Health insurance question (non-political)

[mustangj17]

If my doctor is in an approved network, ANY procedure they recommend must be covered.

If you are in a network, you know what is approved and what isn't.

I wouldn't pay one cent of a claim for a procedure done by an in-network doctor. Eventually, it will be dealt with.

Depends on the insurance, Simon.

You could have an in-network doctor recommending and MRI but the facility he sends you to is out of network. This happends a lot.

Or it could be like mine where it is approved, but they will only cover up to say, 80 percent of certain procedures.

 

[forever_town]

Anyone who needs to see evidence that our health care system needs to be reformed should only have to look at this thread.

And it must be REAL reform, not the Band-Aid measures being discussed in Congress.

 

[bagelchick]

FT--I concur 100%. I am the poster child for someone with health insurance (well, it's Aetna so one must consider that), and my out of pocket costs are through the roof.

And what boggles my mind is that they don't have an agreement with UPMC, the gorilla of health insurance in Pittsburgh. I had to change nearly all of my doctors which just irritated the hell out of me. My PCP has figured out a way around them...I have no idea how, but he has.

I almost had to wait 8 weeks to have a procedure done because the doc only sees people with non-UPMC insurance one day a week (fortunately there was a cancellation).

 

[fishwrapper]

I just can't see an imaging facility administering an MRI without insurance verification and authorization.
This is a failure on many levels.
1-PCP needed to submit for pre-approval.
2-Patient then receives authorization.
3-Diagnostic imaging center verifies the authorization.
This is awful.

I had a $700 lab test done that I later found out wasn't covered by my plan. They took my insurance card and everything, but never bothered to tell me that that facility didn't accept my insurance. Then I got the bill.

We learned this the hard way, too. Labs ARE NOT affiliated with any medical network and are some of the most profitable in the industry. Low overhead, high profitability.
When you go to an outside lab for tests, chances are, YOU ARE NOT COVERED.
Unfortunately, it is explicitly spelled in your coverage manual.

 

[Ace]

I have a high deductible plan. I really like it. None of these worries. The first $2,500 of any visits, prescriptions, tests, whatever comes out of my pocket. But it is charged at the rate that they agree with the insurance company, so an office visit my be $36 instead of $75 or whatever.

After the $2,500 I don't pay for anything.

 

[bagelchick]

I went to the lab at UPMC Shadyside. This is when I learned that Aetna doesn't have a contract with them, even though the person at the desk was perfectly happy to take my insurance card and info.

Ultimately it was still my fault. This was back in January, and my company had just changed from Blue Cross/Blue Shield (which I loved) to Aetna. And I was feeling like death so not really in my right mind...I ended up getting diagnosed with food poisoning.

My other favorite part about Aetna is the $45.00 office visit.

 

[Dyno]

The nuanced language that insurance companies use pisses me off. Last year, I needed a mammogram (first one). Every year, I get a document from my insurance company that's specifically about mammograms, but that I had never really read before - just stashed it with the rest of my insurance papers. I took out the file and started reading through. Everything said that my plan "covered" mammograms. I took that to mean there might be a co-pay, but that insurance would pay for the mammogram. Just to be sure, I called. That's when I found out that when they said "covered" they mean "allowed." I was allowed to have a mammogram and I'd be able to get a preferred, discounted rate at the on-plan lab facility, but I would have to pay for the mammogram.

 

[OTD]

The nuanced language that insurance companies use pisses me off. Last year, I needed a mammogram (first one). Every year, I get a document from my insurance company that's specifically about mammograms, but that I had never really read before - just stashed it with the rest of my insurance papers. I took out the file and started reading through. Everything said that my plan "covered" mammograms. I took that to mean there might be a co-pay, but that insurance would pay for the mammogram. Just to be sure, I called. That's when I found out that when they said "covered" they mean "allowed." I was allowed to have a mammogram and I'd be able to get a preferred, discounted rate at the on-plan lab facility, but I would have to pay for the mammogram.

My wife gets regular colonoscopies because of her family medical history. We changed to United Health Care this year. They charge $125 for this; it was free before.

You'd think they'd charge you a fee if you DIDN'T get these vital exams. But it's not about health, it's about cash.

 

[Dyno]

The nuanced language that insurance companies use pisses me off. Last year, I needed a mammogram (first one). Every year, I get a document from my insurance company that's specifically about mammograms, but that I had never really read before - just stashed it with the rest of my insurance papers. I took out the file and started reading through. Everything said that my plan "covered" mammograms. I took that to mean there might be a co-pay, but that insurance would pay for the mammogram. Just to be sure, I called. That's when I found out that when they said "covered" they mean "allowed." I was allowed to have a mammogram and I'd be able to get a preferred, discounted rate at the on-plan lab facility, but I would have to pay for the mammogram.

My wife gets regular colonoscopies because of her family medical history. We changed to United Health Care this year. They charge $125 for this; it was free before.

