How does a mere mortal navigate healthcare/insurance issues

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marcopolo
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How does a mere mortal navigate healthcare/insurance issues

Post by marcopolo » Wed May 31, 2017 9:12 pm

I know there are a lot of people in the medical field on this board, and maybe some insurance experts as well. Would love to hear their thoughts.

Turned 50 recently. Doctor recommended i have Colonoscopy done, and suggests a few doctors and facilities.
So, I go to insurance (CIGNA) web site and check for in-network GI doc and Endoscopy facility. The web site has a nice tool that lists in-network doctors and the facilities that they operate out of and gives estimated cost with nice detailed cost breakdown. I schedule at one of these facilities and get the procedure done. Everything goes well.

Then the bills start showing up. The GI doc bill is actually lower than estimated. The facility charge is about as expected. Then i get the Anesthesiologist's bill, and it is about 10x the estimated amount, and about 20x what the insurance says they will pay because she is out of network!

I never was given an opportunity to select the Anesthesiologist that was going to work on me. No one mentioned that she was out of my network, and would cost me several thousand dollars, when the rest of the procedure was less that a few hundred.

I consider myself reasonably diligent about navigating issues like this, and i thought i had done my homework. What else could i (or others in similar situation) have done to avoid this scenario?

A procedure costs what it does. Surely, the insurance negotiated rate must be profitable. I can understand there being a somewhat higher rate for non-negotiated service, but how is a 10x-20x increase in charges justified? Since the patient in many cases has no choice in the matter, and only finds out after the fact, why not 100x, or 1000x ? It just feels like gouging.

In the scheme of things it is not a lot of money, and I will pay the bill and consider it a lesson learned. But, I am sure this happens quite often to people for whom, this would be heavy, and quite unexpected, and unnecessary burden.
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Phineas J. Whoopee
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by Phineas J. Whoopee » Wed May 31, 2017 9:24 pm

Here was my approach for that, ahem, procedure:

Ask. Ask. Ask. If it's not emergency medicine, ask ask ask. I made it clear one of my chief concerns was that everything and everybody was in network.

I still could have been billed, and maybe I still will be, but at least I made a special point of asking everybody I came into contact with.

Beyond that, I don't know. At least one state, NY, has legislation that if you're not able to ask and choose, like you're sedated and a consultant is called in, it's up to the providers and the insurer to work it out between themselves. The patient isn't involved. I don't know of any other state to do that, though.

And it wasn't my situation anyway.

All I know of to do is ask and make my concern clear from the beginning through the middle to the end. Individual health care professionals probably don't even know what networks they're in, but I expressed my concerns to them, their support staff, and the office staff.

It was irritating. Good luck with your situation.

PJW

ragnathor
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by ragnathor » Wed May 31, 2017 10:57 pm

This is unfortunately a product of our overly complicated medical system. As an anesthesiologist, this is not all that uncommonly​heard of and I don't know a great solution. I'd recommend calling the anesthesia billing department and negotiating. The listed price is overly exaggerated and insurance/Medicare/Medicaid pay only a fraction. Sometimes waiting to pay can increase willingness to negotiate.

I'm not sure what else you could have done besides ask beforehand as the above poster mentioned. Going to facilities that are integrated (large hospital networks, university systems) can lessen these surprise out-of-network charges but they can certainly occur even in these cases.

InMyDreams
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by InMyDreams » Wed May 31, 2017 11:01 pm

In my network, all providers are required to accept as in-network what the hospital accepts as in-network.

Hmm, aren't colonoscopies part of routine screenings, covered under ACA?

Ask CIGNA how you are supposed to know.

Yes, since you're not working under my kind of system, Ask, Ask, and Ask again. And when you schedule a procedure, state that you need to have providers that accept your insurance

OnTrack2020
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by OnTrack2020 » Thu Jun 01, 2017 6:08 am

We've had this situation occur on numerous occasions where one of our children has had several surgeries wherein "one part" of the surgery is considered out-of-network.

The two options that we've had are: (1) appeal the bill asking the insurance company to pay in-network rates. The vast majority of the time this has worked; or (2) call the medical/billing office and ask them what their policy is regarding this matter. Sometimes, depending on their policy, they will discount the bill down to the in-network rate. We've had this happen also.

We have been in medical offices where if something, such as orthotics, is not covered by our insurance, the office has discounted around 70% of the bill.

I would start by calling the anesthesiologist's office first and see if they can help you.

marcopolo
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by marcopolo » Thu Jun 01, 2017 7:21 am

Thanks all. Appreciate the helpful replies. I will try calling both the insurance company and the Anesthesiologist's office to see if i can work out a compromise.

The whole system seem overly complicated. Makes the financial services industry with its AUM, 12b-1, Expense Ratios, and other fees, seem downright transparent by comparison.
Once in a while you get shown the light, in the strangest of places if you look at it right.

tech_arch
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by tech_arch » Thu Jun 01, 2017 7:26 am

This happened to me at my last colonoscopy. There's one facility in town that all of the local GI docs use, and it was in-network. My insurance made the anesthesiologist's accept the in-network rate since they were working at an in-network facility. Talk to your insurance company; I think it's reasonable to expect all practitioners at an in-network facility to also be in-network and treated as such.

