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Denial of care as a business model

DCblogger's picture

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wasabi's picture
Submitted by wasabi on

I have had two lab work insurance claims (from different labs) denied in the past 3 months because my insurance company could not "recognize" me as a covered person. In both cases, the billings were for rather large costs. In both cases I dutifully submitted my insurance card for PHOTOCOPYING before any services were rendered.

I talked with the insurance company and they said it was my responsibility to make sure that when the billing company submits the bill that they have the correct information down when they go ahead and submit the bill. In other words, if the service was rendered on the 10th on June, I need to go to the business office and check their paperwork to make sure everything is correct when they submit the bill on the 12th. Does that make sense?

I live in Texas and it is a very friendly environment for the insurance companies. There is a rule that all claims must be submitted within 95 days or the claim does not need to be paid. However, if the first claim is denied, then the service provider must wait an additional 45 days to resubmit the claim. See the catch there? The insurance company gets to sit on the claim, then the service provider needs to wait until they get rejected, then resubmit the claim before 95 days elapses. 95 days is not a long time when paperwork is shuffling between two offices.

I have never had claims rejected before and I have used the same insurance card for the past 3 years. Only until the bills were substantial has the insurance company not been able to identify me. Hmmmm....

Word to the wise. If you ever get a notice of a rejected claim, get on it immediately as there is very little time in which to work, especially if you live in one of those insurance friendly states.

Submitted by lambert on

When it rains, the inscos take your umbrella away.

[ ] Very tepidly voting for Obama [ ] ?????. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.

badger's picture
Submitted by badger on

I won't have to pay $1050 to Aetna Insurance to meet my daughter's college health insurance requirement.

For the past three years, the college has only required you fill out a simple form that says your personal insurance coverage is as good as what they offer (via Aetna) or that at least you, and not them, are responsible for any expenses.

We have only major medical, and a very good policy when we've used it. In addition, between personal and business credit lines, savings, and retirement money, we have a large chunk of change accessible to us, which I consider self-insurance (although out-patient charges are never going to be a significant fraction of that).

But this year, to get a waiver, you have to go to an online site - run by Aetna. Before telling you whether or not you get a waiver or what the conditions are, it requires you to swear a blood oath to buy Aetna's insurance if you don't qualify for a waiver. We qualified 3 times before, so I figured what the hell.

To check eligibility, they ask you to answer 4 questions about your policy (after collecting all the info about the policy and repeatedly warning you that they really don't believe what you're telling them and are going to check it out). I failed question #2 - something about "Does your policy cover out-patient stuff? Well does it, punk?" Then the site locks you out.

So I wrote the college a (polite) two-page letter explaining why my insurance was "comparable or better" then the stuff Aetna was peddling. Part of my argument (thanks to links I found here) was that Aetna had lost a $100 million judgment for denying care, been fined $1.5 million for failing to pay claims in a timely fashion by the state of NY, and one or two other things.

I pointed out that neither my carrier nor I as self-insurer had ever incurred such judgments or fines, so we were clearly comparable or better. In addition, the Aetna policy had a $25,000 cap - I have several credit cards with higher limits.

The lady that called from the college business office liked my letter very much and told me if I sent in the same form as last year they would waive the insurance charge. Which they did.

DCblogger's picture
Submitted by DCblogger on

thanks, the more we can get these stories out, the more we can persuade people that just because they pay premiums doesn't mean that they have insurance.

wasabi's picture
Submitted by wasabi on

My insurance company also refused to pay for a anti-rejection drug that my doctor prescribed as part of the treatment for my condition. I need to follow their "recommended" treatment program first for a YEAR, then have my progress evaluated (biopsy - $10K; $5K deductable) before they will pay for the "top tier" drug. This prescription would cost me $6000 per year w/o insurance. According to my insurance carrier's prescription website, their negotiated cost from the manufacturer would be $2300 for the year for the same drug.

And this stellar plan costs my husband's small company $15K per year for our family.

Damon's picture
Submitted by Damon on

I went through a battery of tests (MRI's, CAT's, blood work, the whole nine) back in 2004, and under my parent's insurance, at the time, only to find out later that some procedures were covered and some weren't. There didn't seem to be any rhyme or reason to what was and wasn't covered. I still have quite a bit of medical debt, some stuff I don't even remember having done. It's totally disillusioning to the point of where I don't even like going to the doctor. They count on folks like me not having had any idea about how health serves are rendered.

