thing; I care not one iota whether some insureds tout their good experiences, because having been on the inside, the good experiences are funded by the vastness of the pool of premiums from insureds with covered losses, who accept the illegal denials, presuming its accurate, because after all, "Its Unum, its Allstate, its Hartford, its Narragansett, its State Farm, et al., (research a PBS report on these charlatans, and then cancel all policies with them), and surely these guys are trustworthy !!!
Insurance coverage in America, especially Healthcare Insurance, is a Gordian knot, made so and kept so, and, as in mythology there is only one way to solve this problem, which is to cut deeply, to the quick, releasing all for a new beginning.
Insurance corporations exist to legally steal money from the masses, and for the most part, they do it with aplomb and unequaled confidence.
I like that word, "Confidence", as in "Confidence Game"
Remember that next time you shop for Insurance.
32
This doesn't affect me at all as a patient. I have Medicare and an inexpensive supplement.
But this organized crime establishment you so accurately describe does fill me with despair, having practiced medicine for 40 years. It's like watching metastatic lung cancer slowly destroying human life. The medical industrial complex is destroying medical care. That institution is a societal pathogen yet physicians comply in silence.
Burnout and early retirement are the only responses of which I am aware.
We are the only Western country where such an outrage is accepted and in force.
Canada.
19
I thank GOD every day that I work for a municipal government in PA that has binding arbitration with our police department. You’ll never see the GOP go after the First Responders. Even Wisc was not that stupid! Wonder why? First Responder’s seem to vote GOP in large numbers. Same for going after First Responder pensions - don’t hold your breath!
5
@Kevin Bitz
Yeah, and teacher's be damned!
1
Anthem's business model: Collect Premiums, then Delay. Defer. Deny!
11
It does not matter who pays. An unnecessary visit to the ER is expensive. And with single payer and no skin In the game this will be worse.
Medicaid pays far too little for any doctor to accept unless they are salaried by a big organization. The same people screaming for us to accept Medicaid are the ones who want more immigrants who can’t afford to be here allowed in, the same people who excuse drug abuse as a disease etc. they leave no money for the truly unfortunate who need our help.
You can’t have everything particularly when you want someone else to pay for it.
12
@NY Surgeon - I have heard many doctors who work in the ER say they are very happy to send a patient home alive and well rather than have that patient delay or not go to ER and end up dead or with a serious issue that may not have been so bad if the patient had been treated in a timely manner.
5
@Surfer
Absolutely agree. But single payer does not fix the problem of overuse. It makes it worse.
Yes, we need to identify those unnecessary visits before they occur, Which is hard to do without results of physical examination and laboratory testing done during those visits. If you can distinguish the one case of sepsis from the 250 cases of bad flu over the phone, you must be a pretty good doctor.
16
Single-payer health insurance programs in other nations such as Canada, Taiwan, and Australia show that it’s possible to provide high-quality care for everyone at about half the cost, per capita, that the U.S. is spending now. Medical outcomes in such systems are generally as good if not better than those with private-profit insurance in the U.S., and everyone is covered.
Our traditional Medicare program, which provides coverage for our nation’s seniors and the severely disabled, operates with low overhead, about 2 percent, in comparison with private insurers’ average overhead of about 12-14 percent. And Medicare enjoys very strong public approval ratings. A single-payer national health insurance program covering everyone, cradle to grave, Medicare for All, is the solution.
It’s hard to imagine any greater disconnect between public good and private profit/enterprise: the interest of private health insurance companies lies not in the obvious social good of delivering quality health care to patients but in having as few as possible treated as cheaply as possible. No better example exists of a private business enterprise that feeds on the misery of man.
Even minimal fact-checking will show that the real enemies of single payer, Medicare for All, aren’t disgruntled patients or doctors. Opposition by profiteering Big insurance and BigPharma firms is the real problem we need to overcome if we are ever to establish universal healthcare insurance.
26
Corporations rule America. If you want change emigrate. Even Obama did not fight for the public option.
4
The majority of commenters here are woefully uneducated about healthcare financing and the actual cost of doing business. The goal is to keep expensive ER visits to a minimum, as ER costs are significantly higher than a primary care visit. It ER visits were to go unchecked, health insurance premiums would skyrocket even further, thereby giving the unknowing and the politicians another reason to stoke the fire.