SQRT
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by SQRT » Thu Jun 01, 2017 7:47 am

Canadians also have some issues with navigating our health care system, but they really look minor compared to the US. Must be awful?

cas
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by cas » Thu Jun 01, 2017 10:40 am

marcopolo wrote: Turned 50 recently. Doctor recommended i have Colonoscopy done ... I ... get the procedure done. Everything goes well.

Then the bills start showing up. ... Anesthesiologist [bill was] several thousand dollars, when the rest of the procedure was less that a few hundred.
This isn't what you asked about, but ... by the way ... just to be sure something else financially odd isn't going on here, since it sounds like you may have gotten bills of a few hundred $ even for the in-network portion. (Obviously the details of your procedure are none of our business, so this is just for your information ... no need to say any more details.)

In the case of the in-network stuff (I'm really not sure about the out-of-network stuff ... google would know), you shouldn't be getting any bills at all for a purely screening colonoscopy. A purely screening colonoscopy at age 50 is 100% covered pre-deductible under the ACA. I'm just a mere mortal (should I have to be an expert?) on the "purely screening" bit, but my understanding is that it should be considered "purely screening" if
[*]the only reason your doctor referred you for the colonoscopy was because you turned 50. (And not because you or the doctor had noticed some sort of warning sign or symptom.)
[*]As you said "everything went well," and the screening turned up nothing abnormal
[*]You never, at any point to any medical-system person, implied that you were having any sort of abnormal symptom, but repeatedly confirmed that the only reason you were there was because you had reached the magic age of 50 where a screening colonoscopy was recommended.

When I went in for my age-50 screening colonoscopy a couple of years ago, the check-in person got to the end of check in and then unexpected asked me to write a pre-procedure check (a couple of thousand $, if I recall). I got very confused and stuttered out "but a screening colonoscopy is covered under the ACA, so I shouldn't owe anything out of pocket." And the check-in person said "but if they find something during the procedure, then it wouldn't be a screening colonoscopy any more." And I stuttered out something about "the only reason I'm here is because I turned age 50. I don't understand why I'm being asked to pay ahead of time for a situation that the probabilities say won't happen." She called someone else (supervisor?) and then said "OK, we can waive having you pay before the procedure is done."

The screening came back clear, and I never did receive a bill from anyone (and could see on my insurance EOB that the insurance had paid and assigned $0 as my responsibility for all the various charges.) But the whole situation about me having to be informed enough to argue that I shouldn't be pre-billed seemed very odd. (I'll guess that from the hospital's point of view, they were having problems with people not paying bills when polyps were found or something, so they wanted their money up front, but... it just seemed odd.)

Jack FFR1846
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by Jack FFR1846 » Thu Jun 01, 2017 11:05 am

It's hopeless.

Things I've run into: Doctor is not in network and has been trying to join in network for 3 years. Network tells me that they have enough of that specialty so are not accepting new doctors. We go to network list and in calling around find several interesting things. Doctors who are retired and no longer practicing, practices no longer accepting patients and one in network facility who won't accept this network's patients because the network doesn't pay it's bills.

We put in a prescription that's not new. The drug insurer had fired the distributer (during plan year) with no new provider on board. 30 hours of phone time, with every phone call starting out not being able to find us dispite having our member number, ss number, date of birth and their reference number on the case. I do see them now pushing a big tv ad campaign, however.
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straws46
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by straws46 » Thu Jun 01, 2017 11:20 am

[quote="ragnathor"] As an anesthesiologist, this is not all that uncommonly​heard of and I don't know a great solution. The listed price is overly exaggerated and insurance/Medicare/Medicaid pay only a fraction.

I would be happy to pay a fair and reasonable price, but when uninsured patients get billed more than ten times what the provider has agreed to accept from insurers, something is terribly wrong. Never pay without negotiating.

Alan S.
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by Alan S. » Thu Jun 01, 2017 11:24 am

I certainly would not pay such a bill unless all appeal processes were exhausted. Unless you received a specific warning before the procedure that some action was required in your case to eliminate this exposure, I would take the position that the medical industry collectively did not provide due diligence in determining the network status of the anesthetist selected for the procedure. Once you pay the bill, your negotiation leverage is all but gone.

Providers are well aware of this problem and it involves anesthesia in a vast majority of cases. Since the coordination to prevent this activity within the healthcare industry has been sorely lacking, some states including Arizona are passing legislation to eliminate this practice, or in the case of Arizona limiting the additional cost to 1,000.

As long as patients continue to pay these bills, they will keep coming, at least until states compile the rage into limiting legislation.

Perhaps the anesthesiologist who posted earlier could enlighten us why this problem continues to surface and why it cannot be resolved. It's one thing when a patient makes a mistake and quite another when the patient had no reasonable chance to prevent this excess billing.

ragnathor
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by ragnathor » Fri Jun 02, 2017 5:35 am

Alan S. wrote: Perhaps the anesthesiologist who posted earlier could enlighten us why this problem continues to surface and why it cannot be resolved. It's one thing when a patient makes a mistake and quite another when the patient had no reasonable chance to prevent this excess billing.
I am a fresh graduate and will not claim to know the ins and outs of anesthesiology billing, but I'll post my thoughts.