Submitted by lambert on

Disillusionment, even if insured:

It’s totally disillusioning to the point of where I don’t even like going to the doctor.

And that's when you can go to the doctor!

[ ] Very tepidly voting for Obama [ ] ?????. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.

Submitted by lambert on

No care, no pre-existing condition!

[ ] Very tepidly voting for Obama [ ] ?????. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.

Submitted by gob on

if no diagnostic work is done. I refused a cholesterol test recently for that very reason, as my COBRA coverage runs out soon and I'm still researching my options.

My doctor was appalled, but she understood. We also shared a nice, wordless, but crystal-clear "oh, shit, the Democratic nominee" moment.

Policy not party!

Card-carrying_Buddhist's picture
Submitted by Card-carrying_B... on

$1330/ month. And with a $3K deductible.

No relief in sight, either.

So good to be an American, eh?

Submitted by lambert on

That's a lot of money!

But the peace of mind makes it all worth it, I am sure....

[ ] Very tepidly voting for Obama [ ] ?????. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.

Mandos's picture
Submitted by Mandos on

*geek moment* I find it hilarious that the health insurance bridging strategy in the US is named after the enemies of GI Joe.

DCblogger's picture
Submitted by DCblogger on

I assume you have a family. I pay $550/month to Kaiser P. Very low co pays and no copays the only time I had to go to the hospital. I know there are horror stories about Kaiser P., just like every insurance company, but they did a good job for both my parents and a good job for my friend who had cancer, so I am optimistic.

But I would feel much better in a Medicare for All environment.

MsExPat's picture
Submitted by MsExPat on

I just opened up my mail, and there was a letter from my (U.S.) insurance company. I had a routine test last month, and they won't settle my claim until my doctor signs a form declaring I had no pre-existing condition.

Mind you, they sent the form to me, not the doctor. But the doctor has to fill out and sign the paperwork. So I have to send it to the doctor, and follow up and make sure he crosses all the Ts.

In other words, I have the responsibility for doing the clerical work for the insurance company. And if I don't get it done in 180 days, they stick me with the bill for this routine, but pricey test (those of you over 50 will know EXACTLY what routine but pricey test I am referring to..heh).

After reading this thread, you can be sure I am going to be ON this. But, jeez, it feels like such a scam.

Truth Partisan's picture
Submitted by Truth Partisan on

They actually sell these. Not cheap but not too expensive either. You have to be able to prick your own finger or get someone to do it for you, but the ones a close friend used to use were very accurate. Actually we thought the first time she used it that it was a mistake but the surprising result was right on. And, a long while afterwards, with self-treatment for high cholesterol, she has had good results. (BTW, both the surprising one and the low one were confirmed by regular lab tests.)

Submitted by lambert on

because it's happening to a lot of people at once, but they never compare notes.

Actually, that is another PB 2.0 slogan/thought: "Comparing notes"

[ ] Very tepidly voting for Obama [ ] ?????. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.

Truth Partisan's picture
Submitted by Truth Partisan on

and
how to feel better with or without health insurance
(not medical advice!=don't sue us):new departments!

badger's picture
Submitted by badger on

that will do diagnostic tests without doctor involvement or insurance reimbursement. I won't recommend the one I used, because I think for most people the tests are unnecessary, but they did an ultrasound I needed periodically (family history), and this time it came out positive.

The cost was $135 vs probably close to $1000 (that my insurance - catastophic - wouldn't cover) going the doctor/hospital route. I ended up having to do some of that $1000 because I was diagnosed with the condition I was concerned about and that means I need to get into the traditional doctor/hospital system, but otherwise wouldn't have had to pay the extra amounts.

Other than that, I've had no reason to see an MD for the last 20 years or more. My bloodwork and everything else always comes back perfect (and still does), and the condition I have is one most GPs know next to nothing about. (My Dr. - who I think is excellent - basically agreed to my treatment plan, and wouldn't have come up with it herself).

If undiagnosed, which it most often is, the condition (abdominal aortic aneurysm) is usually fatal or worse.