And if you think healthcare for all, financed by increased federal income tax on all (Single Payer) is the answer, you need to take a deeper dive. The ability to seek medical care from any provider, for any perceived ailment, at any time, will no more happen under single payer than it does under private insurance. Cost controls and rationed care will be a part of any healthcare financing plan that has financial sustainability as a goal.
7
@Joe
You are spot on in pointing out the issue of the cost of medical care. I agree that the notion of unlimited services is not affordable by society.
However, it is still the case that insurance companies view paying a claim as a "loss".
This article illustrates the need for emergent critical care availability.
14
I work in healthcare, and the biggest problem with the costs of healthcare, is directly related to insurance companies. Furthermore, insurance companies aren’t in a position to decide what’s emergent and what isn’t, it’s like pain. Pain like art, is subjective, what’s painful to you, may not be to me, conversely, what’s emergent to me, may not be to you. Healthcare is NOT a business, it cannot be structured like a business, since there are too many variables, for example, the cost of medical equipment isn’t the same from one manufacturer to another, prices aren’t stable in other words. You have drugs that are overly expensive, you can have a heart attack and be transported to a hospital and be charged 200k, while the hospital 3 miles away is 100k. Everyone wants a piece of this grossly expensive product, from pharmaceutical manufacturers, to medical equipment suppliers, to the insurance companies that can arbitrarily rIse rates while posting billions in profit.
While a single payer isn’t the total answer, if you look at countries that have it, their costs are controlled because the governments leverage their buying power. The US is the only country left where pharmaceutical companies can charge $1,000 dollars per pill for Harvoni the Hepatitis C cure. In Europe for example, that drug is about $10.00, and contrary to the “fake” assertion that people are dying on the streets in Europe, simply isn’t true, that happens only in America.
43
I am a paralegal at an insurance company and my sole function is to review Medicaid disputes and requests for hearings. Disputing a denied claim can be easy to do. Write a letter, include the facts and any documents, and what state laws or policies support your dispute. Plan policies are on the company's web site (don't be afraid to click on the "provider" tab even if you are a member) and laws can be found with a google search. The policy and laws that support the denial have to be in the denial letter.
If the dispute is denied then file a complaint with the state insurance commission for commercial insurance or request a state fair hearing for Medicaid. FIGHT FIGHT FIGHT!!!
26
It’s too bad people that are sick have to fight, fight, fight, to keep from being run into bankruptcy or from having to decide how long they will have to eat Top Ramen or Mac and cheese, because of the huge bills they will be receiving. Let’s not forget the out of network loop hole as well. You can be in an in network hospital, but the dr that your seeing my be out of network, because he/she isn’t an employee of the hospital. More Drs are going that route because the can charge more for their services. But, they aren’t required to inform the patient of that minor fact, the patient finds out only after getting a much larger bill than they anticipated.
At some point we’re all going to need a Dr, or an ER, at some point we’re all going to be a senior citizen. Healthcare is a real threat to this countries overall productivity. If you have a large swath of your citizens that don’t have access to healthcare, at some point when the have to go to the ER, it will cost much, much more. Take Hepatitis C, insurance companies make Drs jump through hoops, liver scans, blood work, mounds of paperwork, then deny the claim, to avoid the $80,000 plus Harvoni costs.Instead insurance companies are willing to potentially absorb hundreds of thousands of dollars MORE in costs, because the only course of treatment would be a liver transplant, those cost $500,000 plus dollars, not to mention the high cost of the anti rejection drugs the patient will have to take the rest of their lives.
10
Report these insurance companies to your state Insurance Commissioner’s office.
UNUM tried this on me on long-term care insurance. The Insurance Commissioner went after them.
Don’t let them get by with this behavior..!
21
Another chink in the conservative "Corporations are beautiful" fantasy.
This is nothing more than phishing by a multi-billion dollar corporation.
Whatever the real reason this ugliness began, the result is that Anthem has learned that they save big time by just sending the notice they will not pay for ER visits if they don't feel like it.
No standards, no decision making tools, just the bald threat.
To increase the likelihood of profit, they cave as soon as challenged. Cuts down on book-keeping, evidence gathering, legal proceedings.
Expect to see more of this.
And now, Dear One, God has blessed me with this precious times in your gaze, and I want to share with you the great good luck I have experienced recently.