All out-of-network prices are outrageously expensive, whether it is the anesthesiologist, surgeon, GI, etc. Anesthesiology groups have insurance contracts completely separate from the surgery group, the hospital, or the GI specialist. When a GI group contracts with an anesthesiology group, ideally the insurance contracts overlap exactly, but I am sure in many cases there are differences. And of course contracts can change over time. Neither the anesthesiology group, GI suite, or the insurance company make it easy for the consumer to determine.

After talking to a colleague, I would change my previous advice to speaking to your insurance company directly first. Tell them you went to an in-network facility and did not have a choice in anesthesiologist. They may (should?) pay the in-network price to the anesthesiology group. If they do no accept ask the insurance to pay you directly and then you can potentially negotiate.

Now as to why does this keep happening? There is no incentive to stop it. Let's say the given price for an out-of-network anesthetic is $1,000. Blue Cross pays $500, and Medicare pays $200 (made up numbers but ratios may be in the correct ballpark). Even if 1/3 of those charged the out-of-network price pay the full bill and the others pay a fraction, it is still highly profitable.

If you are in an integrated network/university hospital system, you can generally avoid this problem as everyone will be under one network. Besides that, the only way I see the problem being completely eliminated is through legislation or a single payer (i.e. government) system.

EnjoyIt
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by EnjoyIt » Fri Jun 02, 2017 5:52 am

To answer your question, call and negotiate. I know you can bring the price down to an in-network reimbursement. Personally I would not pay a penny more than that.

The reason why this practice occurs is because people want to make more money. Many insurance companies will pay out of network providers more than the negotiated price and therefor there is a huge incentive to stay out of network. I know quite a few practices that take advantage of this and purposefully stay out of network. The general practice is to not aggressively collect the remaining balance from the patient (balance bill.) They accept what the insurance company offers, what you are willing to pay, and waive the rest. As a member of the medical community I am embarrassed at how convoluted the process is. Good luck negotiating what you owe.

bluebolt
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by bluebolt » Fri Jun 02, 2017 7:16 am

I honestly don't know how people deal with the system. I consider myself an informed medical consumer. I just went through an 18 month battle with my health insurance company over money they owed me. I must have spent 40 hours on the phone with them over that time. They know that most people will just give up. It's disgraceful.

fsrph
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by fsrph » Fri Jun 02, 2017 8:18 am

This issue of being directly billed for non network providers (that you had no choice in selecting) in an in network facility is a problem that needs to be addressed. This practice is unfair to consumers. This thread deals with anesthesiologists but also routinely occurs with er physicians and those in radiology and pathology. When a facility enters into a contract with a group representing these specialties there is no incentive to be in network because they know they will be the sole provider of these services. The hospital or clinic bears some of the blame because they signed the contract granting exclusive use of one group.

Neither of these possible solutions are easy to implement but would help.

1. Legislation that would require in network facilities to use ALL in network providers.

2. Hospitals go back to hiring their own specialists (anesthesiology, er, pathology, radiology) and require them to be in network. Do not deal with a group that wants to be the sole provider to a facility.

3. Supply and demand. Open up more residency training slots for these specialties. Increase the supply and you'll find those willing to accept in network rates.

Francis
"Success is getting what you want. Happiness is wanting what you get." | Dale Carnegie

cranzel
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by cranzel » Fri Jun 02, 2017 9:01 am

A while back I ran into a situation with a bill from a physical therapist and the amount of visits "per injury" (if I recall correctly) available through my wife's work insurance for work done prior to a surgery and then needing PT after surgery. While not the same thing, the calls we made to her employer's HR department to talk with the benefits consultant was well worth it. In addition to speaking/negotiating with your insurance company, they may be able to help. Especially if the insurance pool is large (they see more issues and may have a go to plan to deal with them.)

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mrc
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by mrc » Fri Jun 02, 2017 9:32 am

A colonoscopy is a great example of an ACA-mandated screening procedure that for most people results in zero out of pocket, and one that tends to span multiple groups (GI, facility, and anesthesia). And it's elective and scheduled so there is time to ask ask ask. Ask who? The offices generally do not know whether they are in network, and do not know what you'll be billed. That's problem number one, covered above for the most part.

Here is problem #2: Some insurance plans (e.g., BCBS Standard) ding you hard for going out of network, they pay less but they pay their "allowance amounts." Other plans (e.g., BCBS Basic) does not pay any benefit for out of network: You are responsible for all charges. This makes for an interesting EOB comparison:

* Standard: submitted charges $3000, plan allowance $435 (the difference is not your responsibility), your 20% out of pocket coinsurance $87.

* Basic: submitted charges $3000, OUT OF NETWORK YOU OWN THE PROVIDER THE FULL AMOUNT THANK YOU HAVE A NICE DAY.

