So, let's translate this:
1. It's okay with us if you have an MRI.
2. We may pay for it. Then again, we may not. We won't decide until AFTER you actually have it done.
3. If, after we get a bill, we decide not to pay for it, you will have to pay for it.
4. If we do decide to pay for it, you'll still likely have to pay part of the bill. How much this will be will depend on what we decide. We'll let you know after you've already had the test.
5. Once you get the test, you have absolutely no say in the matter. We, on the other hand, can change our mind at any time.
36 comments:
It's not doublespeak. It's plain as day.
And patients want to know why we can't tell them what something will cost. Heck, the company that decides that doesn't even know yet.
That is supremely fucked up.
Sounds like Humana or United?
I was once so naive that I used to just agree to tests assuming, since I had insurance, it wouldn't cost me much out of pocket. Definitely now older and wiser but I agree...the system sucks worse than ever!
Plus, they have their fingers crossed behind their backs.
Wish I could say that I'm even slightly surprised by that letter but it's too common.
As a speech therapist, I'm trying to get insurance to cover a device that talks for a patient who can not talk himself. Device costs $5000. Insurance response was that in order for them to pay for device, I needed to first submit video of him using the exact device to communicate. Ummmm??? How do I do that if he doesn't HAVE a device yet? If he HAD a device, I wouldn't be asking insurance to buy him one. If the family had the money to buy him one, they wouldn't be throwing themselves at the mercy of the insurance company.
I had nearly the exact experience yesterday concerning lab tests. After a long telephone call with my insurance company, I finally gave up and allowed the clinic to draw blood and am just hoping for the best.
So I says to myself: Feeling lucky punk ? Do I really need this MRI or not, am I feeling lucky today ? In all that talk I ask myself did I loose track of something
Well, ya gotta say dat da way't wuz bifor, if youzea hadda da dezeez, orda yer aunty hadda da dezeeze, yuda woundna e'en hadda da insurance cuz yuda wouda bin disqualified from da gitgo. Eeny way yuda look at't da insurance ain't gonna be oudda da pitcher. So, now da compn'y jes hires da folks widdow no soul and comes up widda dis Engrish explanation, all in Engrish perfickly leego-like.
It's all driven by greed. If we don't regulate these companies, it'll continue to get worse.
Amen, Packer...
Blue Cross/BlueShield is a rip off on MRI's in Idaho.
They've decided that a "reasonable" maximum for radiological procedures is$200. So the most they will pay is 80% of $200, or $160 towards an MRI. Leaving you with the $1800 balance.
They've done it twice to my family, about 10 years apart. They do apply the full $2000 towards my $3500 deductible though. That is nice of them.
This stuff is usually done up in such tortured English that you can't even figure out the facts in it. The facts (such as they are) are clear - they just don't have any logical relationship to each other, and do not answer the question being asked.
Yep, United or Humana, with a little BCBS flavoring,
And docs wonder why pts hesitate about tests. It's not the pain or fear of the unknown. It's because the "wallet-ectomy" they KNOW is coming. Do you know when most bankruptcies occur? Right after a major illness.
I am a special ed teacher and have gotten trials of devices for many, many students. I have used or state system for loaning but I have used the actual companies too. The ones I have used have done trials. It does make sense to trial it first if it is at all possible. Now I have never ever heard of providing a video but we typically have to provide data. MA is what we typically go through.
This is the current definition of "Prior authorization" obtained from insurance companies. Even if they approve a service, they reserve the right to rescind that approval after the service has been performed. I think if more people realized this there would be outrage. But I guess there are too many things to be outraged about these days.
I think what they are actually saying is:
1. It's okay with us if you have an MRI.
2. If your doctor actually just does an MRI, that's cool.
3. If we get the bill from the doctor, and instead of just an MRI, he also did a head transplant and a leprosy test, you are on your own.
My orthotics were approved without doublespeak. Then, after the $400 bill arrived, insurance decided they weren't covered after all. Ouch. Better than eating an MRI bill, though.
Dr. Grumpy provided the exact translation for my medicare provider's authorization. To condense even further: We will, or we might not (shrug.)
Years ago, when my son was very sick, in the hospital and hooked up to machines, when the doctors weren't sure if he'd be leaving the hospital, we got a a letter from the insurance company saying that they were denying payment because he could be treated on an outpatient basis.
Insurance companies vary greatly in how reasonable they are and how they treat customer service. Some it's like pulling teeth and cutting off an arm and a leg to get anything covered, and others are cool as long as the doctor can show that the test is necessary, even as a precaution.
In this particular case, though, they really need to take a class in legally covering their tails without falling into weasel words.
That sounds about right.
Carrie,
How did you get these "loaner" devices? I work for a hospital and don't have access to any used or older model devices. I contacted the device company but they are not able to provide a loaner.
I wish I could use the child's school as a resource but they have made it clear that they don't have funds for any other types of equipment.
Yep, Bunkywise and anonymous 11:03, you have hit the nail on the head. Having worked in health care for years and seeing how depraved it all has become I sing this ditty to myself daily: "for profit medicine is a piece of dung, it's a piece of dung, it's a total piece of dung. Only thing that MATTERS is the almighty dollar.
I don't really understand the US medical system, but can't you just change your insurance provider if your current one is crap? Free market something something?