You see, I have received in the mail a communications from The American Currency Launderette in Washington, your capital city, DC. announcing an awards of money to me.
I am but a poor one in Europe and cannot travel but if you, my beloved, send them $250, they will release this funds and when I receive it I will be blessed to reimburse you tenfold for you kindness.
I cannot go to the post, but if you will send me your card number, I will prayerfully repay this wonderful gift love and charity. All my hopes resides in you and the goodness of your beloved heart...
7
Uhmm what?
A money laundering place wants to give you money?
I can give you my CC and you will use only $250 but you will give me $2500?
Oh yesssss! What a good deal!
3
What’s your point
1
Nice. Real nice.
1
Our politicians sold out their oversight of the dysfunctional, corrupt, money-sucking insurance (and pharmaceutical and hospital) industries a long time ago, making it extremely difficult for patients, physicians, and other providers, its a huge mess ...
11
They didn’t sell it out, instead they own stock in there companies that they are writing bills for or voting on action that comes to the senate floor. They benefit from being an elected official, look at Tom Price.....perfect example.
8
@James ... "sold out their oversight" ... their supposed mission ...
Single payer
46
We Americans are big talkers about values, but it's insurance company CEOs, supervisors, and workers knowingly cheating their customers by stiffing patients. On purpose. Willingly. Callously. Cynically. What exactly are those values again?
31
Universal health care (Medicare for all) is the only long-term resolution to these kind of shenanigans.
79
It will need to be paid for, in countries that have universal coverage pay a high tax rate. However, the government should have an opt out box, you check the box you aren’t taxed. The downside is, when those who have opted out need a Dr, (and they will) the short answer will be, no government insurance card, no healthcare, simple. That would shut the mouths of those GOPers, that are against any taxation, but line up for unemployment benefits, welfare, food stamps, since white in poor red states get more of per capita. But that’s another story for another day.
5
Thank goodness for original Medicare, as long as it remains with us. I can go to any doctor, any hospital and they must pay. With middle of the night asthma attacks, this is a relief.
Everyone, though, should have such coverage. We would cut emergency room visits if people could see a doctor before they have an emergency.
42
@Barbara
"We would cut emergency room visits if people could see a doctor before they have an emergency."
Many times the patient did have an appointment at the doctor's office but didn't keep the appointment. This is an especially common practice with people on Medicaid who don't show for multiple appointments. My nieces and wife work for medical practices and say that after three missed appointments the patient is dropped and can no longer go there. Each miss is lost revenue because that time could have been scheduled for someone else.
Having missed the appointment(s) the problem then becomes severe and a trip to the ER is in order.
2
@NYHUGUENOT "Each miss is lost revenue because that time could have been scheduled for someone else."
We need more walk-in clinics that will accept the patients you describe who, for whatever reason, cannot or do not keep appointments. I would put these clinics adjacent to emergency rooms (to divert the non-emergencies and thus lower costs and free up ERs for real emergencies) as well as in areas where drug use or poverty is rampant. This could be done if health care was recognized as a service we chose to provide for all Americans, funded it through our tax dollars, and removed insurance companies from the equation as they add cost but not value to our health care system.
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@NYHUGUENOT A little bit of whataboutism, I'm afraid.
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Insurers have been doing this for years. At least two times, both more than 10 years ago, I had claims denied because someone was out of network. I think an anesthesiologist once and an ER doc another time. Both times I appealed and had my employer's ombudsman contact the insurer. Both times I received a notice from the insurer that my appeal had been denied and then I received notification from the provider that the bill had been paid.
The galling thing is that if I had really been in a health crisis I'm not sure I would have had the ability or energy to do the work to get my bill paid.
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@Paul The denial letters was most likely a mistake in the case of the ER physician and reconsidered in the case of the anesthesiologist. Health insurers almost universally cover out of network ER doctors since the nature of a true emergency would cause you to seek medical attention at the nearest facility. Anesthesiology and other surgery related services are often performed by providers who are not necessarily enrolled in the patients network. Since the patient rarely knows in advance who will perform these ancillary services, the insurer will often cover the service. Unfortunately, they will usually only do so if the patient appeals. Yet another reason that we need a national health care program that does not require the patient to check the credentials of every service provider or suffer the consequences. Universal healthcare for all!