I live in fear of this (having elected a BASIC plan). There is a big difference between $3000 and $435. But there's also a big difference between $435 and $87. Even if you can negotiate with the "out of network" provider for a reduced fee, you must still pay a much larger amount. All for the same service.

All I have to do is stay in network. But that's not something I can always achieve every time. Heath care shouldn't work like a game show where (for the same procedure) you can land on $87, $450, or $3000.
A great challenge of life: Knowing enough to think you're doing it right, but not enough to know you're doing it wrong. — Neil deGrasse Tyson

InMyDreams
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by InMyDreams » Fri Jun 02, 2017 9:39 am

bluebolt wrote:I honestly don't know how people deal with the system. I consider myself an informed medical consumer. I just went through an 18 month battle with my health insurance company over money they owed me. I must have spent 40 hours on the phone with them over that time.
It is terrible. I don't know what other forces you may have tried to bring to bear, but I would suggest

* Your state's insurance commission (mentioning it just once to the insurance company's rep, and I got the telephone number of the manager that they said they couldn't give the number to)

* a "reimbursement specialist" - let google be your friend. The monies in contention must be pretty big to make it worth paying the specialist's bill, but she did amazing things for me.

* for an employer-sponsored plan, using your benefits office.

* for Medicare & supplement problems, you might try asking at your county's division of aging services (or equivalent). They may have an ombudsman.

Jack FFR1846
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by Jack FFR1846 » Fri Jun 02, 2017 9:42 am

mrc wrote:
All I have to do is stay in network. But that's not something I can always achieve every time. Heath care shouldn't work like a game show where (for the same procedure) you can land on $87, $450, or $3000.
amen to that.

Scenario: You have chest pain. You have heart problem history. You go to the ER at an in plan hospital. The ER doc working that day isn't in plan. Should you:

A) Ask the doctor if he's in plan and if not, refuse treatment until an in plan doctor can be found?

B) Receive treatment because.....well.....you're mostly concerned about becoming dead?

Hint: if you choose B, you will be paying more money out of pocket. Second hint....if you are unconscious, you will pay more money just the same. Take an out of plan ambulance ride? Much more out of pocket money.
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pintail07
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by pintail07 » Fri Jun 02, 2017 9:50 am

Been a victim of this "balanced billing 'issue a few times. Twice went to an out of network ER and told the staff and doctors that if I was admitted I wanted to be transferred to an in network facility. Both times they stated I was to critical to move and I would be billed as in network. I wasn't and fought them and finally told them just to suit me. They finally agreed and billed at in network. Another couple of times had different specialist bill as out of network. Politely explained I wouldn't agree to the rates and they finally accepted. Fight and then fight some more.

lkt102
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by lkt102 » Fri Jun 02, 2017 10:04 am

Here are some of the tips I learned after battling for 8 months to get a claim paid:

1. There is a 180 day waiting period before the credit bureaus can report medical debt.
2. Read your plan documentation about how to file an appeal and about the different levels of appeal.
2. Document Everything! When you call your insurance company ask for the "Call Reference Number" and take note of the customer service reps name you are speaking to. I would send myself an email after each call with the call reference number and service rep name along with detailed notes. I also asked for specific notes to be added to my file and made the rep read the notes back.
3. Send all documentation as certified mail otherwise there is a risk that they will never receive your documentation.
4. After getting nowhere through the normal process, I followed up and asked to speak with a supervisor. I asked for the supervisor's email so I was able to determine the companies email format. After that I looked up the CEO, CFO, COO, Board of Directors, VPs, etc and sent them a detailed email with all of the call reference numbers and details all of my interactions including the misleading information I was given. I also included my state's insurance commission on the email to hopefully show I was not going away.

I don't have any advice for negotiating with the provider as my medical emergency happened when I was out of the country and I was required to pay for all of my care upfront. But due to not giving up and documenting everything all of my medical expenses were eventually paid and the insurer even had to pay about $300 in interest due to delaying the processing my claim. It was interesting how quick my claim was paid after I sent the email to top management of the company. I was contacted on a Monday and by Wednesday they had cut me a check for the full amount.

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dm200
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by dm200 » Fri Jun 02, 2017 10:32 am

Medical billing and insurance is a real puzzle and challenge. Just when you think you have something figured out, the rules change - often in the middle of the "game". Just like a football game where the goal line or first down line moves after the ball is snapped.

Others can comment on the details, but there are, apparently, two types (for billing, ACA and insurance purposes) of Colonoscopies.

Did you ask the Gastroenterologist (after getting the bill) about using an out of network Anesthesiologist? Or the Hospital?

For family history reasons, I have had Colonoscopies about ten times over the last decades (never discovered Cancer) with various Gastroenterologists and insurance. Fortunately, never any billing/insurance problems. Some of these were with Kaiser - and that is integrated so this (your experience) does not happen. The two recent ones with Kaiser did have an anesthesiologist.