You'd think they'd charge you a fee if you DIDN'T get these vital exams. But it's not about health, it's about cash.

I'm with United Healthcare, too. Must be their way.

 

[Smallpotatoes]

I received a letter today from a company called CareCore National LLC that my insurance company contracts with that said that it was determined the MRI was "not medically necessary."
The reason was "The history presented of right knee pain, does not demonstrate sufficient medical necessity to justify certfication of this examination at this time. There is no evidence of progressive growth of a palpable lesion, new findings on leg x-rays to suspect a bone tumor."
The letter says I have a right to appeal.
So let's see: An x-ray does not show anything so the doctor decides to order an MRI. Yet somehow it's not medically necessary. The whole point of the MRI, I thought, was to see what was wrong. And because the person reviewing the claim was not convinched something was wrong, the claim can be rejected?
Perhaps it was my choice to have the MRI done, but I don't know enough to decide if I need it. That's why I saw a doctor.
Meanwhile, I'm still scheduled to have the knee scoped next month and within the last week, after tripping over something, it's gotten worse, to the point where it is very painful to walk after sitting for a long time and I limp for a while.
If not for a $150 copay I would have checked into an emergency room a few days ago.
Now I'm wondering if I should cancel the surgey. because I could never pay for it.

 

[Sam Mills 51]

I received a letter today from a company called CareCore National LLC that my insurance company contracts with that said that it was determined the MRI was "not medically necessary."
The reason was "The history presented of right knee pain, does not demonstrate sufficient medical necessity to justify certfication of this examination at this time. There is no evidence of progressive growth of a palpable lesion, new findings on leg x-rays to suspect a bone tumor."
The letter says I have a right to appeal.
So let's see: An x-ray does not show anything so the doctor decides to order an MRI. Yet somehow it's not medically necessary. The whole point of the MRI, I thought, was to see what was wrong. And because the person reviewing the claim was not convinched something was wrong, the claim can be rejected?
Perhaps it was my choice to have the MRI done, but I don't know enough to decide if I need it. That's why I saw a doctor.
Meanwhile, I'm still scheduled to have the knee scoped next month and within the last week, after tripping over something, it's gotten worse, to the point where it is very painful to walk after sitting for a long time and I limp for a while.
If not for a $150 copay I would have checked into an emergency room a few days ago.
Now I'm wondering if I should cancel the surgey. because I could never pay for it.

Have your physician - or more likely, the physician's office - set up the procedure with a hospital which uses a pre-authorization team. These are set up so that a hospital/health-care system has some measure of assurance that they will get paid for the procedure.

The coverage company should come through. Obviously, if not, then the decision could be a tricky one for you.

That company which questioned medical necessity is full of crap if your physician recommended the test. If you refuse, the physician would likely ask you to reconsider because he/she wants the bases covered ... and, importantly to him/her, his/her butt covered so that they rule out certain diagnoses and to stay out of litigation.

If you didn't have an MRI done, how can rule out something seriously life-altering (i.e. cancer) or something orthopaedic which would require action a little more intrusive than an arthroscopic procedure? Appeal.

 

[Smallpotatoes]

I was discussing this with my brother today and he asked me "If you were told you needed to have the MRI done, but you had to pay for the whole thing, out of pocket, would you do it?"
I told him I don't think that's a question that should have to be asked. While, yes, ultimately it was my decision to have the MRI or not, I do not have the necessary medical knowledge to make an informed decision. I rely on a doctor's knowledge and experience to make that decision and if he decides that the test is necessary, it is, by definition, medically necessary.
But perhaps there are holes in my logic.

 

[HC]

You must all move to Canada. Immediately.

 

[TrooperBari]

You must all move to Canada. Immediately.

Is there a surplus of smart, funny and single Canadians?

 

[PCLoadLetter]

I have a high deductible plan. I really like it. None of these worries. The first $2,500 of any visits, prescriptions, tests, whatever comes out of my pocket. But it is charged at the rate that they agree with the insurance company, so an office visit my be $36 instead of $75 or whatever.

After the $2,500 I don't pay for anything.

I just switched to that starting next year. It will save me more than $200 a month in premiums.

 

[Sam Mills 51]

I have a high deductible plan. I really like it. None of these worries. The first $2,500 of any visits, prescriptions, tests, whatever comes out of my pocket. But it is charged at the rate that they agree with the insurance company, so an office visit my be $36 instead of $75 or whatever.

After the $2,500 I don't pay for anything.

I just switched to that starting next year. It will save me more than $200 a month in premiums.

It's not a bad idea, with the understanding that all the minor stuff will be yours and yours alone for a while in addition to the fact that, if some sort of procedure is needed early in the fiscal year of the coverage, you'll be on the hook for $2,000-$2,500.

If you have the means to cover that if it were to happen, it's not a bad way to go about this.