Anonymous @5:51: Not really. Most of us are locked into the one our employer picks. You can get individual plans, but most are outrageously expensive; then they throw in "pre-existing conditions." If you've been treated for a problem in the last six months/year, they do not cover that problem at all.
Happy Catch-22!
When my son was born, he was a premie.
Blue Cross paid the ICU bill, no questions, then denied the Neonatologist because they didn't cover "Well Baby Care".
Doctor took care of that appeal, never heard anything else about it.
ACA is in transition. Purportedly people have more room for complaint about the unfairness.
When I had a brain tumor back in the 70s, my grandparents helped out when the liberal insurance situation didn't cover everything, including the flight coverage to a hospital thousands of miles away from a MRI.
For years, yes nearly a decade, while my husband and I were in school, our firstborn had what is called proactive preventative medicine; everything free that we qualified for, and a trip to the doctor at the first sign of some sort of infection, and we were lucky that was the extent of his illnesses. In the 'old' days, we did not see a doctor, because we couldn't afford to get or be ill.
However, when I asked our GP at graduation, relocation to another state for residency about health insurance, she helped me to sign up our family--and told me NEVER allow the coverage to lapse, because the next time I would be denied because of the brain tumor, and then I would ever after have to reveal that I, as breadwinner, had previously been denied insurance coverage. Which forced me to be employed by large corporations and never have sequelae.
When I decided to change jobs 10 years ago, I had to apply for COBRA--a temporary and exorbitantly expensive 'national' right to access to health insurance under the law, because employers gave the potential employee 90 day 'probation' and health insurance wasn't available until that period passed.
AFTER that, then employer-sponsored group insurance plans were available, of a couple different options, and were either take-it-or-leave-it.
Since I had my 'pre-existing condition', and I was sole support for my family, healthcare coverage premiums were based on my 'pre-existing' historical health status, no matter that my spouse and children were the healthiest creatures on the planet.
So, to answer the question from someone from another country, the previous system had inherent flaws that served to benefit the super-rich speculators and middle-men, and now, this system which is still built on 'free-market' freeforall cannot be designed to get rid of the grafters who get by with this BS in attempting to limit access to healthcare.
I remember for a long while, i.e. 20 years ago, there was this discussion in our country as to whether access to healthcare was even a 'right'. Can you imagine?
I couldn't imagine how hopeless this sort of murkiness existed until my close family member was involved in a crisis for which care was denied resulting in suboptimal outcome with long-term impact affecting his ability to think, reason, memory.
I couldn't believe that I was writing letters to hospital administrators, insurance companies, medical review boards, medical credentialing committees, pharmaceutical benefits managers, and in return, I am still getting calls from collection agencies, and my credit rating--with a bank that I'd done business with for 25 years denied a home-loan line of equity on a home paid off for more than ten years because of the debts incurred--that I've only now been able to reduce to just in the hundreds of dollars.
ACA was designed to provide for American consumerism capitalist 'rights' as opposed to 'socialism' and 'communism' and insurance companies will get away with the double-speak, until we as a nation realize that good health is fundamental to a healthy nation, not just for the wealthy. Notice, I said 'good health'; I didn't mean every nth degree of whatever money can buy but decent, affordable, accessible care.
(Hopping off soapbox, now)
ACA has nothing to do with it. I was in practice LONG before ACA, and have seen this sort of the thing since I started. I don't think it's any more (or less) common or confusing now than it was then.
@tbunni: Okay, that explains a lot, but why is it set up like this? In Germany, you choose your insurance provider and your employer pays half of it. Since all companies want a lot of customers, their prices are similar and their coverage is basically the same. Some pay an extra vaccination here or homeopathic treatment there to attract customers, but none could afford to deny you an MRI your doctor deems neccessary, or everyone would simply swith insurance if the word spreads.
Insurance providers can't refuse to take you as long as you stay in the statutory health insurance. Only if you choose private insurance (which covers a little better service but is much more expensive) they can demand health checks and set your premium at any rate they want, and it's incredibly hard to get back into statutory health insurance once you had private for a while.
"We have approved your purchase of a new Toyota Camry. Although we have received your payment of $22,000 this approval is not a promise that you will actually get to drive the car. We can't be sure you can have the car you have already payed for until one of our clerks who knows nothing about cars performs a time-consuming analysis using our top-secret algorithm. In fact, we may just keep the car and sell it to someone else."
Oh, don't get me started. After an auto crash last May (we were not at fault) I spent a month in the hospital and then rehab. Most bills STILL not paid, despite our having insurance, and despite my needed emergency surgery (I did almost die...that would have been cheaper!)
Rehab place, after our making sure it was in-network when we picked where to send me and got Blue Cross approval, has decided NOT to bill insurance, so they won't have to accept the contracted network payment. So even when you do everything correctly, you lose. Sigh.
JFS in IL
Not to bring politics into this, but this is why I want universal health care. Pay for only the basics..at least then we can PLAN for our expenses. We will KNOW what is and what is not covered.
As it stands now, we pay a bloody fortune every pay period for a promise to have medical expenses covered IF the insurance can't find a way to weasel out of it. What kind of a system is that?
Gotta love insurance companies. Where else can we pay money for a service and have to fight to collect on that service.
Late to this Kafka party and now in pain from vigorously nodding YES! YES! YES! to the post and comments!
Dr. Grumpy, have you considered sending this piece of genius off to the Upshot NY Times column? They are doing a series called "Paying Until It Hurts".
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