However, when away from Kaiser for 10-15 years and with several different insurance coverage, I saw a Gastroenterologist for 3 or 4 Colonoscopies where they were done, not in a hospital or outpatient facility, but in his office (procedure room). This was very simple. He had two procedure rooms. You go into one, get ready, and he came in with a nurse/assistant. Just two of them. The Gastroenterologist administered the IV drugs himself, did the Colonoscopy - and move to the other procedure room. Then I would get dressed, he would tell me what he did and did not find and I was on my way. His "process" took about half the elapsed time of having a procedure at a hospital or, as now, at a Kaiser outpatient facility.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by IlliniDave » Fri Jun 02, 2017 10:44 am

I could add similar stories that happened both before and after ACA. Along with things during the same time span that that went without any hitch or surprises (ironically, perhaps, my "50th birthday present" was one that went smooth). I roll my eyes whenever someone points to the "free market" as the magic bullet to clean up the twisted mess we have. I'd like to see a dollar estimate for what the cost of errant/improper billing is. There are times I swear I'm in a Monty Python episode.
Last edited by IlliniDave on Fri Jun 02, 2017 10:58 am, edited 1 time in total.
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Nowizard
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by Nowizard » Fri Jun 02, 2017 10:55 am

Numerous policies make a distinction between a screening and diagnostic colonoscopy, and a routine one starting at about age 50 is often covered under the current insurance regulations allowing annual physicals and some other items, such as a colonoscopy, to be covered at no cost or deductible for the patient. I cannot imagine 10X estimated cost for anesthesiology for a procedure that lasts about 15-20 minutes under relatively little anesthesia. I would definitely call the office since they have had complaints about this on multiple occasions. If charges are truly as outrageous as you have mentioned, I would contact the local medical society and possibly file a complaint with the licensing board of the state if the office will not negotiate a lower charge.

Tim

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dm200
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by dm200 » Fri Jun 02, 2017 11:15 am

Nowizard wrote:Numerous policies make a distinction between a screening and diagnostic colonoscopy, and a routine one starting at about age 50 is often covered under the current insurance regulations allowing annual physicals and some other items, such as a colonoscopy, to be covered at no cost or deductible for the patient. I cannot imagine 10X estimated cost for anesthesiology for a procedure that lasts about 15-20 minutes under relatively little anesthesia. I would definitely call the office since they have had complaints about this on multiple occasions. If charges are truly as outrageous as you have mentioned, I would contact the local medical society and possibly file a complaint with the licensing board of the state if the office will not negotiate a lower charge.
Tim
While I support the majority of the aspects and features of the ACA, one of the aspects that greatly puzzles me is that some things are mandated to be "free" when there is nothing (known) wrong with you, but you have to pay for things when they are wrong with you.

GoUBears
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by GoUBears » Sat Jun 03, 2017 7:18 am

One of the other caveats about screening colonoscopies is that the type of sedation and what is considered medically necessary isn't obvious to patients. Most policies would consider mild sedation with IV meds to be the medically necessary minimum, but GI centers offer full sedation/anesthesia for the colonoscopies (due to patient preference to not be awake) which is not covered by the insurance. Lots of straight medicare beneficiaries get caught up in this trap, and some GI centers won't explain this to you ahead of time so that you can make an informed decision, they just ask, do you want to be awake or asleep during your colonoscopy, without telling you the financial implications of your decision.

rantk81
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by rantk81 » Sat Jun 03, 2017 7:43 am

It seems like the way my insurance company (Aetna) processes claims for me is almost never correct. Three years in a row I've had to call after my annual physical because they screwed something up with the billing. Mess-ups include:

1) Incorrectly processing the claims as if my PCP was not in network (when he was in network!)
2) Incorrectly processing the claims as if the Lab company (Quest Diag) was not in network (when in fact it IS in network, and the Aetna webpage specifically says to use Quest because it is the preferred provider -- and the website says to not use LabCorp because it is not in the network.)
3) After re-processing the claims as in-network for lab work, still not including it as "routine covered at 100%" as part of the physical and trying to get me to pay it as if it counted toward my deductible.

Basically, screw-ups at every turn.

I don't think this is just Aetna, as I had similar problems (although not nearly as frequent) with BCBS in the past.

Sometimes I think that their systems are designed to screw up in their favor by default, and only correct it when you call them out on it -- because every time I have contacted them about errors, they have been able to "fix" them while I was on the phone, in 5-10 minutes.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by InMyDreams » Sat Jun 03, 2017 9:47 am

dm200 wrote: You go into one, get ready, and he came in with a nurse/assistant. Just two of them. The Gastroenterologist administered the IV drugs himself, did the Colonoscopy - and move to the other procedure room. Then I would get dressed, he would tell me what he did and did not find and I was on my way.
I was just talking with another nurse last night. She has years of experience in the OR. She was talking about how difficult it was, back in the day, when the circulating nurse was also providing conscious sedation. It is not permitted in my institution - nurses may provide conscious sedation under MD's direction, but she must be dedicated to that task only, no procedure assistance duty. Even that level of safety still gives anesthesiologists heartburn.

Glad you got thru the procedures safely.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by Bmac » Sat Jun 03, 2017 10:02 am

1. Agree that the age 50 screening colonoscopy should be fully covered under ACA for routine preventive care.
2. Not clear why an anesthesiologist was even involved. Usually, unless the patient is "high risk" conscious sedation is delivered by a nurse under the guidance of the gastroenterologist.