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I manage Anesthesia billing, and this absolutely correct. insurance carriers hope that their bogus denials are ignored so they don’t have to pay claims that they are otherwise legally obligated to pay. Just Another underhanded thing the wealthy do in attempting to make higher profits at the expense of the American people.
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Kaiser Permanente provides urgent care services right next to their ER—-unfortunately not 24 hrs per day. The sane answer to the problem of misuse of the ER: a triage advanced nurse practitioner at the entry point of the ER who assesses patients using a universal protocol and refers to ER, urgent care or behavioral health care. If all services are under one roof, urgent care can access higher level intervention easily. A common medical record system and a sharing of basic protocols for the most common emergencies, chronic illnesses and infectious diseases could create “universal” health care without developing yet another wing of the federal bureaucracy.
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@Elizabeth Urgent care?? Lol! I asked if any of the urgent care ffices around South Lake Tahoe, CA took Medicaid (Medi-Cal). They all said no. In addition, when I was in the Bay Area, the urgent care offices would not see me without an appointment and did not have the necessary x-ray machines. They are only open until 7 PM on weekdays. Urgent care is nothing but glorified family practice. Also, since you're not from California, how do you know about Kaiser Permanente?
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@SJW, you do know that Kaiser Permanente insures outside of California? I moved to Colorado from California 15 years ago and Kaiser is available here, as well as other areas (Hawaii, Oregon, Washington, Georgia, Washington, DC, Maryland, and Virginia).
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There are just 4 words which account for almost every issue, failure, fear and cost in regards to healthcare in America:
For profit health insurance.
Or, if you are a minimalist, just 2 words:
For profit.
Either/or, most Americans will never profit from a system that relies on it.
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So in other words, by making people afraid to go to the ER because of Anthem's threats not to pay, a certain number will inevitably die, saving Anthem $$$...
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@MS
I don't buy that, at least with the uncritical alacrity of those (57) who have upvoted you so far. If people die, they won't be paying premiums, which everyone contends are sky high and never result in material claims actually paid.
Same with automobile insurance.
Late wife's car gets sideswiped by another driver. His insurance company responds to our claim by saying something like "we carefully examined all the facts related to this accident and determined that our insured bears no responsibility" (seemed like a form they routinely send out).
I go to small claims court.
Next thing I know we get a phone call from that insurance company, ready to pay the full damage.
For each person who, upon receiving that letter, would simply give up trying to pursue a claim the insurance company gets to keep the money that would rightly belong to the aggrieved individual.
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Single payer national health care. Let's join the civilized world on this most important of issues.
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Here’s an idea for some entrepreneur. Set up urgent care centers (aka Doc-in-the-Box) across the street from emergency rooms. I’d bet every insurer would immediately qualify them as in-network and these centers could put up giant signs reading: “We’re in Your Network. Are They?”, with a big arrow pointed across the street. For both ethical and liability reasons docs in these centers would refer complex and critical cases over to the ER. Doesn’t solve the problems of the uninsured or many Medicaid patients, but certainly lowers the overall cost of healthcare.
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Oh my sweet summer child- and what person is going to set up these clinics, out of the goodness of their hearts, when they could set up a facility that in every way looks like an urgent care clinic, but calls itself an ER? That is what is going up in droves across the country, often across the street from the real ER, with signs advertising zero wait. And these minimally staffed clinics bill just as much as the real ER, which is required to have at least some specialists available, and the ability to admit you if needed (services which somewhat justify the higher cost.) And guess where the doc in a box ER will send you if you are having a real emergency?
A for profit health care system means that everyone is going to try to maximize their profits. If all you care about is your bottom line, why open a clinic that would save payers (and thus consumers, whose premium price is a direct reflection of what the insurer pays out) money?
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Single Payer and this wouldn't even be a problem.
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@Still Waiting for a NBA Title
from a retired health care attorney:
Single payer doesn't mean there won't be coverage and claims denials. Any time there is any choice for consumers, there will be consequences for choosing the cheapest premium or co-pay or network. That is precisely why there is a thriving private insurance market in the Canada and the UK and Germany--for those unwilling to accept the shared-by-all limits and able to pay for better insurance.
