How not to get screwed by Health Insurance Companies..

Discussion in 'Educational Resources' started by bungrider, Sep 4, 2003.

  1. Ah, the insurance seems like everyone these days has strong feelings about them.

    This came up in another thread and seeing as how many of us have or need individual health insurance, I thought it would truly be a benefit to the brotherhood for us to have a resource where we can discuss what to consider when choosing an insurer, and also what NOT to let appear on your medical record.

    It seems these days that everyone has a friend or relative with a health insurance horror story, and these things really appall me, so let's have it all...

    -what pre-existing conditions you don't want to appear on your medical record, and how you can either prevent them from being recorded on your medical records or how you can prevent insurers from seeing this information
    -what deductibles are right for your age group (buying insurance is no different than trading options)
    -how you've gotten screwed by insurance companies (let's hear some stories)
    -what alternatives there are to getting screwed (litigation, etc)
    -what alternatives there are to normal health insurance (health savings plans)
    -how you can unexpectedly get dropped from your insurer, for example if they stop offering individual insurance as mentioned in another thread
    -individual states' and federal laws to help you battle the insurance industry

    Thanks in advance to all of you who contribute.

  2. well if i were you i wouldnt tell them my my nickname is bungrider
  3. trdrmac


    The first is a general guideline and I am not a doctor. Although I play one in some of my fantasies. The more you can keep off your record, the better. Pre-Existing Condition denials for both coverage and treatment are huge. A visit for Lumbago may lead to an exclusion for a Herniated Disk. Not that this always legal it happens. In addition to Federal HIPPA laws most states have laws in their general statutes about what constitutes a pre-existing condition. State departments of Insurance are a good place to start.

    On that line I think from both a cost and planning standpoint a large deductible with a Medical Savings Account gives most people the biggest value. The more visits to the doctor, the less practical this may be.

    Know your Policy.

    Most policies require a notification of admission and an authorization for inpatient stays. In many cases specialist referrals are needed to see a specialist. And of course watch your deductibles and co-pays..

    If care is denied by the HMO, most if not all states have a peer to peer review process the HMO must follow. This is would also hold true if part of a stay is denied. For instance the insurance company says you should be discharged in 2 rather than 3 days.
    Peer to peer would be a review between your Dr and the insurance companies Dr.

    Hospitals can not turn people away from emergency rooms because of EMTALA. But that does not mean your insurance carrier will pay. This can often result in a huge bill from the er at the hospital.

    The thing to know here is that the ADMITTING Diagnosis (Presenting symptoms) is not always the same as the FINAL Diagnosis. Insurance companies know this but often ignore it.
    For instance if you had severe chest pain and difficulty breathing it may be severe heart burn. (But you thought you were having a heart attack) It may be Saturday Night and your child has a fever. (PcP was not open) Many times appealing the claim with medical records and a few phone calls will get the carrier to reverse the decision.

    Coding is somewhat subjective, so your Dr and the Hospital may not have the same code. The best way to handle this is to have your Doctor contact the hospitals medical record department with a letter.

    This is what comes to my mind from a few years of dealing with insurance companies. Next hospitals and physicians.
  4. trdrmac


    In most healthcare facilities the business office is the elephants ass. All the things that go wrong can end up on your bill.

    I have seen quite a few things here but the two biggies are charges that don't belong on the bill and claims that the "insurance company never got".

    Under most managed care contracts there is a discount of charges taken which offsets some billing errors. If however you are paying out of pocket it pays to get an itemization of charges and eyeball it for errors.

    The second thing is to make sure your provider posted the adjustments correctly. Just last week a friends mother showed me a bill from a doctor for $400. As it turned out Medicare paid, her secondary carrier had paid and nothing was actually due. The person posted the payment never took the adjustment.

    Along this line by way of information I used to do and still occasionally get a call to do some business office "clean up".
    One of the typical practices industry wide is to send unpaid accounts to a collection agency. That is when a lot of people find out they still have bills due. Not good, but it happens.