My screening colonoscopy was 100% covered. They even did a biopsy and I paid only a small amount for that and the pathology. There were EOBs for the GI doc, pathologist and facility fee. No anesthesiologist EOB.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by tibbitts » Sat Jun 03, 2017 10:15 am

I had the exact same thing happen to me during a colonoscopy, pre-ACA not that I think that matters.

I didn't read the entire thread but I don't the it matters if the provider was an MD or a nurse or the guy who cleans the toilets in the office (I'm expecting to see a billing code for that any day now), it's the same problem. In my case the problem was solved by the provider changing their bill so it went through another provider. I didn't have to pay more but I'm guessing they earned a little less. Maybe the idea for providers is to bill everything yourself and see what sticks, even if you don't have any insurance affiliations, then have an array of other providers to bill through as a fallback.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by Naismith » Sat Jun 03, 2017 11:06 am

GoUBears wrote:One of the other caveats about screening colonoscopies is that the type of sedation and what is considered medically necessary isn't obvious to patients. ......
Yes, important point. And keep in mind that most places in the world, they do most of them without sedation at all. I am not sure of the standard of care and if ACA even requires that the sedation be covered.

When I had my first colonoscopy, pre-ACA, they refunded me several hundred dollars because I did not have sedation for the procedure.

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dm200
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by dm200 » Sat Jun 03, 2017 12:16 pm

Regarding anesthesia/sedation and Colonoscopies -

1. Having had, perhaps 8-10 or so over the last 40 years, until the last 2 or 3, I was awake during the procedure. I liked to watch on the TV screen. Fascnnating. I think I was given (IV) a relaxer and pain drug.

2. Other folks claimed they were out during the Colonoscopy. I asked my gastroenterologist about that and, at the time, he told me that often patients are awake but the sedation/drugs cause them to forget everything.

3. For some reason, the last 2-3 I have had, I don't remember anything. I can't recall what drugs they told me. I am quite sure the drug(s) used in these are different than when I was awake and remembered.

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dm200
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by dm200 » Sat Jun 03, 2017 12:19 pm

Naismith wrote:
GoUBears wrote:One of the other caveats about screening colonoscopies is that the type of sedation and what is considered medically necessary isn't obvious to patients. ......
Yes, important point. And keep in mind that most places in the world, they do most of them without sedation at all. I am not sure of the standard of care and if ACA even requires that the sedation be covered.
When I had my first colonoscopy, pre-ACA, they refunded me several hundred dollars because I did not have sedation for the procedure.
OUCH!!! I tolerate medical procedures fairly well, but I understand a Colonoscopy is quite uncomfortable/painful without drugs! The flex sig is done without drugs - and it was "ok", but it only goes about 1/3 of the way that a Colonoscopy does!

Naismith
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by Naismith » Mon Jun 05, 2017 8:04 pm

dm200 wrote:
Naismith wrote:
GoUBears wrote:One of the other caveats about screening colonoscopies is that the type of sedation and what is considered medically necessary isn't obvious to patients. ......
Yes, important point. And keep in mind that most places in the world, they do most of them without sedation at all. I am not sure of the standard of care and if ACA even requires that the sedation be covered.
When I had my first colonoscopy, pre-ACA, they refunded me several hundred dollars because I did not have sedation for the procedure.
OUCH!!! I tolerate medical procedures fairly well, but I understand a Colonoscopy is quite uncomfortable/painful without drugs! The flex sig is done without drugs - and it was "ok", but it only goes about 1/3 of the way that a Colonoscopy does!
Part of the reason it may be painful is that USAmerican doctors are not trained to do it without drugs. I had a doctor from South America, and it worked well. They also let me use my headphones and ipod with a playlist to encourage breathing techniques. So it is not that I was doing it without anything.

Where my husband goes, it is a factory. No headphones allowed, and everything is at the convenience of the staff.

Remember that in the 1960s, it was thought that women couldn't birth a baby because it was too painful. Of course they were also forced to lie on their backs, without partner support or any trianing. Nowadays many of us give birth without needing drugs.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by toofache32 » Mon Jun 05, 2017 10:42 pm

Jack FFR1846 wrote:It's hopeless.

Things I've run into: Doctor is not in network and has been trying to join in network for 3 years. Network tells me that they have enough of that specialty so are not accepting new doctors. We go to network list and in calling around find several interesting things. Doctors who are retired and no longer practicing, practices no longer accepting patients and one in network facility who won't accept this network's patients because the network doesn't pay it's bills.
I'm a doc that experienced this back when I took insurance. I tried to join a big network in my area. I met with them and they said they already had enough of my specialty. When I check their website, there was only 2 specialists....one guy in my city, and another 3 hours away. This is called "rationing by inconvenience" and is the result of "narrow networks" that insurance companies proudly advertise to keep "your" costs down. The "rationing by inconvenience" is because there is a significant percentage of patients that will simply avoid treatment because the in-network doctor is 3 hours away and they have transportation difficulties. Narrow networks allow the insurance to limit their financial payout because 1 doctor only has so many appointments each week, so they will not have to pay more than X dollars per week. Adding a second dollar increases their financial liability to 2X dollars per week. So they choose to only have 1 doctor to profit off the bottleneck.