There is the American College of Emergency Physicians. This is a professional organizations. Along with the American College of Physicians, the American College of Surgeons and other similar groups are called "trade group(s)" in this otherwise well researched and written article. The lack of primary care physicians is a significant contributor to the use of Emergency Departments for non-emergency conditions. EMTALA requires care to anyone presenting to an ED. The insurers wearing their retrospectographic goggles penalize the patients and the ED's by denying claims.
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If the insurers don't take underwriting (population) risk - and most have found ways around it - how exactly are they adding value?
Insurers have seen the future - and their diminished role in it.
8
Insurance companies continue to focus on the wrong things. All of this activity (high deductibles, high out of pock maximums, etc.) are all designed to shift the insurance risk from the insurer to the patient.
The problem is that this has little if anything to do with the cost of health care. The largest single variable that drives US health costs is price! We pay so much more than the OECD countries it is just nuts. We pay specialists 3-4 times what they get in Europe.
But insurers do nothing about that problem do they? Why? Because it is hard to get into battles with monopoly health systems or just plain lack of interest. Look at this beauty:
https://www.rand.org/pubs/research_reports/RR2106.html
Why would any insurer pay 3 to 4 times Medicare like this insurer (probably Anthem) pays in Indiana. Crazy!
We need a price controls system for health care in the US as a minimum and a single payer system.
What is worse, all of this spending has led to worse not better health outcomes.
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I was insured by Anthem for several years. I found it to be one of the most evil of companies I've ever been involved with. They would do just about anything to deny payment. I'm covered by Kaiser now, and it's been a relatively stress-free experience so far. Of course, the answer is not to "fix" insurance companies, but to "fix" the system by taking the insurance companies out of it.
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@PR Vanneman, Insurance companies are in the business of not paying claims.
I'm sure Anthem is counting on people not to make complaints. There are probably quite a few who wouldn't think of questioning their authority or who don't have the wherewithal to lodge a complaint.
No doubt many companies and different types of businesses get away with alot by relying on people to let the transgressions pass unchallenged.
28
In 2004 I ruptured a lumbar disc, requiring an ambulance to a local ER and emergency neurosurgery.
Blue Cross denied coverage despite the terms of my PPO policy. I fought and, eventually, they complied.
I wondered how many patients, especially after serious illness, have the energy or belief necessary to challenge a wrongful denial of coverage?
As a sinister policy, it seems many insurers- from health to homeowners- start my stiffing beneficiaries. They count on a small percentage having the capacity to challenge them. They save money so it is a clever obstacle course they create.
This is beyond cynical. For profit health insurance creates bad incentives.
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@Sara
from a retired health care attorney:
Did you know that the least expensive health plans, Medicare Advantage and all PreferredProviderOrganizations/PPO, keep you captive inside their network under unambiguous contract terms? Until we get universal health insurance AND delete the Medicare Advantage (PPO) option for any person who travels more than 9 miles from home, horror stories that result from insurers' enforcing their coverage limits will continue.
Health insurance is a contract. Just like a mortgage or car loan or student debt. It pays to pay attention to what we are enrolling in every year or job change.
3
Anthem simply has decided that most people aren't likely to appeal a decision on an E.R. bill. Once customers see information like this, maybe they'll begin appealing decisions. What will Anthem do then?
51
Ok gang, let go over it again, something that the rest of our peer countries know and many other countries of the civilized and not so civilized world also know.
Establish a national, affordable, quality health care system in this country.
We can choose from many models from Canada to Europe, to Australia, Japan etc.
Let's get out of the Middle Ages with health insurance.
160
from a retired health insurance attorney:
Bottom line with all businesses is (1) top management will enforce the written contract with customers until (2) there is a risk of really bad PR that could be seen by customers or potential customers. I've very nicely by phone told a top manager at all of this country's giant health insurers that I would report in an OpEd the results of my appeal of claims denied. Be nice. Be clear and follow through. I've never had my appeals denied.
That said, I also explain to those who choose to buy the cheapest health plans--think Medicare Advantage--that I won't help them again with claims denied per their contract terms. I choose and pay for AARP/UHC Plan F for Part B supplemental to make sure I can travel and have access to the physicians and hospitals I choose. Never a hassle with out-of-network claims.
I won't make it easy for those who have the means to buy the coverage that I do and choose a "stupid" cheap option instead. I save my gambling for horse races -- not health insurance.
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excellent advice. ALWAYS appeal.
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