    It pays to follow up with your insurance company about 30 days after a visit to make sure they have the claim or claims. For instance an outpatient surgery would generate a bill from your surgeon, the facility and maybe the anesthesiologist. Keep in mind too that ANY of these people may not participate with the plan. This means you may get a big bill. So always check prior to any treatment. But if they do not have the bill(s) contact the business office and ask them to resend it and send you a copy. If they still don't get it after 60 days send it yourself, you are dealing with what I like to call idiots. (Probably 2 out of 10 bills are never received, even if they are all sent together.)

    Also if it is a "contracted" provider and they do not get the proper authorization you may not be liable for the charges. This varies by contract, it pays to know. If you are under a group plan the HR department may be useful in dealing with either the insurance company or the healthcare provider to resolve outstanding issues.
  5. trdrmac


    Here is a typical scenario.

    I did some work for a small hospital in the middle of nothing that was practically broke. A rather large insurance carrier very well known was negotiating contracts for their Medicare HMO. Long story short was the contract offered was not feasible for the hospital to sign due to the huge discounts proposed.

    Under this contract any services at non-contracted providers required notification of the healthplan prior to admission.

    An 86 year old women had the misfortune of falling down the steps. She was brought to the hospital for stabilization as it was the only place available. After that she was transferred to a much larger facility for treatment.

    This large insurance company ended up paying about $100 of a $1200 bill. And was ok with bill the member the balance of $1100. I explained that she would have died without treatment and that the emergency medical laws provided for treatment at non-contracted providers.

    Their response was hey she did not notify us. Can't argue with that logic so make sure your parents have a palm pilot to schedule their falls.
  6. Ken_DTU


    ok that had me laughing this morning, thanks!

    Also I *completely* agree re let's look for healthcare options.. here in Hawaii, it's close to $700 for a family plan under Kaiser etc, very expensive if you're healthy and go to the doctor 1-2x / year..

    Any other ideas?

    also, which of the trader tax services are good, with a guy that knows his stuff cold? I'm *finally* getting back into more aggressive trading and know I'll want help in that area too..
  7. something that's way should tell everyone you know that you're a "bungrider" right away!

  8. :D

    True story -- nurse friend of mine's husband got his blood pressure taken once during a routine physical, and he was nervous, so it was way off what it usually was...

    It was taken again several times thereafter and was normal; however, that one time (called "White Jacket Hypertension" because some people get nervous around doctors) has now prevented him from getting a life insurance policy. (I mentioned in the other thread that it was health insurance, mistakenly).

    Bottom line, you gotta be careful NOT to let your doctor record ANYTHING on your medical history that could be a blackballing "pre-existing condition." That will screw you if you want individual health or life insurance, and haunt you for many years.

    A doctor friend of mine tells me that these days, many physicians will not write the word "depression" on a patient's medical records for the same reason.

    Other blackball illnesses include (afaik) sleep apnia, drug rehab stuff, and pretty much any mental condition, no matter how minor. Cheaper to go to a random doctor and pay out of pocket for the visit, order meds from mexico or canada, than it is to potentially be uninsurable.

    Be careful out there!
  9. Here's a hint for everyone on this thread: MOVE OVERSEAS!

    It's ridiculous what Americans have to go through to maintain health insurance. Read the 400 page policy manual and then recall the fine print years later while you are unconcious following an accident?? And then babysit the insurance company and the several health care providers to make sure they are keeping accurate records?? I'm a raging capitalist like (most) everyone else here, but a no-holds barred health care system is crap - a playground for lawyers, shysters, and their ilk. On top of that you end up with doctors performing 'extra' heart surgeries to drive ever higher revenue growth, ala Tenet Healtcare (THC) - anybody own some of that??

    Been living outside the US in developed and developing countries for several years and without exception the healthcare available has been head-and-shoulders better than in the US. US may have the best advanced research, but patients get screwed by everyone from the HMOs to the insurance companies when they actually need care. My experience has been that outside the US, in any reasonably developing country, basic patient care has been far superior. Universal healthcare works, believe it or not. Just too many deep-pocket interest groups have a stake in US' current status quo to allow for change.

    Whew, got that off my chest ... have a nice day.

  10. I'm had to go and am still going through unbelievable crap to get insurance. At this point HillaryCare is looking good. It seems like the deck is stacked against the individual/small biz owner when it comes to obtaining health insurance.

    #10     Sep 4, 2003