As far as having retired doctors on their in-network list, this is by design. There was a doctor in my practice who moved across the country in 2007. He is still listed on several insurance websites and we get occasional calls from patients wanting to schedule with him. And yes, we have notified the insurance companies. They do this because they want to look like they have a roster full of doctors for people signing up for their plans.

http://www.nydailynews.com/new-york/man ... -1.1966755

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by TIAX » Mon Jun 05, 2017 10:56 pm

cas wrote: When I went in for my age-50 screening colonoscopy a couple of years ago, the check-in person got to the end of check in and then unexpected asked me to write a pre-procedure check (a couple of thousand $, if I recall). I got very confused and stuttered out "but a screening colonoscopy is covered under the ACA, so I shouldn't owe anything out of pocket." And the check-in person said "but if they find something during the procedure, then it wouldn't be a screening colonoscopy any more." And I stuttered out something about "the only reason I'm here is because I turned age 50. I don't understand why I'm being asked to pay ahead of time for a situation that the probabilities say won't happen."
Right. I don't see why OP is being asked to pay anything. All of the services on this page are covered in full - https://www.uspreventiveservicestaskfor ... endations/

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by toofache32 » Tue Jun 06, 2017 12:04 am

tibbitts wrote:I had the exact same thing happen to me during a colonoscopy, pre-ACA not that I think that matters.

I didn't read the entire thread but I don't the it matters if the provider was an MD or a nurse or the guy who cleans the toilets in the office (I'm expecting to see a billing code for that any day now), it's the same problem. In my case the problem was solved by the provider changing their bill so it went through another provider. I didn't have to pay more but I'm guessing they earned a little less. Maybe the idea for providers is to bill everything yourself and see what sticks, even if you don't have any insurance affiliations, then have an array of other providers to bill through as a fallback.
If a treatment was provided by one doctor, but was billed as if it was performed by another doctor, this is insurance fraud. The doctor risks penalties, and you the patient (if you were aware of this) risk losing your insurance coverage.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by toofache32 » Tue Jun 06, 2017 12:16 am

TIAX wrote:
cas wrote: When I went in for my age-50 screening colonoscopy a couple of years ago, the check-in person got to the end of check in and then unexpected asked me to write a pre-procedure check (a couple of thousand $, if I recall). I got very confused and stuttered out "but a screening colonoscopy is covered under the ACA, so I shouldn't owe anything out of pocket." And the check-in person said "but if they find something during the procedure, then it wouldn't be a screening colonoscopy any more." And I stuttered out something about "the only reason I'm here is because I turned age 50. I don't understand why I'm being asked to pay ahead of time for a situation that the probabilities say won't happen."
Right. I don't see why OP is being asked to pay anything. All of the services on this page are covered in full - https://www.uspreventiveservicestaskfor ... endations/
You would think the insurance company would pay in that situation wouldn't you? :oops:

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by toofache32 » Tue Jun 06, 2017 12:25 am

fsrph wrote:This issue of being directly billed for non network providers (that you had no choice in selecting) in an in network facility is a problem that needs to be addressed. This practice is unfair to consumers. This thread deals with anesthesiologists but also routinely occurs with er physicians and those in radiology and pathology. When a facility enters into a contract with a group representing these specialties there is no incentive to be in network because they know they will be the sole provider of these services. The hospital or clinic bears some of the blame because they signed the contract granting exclusive use of one group.

Neither of these possible solutions are easy to implement but would help.

1. Legislation that would require in network facilities to use ALL in network providers.

2. Hospitals go back to hiring their own specialists (anesthesiology, er, pathology, radiology) and require them to be in network. Do not deal with a group that wants to be the sole provider to a facility.

3. Supply and demand. Open up more residency training slots for these specialties. Increase the supply and you'll find those willing to accept in network rates.

Francis
I agree this is unfair to consumers. This is also unfair to providers. The anesthesiologist does not get to choose only patients who have plans the anesthesiologist is in network with. Similarly, ER docs don't get to only treat patients with insurance they are in-network with. If the insurance company actually paid competitive rates, this would not be an issue and all the doctors would sign up. In other words, this is an insurance problem more than a doctor problem. Insurance companies only negotiate with facilities, not doctors, so the docs have to choose to sign a "contract of adhesion" (google this) or be out-of-network with that plan. With this take-it-or-leave-it contract, more and more doctors are choosing to leave it. Ultimately, there are 3 people involved in this...the patient, the doctor, and the insurance. Only 2 of those actually care about your health and the other is doing everything they can to avoid paying. The patients are not the only ones with insurance frustrations, which is why doctors drop plans that are troublesome.

It's simply not possible for every hospital to have everyone be in-network, unless the doctors are actually employees of the hospital. One of my hospitals tried to require everyone to accept plans that pay less than what it costs me to provide care. I'm talking about removing huge head/facial tumors and reconstructing patients in a 8-10 hour surgery that pays me $1200 while it costs me over $2000 per day just to keep my office open. My roofer would laugh if I asked him to fix my roof for $1200 when it costs him $2000 to buy the shingles. So we left the hospital. Now we get calls from that hospital to transfer patients to my other hospital for care. I am not the lowest bidder but many people want the lowest bidder it seems. I got tired of the insurance tricks so I dropped all insurance. Since I now have an office full of patients willing to pay cash for my surgery, my fees must not be too unreasonable. But insurance still pays less than half of those fees...when they do pay at all.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by HIinvestor » Tue Jun 06, 2017 3:47 am

Over a decade go, something similar happened to our family, before ACA, when we were covered under a BCBS family plan. S was scheduled at an in-network Med center with an in-network pediatric gastroenterologist. S had a procedure where a pediatric anesthesiologist gave general anesthesia and they did an endoscopy and I can't recall what else.

A few weeks later, we received bills. For the 1st time, we discovered the anesthesiologist was out of network. We complained to insurer that we were in no position to argue and didn't even meet the guy. We also complained to the pediatric anesthesiology practice. They agreed to accept whatever we could get insurer to pay as payment in full. Insurer increased its payment of that bill from 50% of customary contracted amount to 80% and we didn't have to pay the 20% balance. The other bills were paid as in network and we paid our copay.

I would say you need to be the squeaky wheel and appeal as needed. It's important not to let this continue as business as usual with the patient being forced to bear costs he had no choice in.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by book lover » Tue Jun 06, 2017 9:43 am

In An American Sickness, Elisabeth Rosenthal recommends writing on form that you sign agreeing to payment : I only agree to pay in network providers any care delivered by out of network providers will not be paid should you need emergency services. This sounds reasonable to me.

HIinvestor
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by HIinvestor » Tue Jun 06, 2017 7:49 pm

You may be rejected as a payment if you don't sign their forms without adding verbiage, but if you're willing to take that risk, by all means proceed. At this point, after you've received the services, you still have to appeal to get it resolved in a fairer manner.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by 4ransom » Tue Jun 06, 2017 9:14 pm

I do not think a mere mortal can navigate the system. We tried for 30 yrs. and never could get it straight, it gets worse every year. My wife was an accountant and it drove her crazy. We are on medicare and pay for the F supplement and still get undeciferable billings; I gave up and send them all through the shredder. In 70 yrs these are the only bills I have received and not paid.

HIinvestor
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by HIinvestor » Thu Jun 08, 2017 4:00 am

Most of the time I've had pretty good success in talking with my insurer. When I find someone helpful, I get their name and contact info and keep in contact until we resolve whatever the issue is. We have mostly successfully resolved our differences, with them mostly ultimately agreeing with me and paying. Twice I've paid and not been reimbursed even after appealing.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by dm200 » Thu Jun 08, 2017 10:23 am

In several past health insurance plans, I reached the frustrating conclusion that insurance companies intentionally staff their help lines with folks who have no medical knowledge. In several cases, only when I repeatedly pressed the insurance companies would they let me speak with someone who could discuss the billing/coverage issue. In one case, that was for my wife, once I spoke with a nurse there, I was 100% satisfied that the insurance company was correct and the "fault" was with the procedure that her doctor ordered and performed.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by ncbill » Fri Jun 09, 2017 9:27 pm

when mom was sick (in her 50s at the time) given the nature of her illness & the way she appeared because of it, hospitals often assumed she was on Medicare and submitted bills to them even though I told the billing departments time after time that she was private pay.

so some bills showed up a year or more later (after being rejected by Medicare) - that was a big bag of no fun.
4ransom wrote:I do not think a mere mortal can navigate the system. We tried for 30 yrs. and never could get it straight, it gets worse every year. My wife was an accountant and it drove her crazy. We are on medicare and pay for the F supplement and still get undeciferable billings; I gave up and send them all through the shredder. In 70 yrs these are the only bills I have received and not paid.

HIinvestor
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Re: How does a mere mortal navigate healthcare/insurance issues

Post by HIinvestor » Fri Jun 09, 2017 9:34 pm

Actually, I think insurers just provide low pay and poor benefits for their customer service reps and hire those willing to accept that. Naturally, such conditions don't attract or retain the best workers. Insurers don't have to actively disqualify competent workers, the law of supply and demand will do that for them.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by Jack56 » Sat Jun 10, 2017 4:26 pm

It is difficult because the American health care system is sleazy -- there is no price transparency and the system at all levels -- doctors, hospitals, drugs, insurance bilks consumers with hidden charges and costs.

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Re: How does a mere mortal navigate healthcare/insurance issues

Post by marcopolo » Sat Jun 10, 2017 4:37 pm

Jack56 wrote:It is difficult because the American health care system is sleazy -- there is no price transparency and the system at all levels -- doctors, hospitals, drugs, insurance bilks consumers with hidden charges and costs.
I may be naive, but i like to give people the benefit of the doubt. I am not sure how much of this is due to the system (or people in it) being sleazy as much as it is from being overly complicated. Probably some of both... I do agree that it definitely lacks transparency.
Once in a while you get shown the light, in the strangest of places if you look at it right.

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