why private insurance sucks.

[diamenz]

https://chicago.cbslocal.com/2020/11...ning-reversal/

GRAND RIDGE, Ill. (CBS) — Three patients, decades apart on their journeys, are fighting to stay alive and are also battling to keep their intensive nursing care – after their insurance companies decided to take it away.

“My family is the world, and means the world to me,” said Jeff Lane of Grand Ridge, LaSalle County, who speaks through a computer.

Lane’s world is his wife and his three kids. He was diagnosed with amyotrophic lateral sclerosis, or ALS – also called Lou Gehrig’s disease – in 2002, just three years after marrying his college sweetheart, Debbie.

The disease has progressively taken over his body. He lost his voice in 2004, and he lost his ability to breathe by himself in 2007.

“It was either you’re going to do this or he’s not going to be here much longer,” Debbie siad.

But Lane never lost his sense of humor.

“Embrace the suck,” Jeff Lane said.

“Joking is definitely his thing,” Debbie Lane said.

Since he went on a ventilator, Jeff Lane’s insurance company has paid for private skilled nursing care. It was a blessing to his wife Debbie, who works full time and takes care of their three kids.

She said if she left her husband alone, “he would probably die.”

So you can imagine Debbie Lane’s panic this summer when she opened a letter from their insurer, Aetna, saying Jeff Lane’s nursing was being cut – completely.

“Why now? Why us?” Debbie Lane said. “Thirteen years later and now all of the sudden you don’t want to pay for his care?”

“Are you kidding?” Jeff Lane said.

Denial records sent to the Lanes state that while Jeff’s condition remains critical, the insurer concluded it has “stabilized.” This means he doesn’t need a skilled nurse, according to their clinical policy guidelines.

This determination was made without an evaluation, just based on his clinical records. And it’s news to the Lanes, since ALS is, by medical definition, a “progressive disease.”

“He has ALS,” Debbie Lane said. “How can you say he’s stable?”

The Chengs can sympathize – deeply. Their son, Leo, was born dangerously premature.

“Only a pound and a half,” said his mom, Jing Cheng.

Now at 2 years old, Leo’s little lungs also rely on a ventilator. But that hasn’t stopped him from trying to do all the things that healthy little boys do.

But a misstep for Leo, blocked airway, or a snagged breathing tube could easily be fatal.

“It’s something that keeps me up at night and we worry about all the time,” Jing Cheng said.

Up until now, Leo has also been under the watchful eye of a private skilled nurse. But the family’s insurer, Blue Cross Blue Shield of Illinois, informed them over the summer that those hours would be cut.

“It prevents an emergency from happening,” Cheng said. “It prevents Leo from having to Lose oxygen and have to get revived by paramedics and our home and abroad to the hospital and have a log on still stay. It prevents us that heartbreak.”

And it’s the heart break of losing Leo that the Chengs fear the most.

The Chengs had their first appeal denied. They’re still in the middle of their second.

The Illinois Department of Insurance said they don’t have the authority to comment on medical judgment in cases like these. But if families believe an insurance company is not honoring their policy, the department said they should file a complaint with the state.

Cheng said that’s the next step.

And it’s one of the steps, in addition to a 2013 CBS 2 investigation, that led to the state suing Blue Cross Blue Shield on behalf of another man, Patrick Stein, and others with similar medical needs.

Stein was only 17 when he came home from his homecoming dance with a pounding headache. His parents rushed him to the emergency room, and doctors rushed him into surgery.

“The aneurysm ruptured while he was on the table,” his father, Nick, said in September.

A massive stroke left Patrick with only the use of his eyes, which he now uses to spell out words, using a color and letter code.

BCBS was fined $25 million for failing to provide care. But years later, Stein’s private duty nursing is being pulled again.

What changed?

“Exactly,” Nick Stein said. “That’s the question that we all ask on our side.”

Three different Chicago-area families are stuck in the same boat.

But on Thursday, we are happy to report a stunning reversal in one of these cases.

Aetna never responded to our request for comment. But after we started asking questions, and after State Sen. Laura Fine (D-Glenview) reached out to the state about this case, suddenly the Lanes got a letter.

It stated, without any explanation, that Jeff’s private duty nursing had been reinstated.

[rawimpact]

Why do you think this is just private insurance denying a claim? Medicare/Medicaid insurers require preauthorization and certifications for certain procedures/CPT codes as well.

Most of these issues tend to be avoided once they do an appeal.

Where I work filing pre-auths is a daily thing. Often times we get denials for an MRI when there is a suspected tumor growth along a nerve. Doesnt mean they wont pay -- it just means it needs to go through an appeals process where someone with qualification takes a look at it case by case.

[diamenz]

Why do you think this is just private insurance denying a claim? Medicare/Medicaid insurers require preauthorization and certifications for certain procedures/CPT codes as well.

Most of these issues tend to be avoided once they do an appeal.

Where I work filing pre-auths is a daily thing. Often times we get denials for an MRI when there is a suspected tumor growth along a nerve. Doesnt mean they wont pay -- it just means it needs to go through an appeals process where someone with qualification takes a look at it case by case.

i'll be honest - i can't speak on all of the details and nuances because i frankly know f*** all about it. this story just tugged me at me because it's ****ed up what folks like these have to go through. it's bad enough they're dealing with a sick fsmily member, and their insurance comes to bite them in the ass out of the blue.

one of those families did file for sppeal, and got denied.

[rawimpact]

i'll be honest - i can't speak on all of the details and nuances because i frankly know f*** all about it. this story just tugged me at me because it's ****ed up what folks like these have to go through. it's bad enough they're dealing with a sick fsmily member, and their insurance comes to bite them in the ass out of the blue.

one of those families did file for sppeal, and got denied.

Well I can't blame you, there's a lot of people who don't fully understand health insurance or insurance in general.

Most patients will receive something called a EOB (explanation of benefits) and still be confused.

Then there's a very complicated billing structure that involves in facility out facility fee schedules, insurance allowables and contractual agreements and when there are secondary and even tertiary insurances/supplements it gets even more sticky.

If I had the time i'd write something up to explain it but i'm sure there are better writers and articles out there that explain if it you're wanting to better understand.

[diamenz]

Well I can't blame you, there's a lot of people who don't fully understand health insurance or insurance in general.

Most patients will receive something called a EOB (explanation of benefits) and still be confused.

Then there's a very complicated billing structure that involves in facility out facility fee schedules, insurance allowables and contractual agreements and when there are secondary and even tertiary insurances/supplements it gets even more sticky.

If I had the time i'd write something up to explain it but i'm sure there are better writers and articles out there that explain if it you're wanting to better understand.

'ppreciate it.

[Vino24]

I like my private insurance. Compared to my Canadian friends the level of care I can receive is worlds better. I think it’s fair you pay for the quality just like everything else.

[Jasper]

I worked in the insurance industry for 36 years for a reason... (so I would get insurance breaks from the average joe)

Wife is an RN --- same thing

Now the industries do not care if you work for them or not -- -we are all ripped off.
This year I had 27 injections in my back. ($30,000) worth of procedures...
Bill's started rolling in , as well as insurance statements (it was a mess)
Saw something on a statement and questioned how the insurance made an adjustment..
Get this -
My surgeon at the beginning of the year sign a contract with insurance companies (GETS PAID literally 100's of thousands of dollars)
so that adjustment shows up on your statement.
My doc lives close to me , in a million dollar home... Now you know how they get money before they even see a patient.

[Axe]

Third-world service in a first-world country? Lels

[rawimpact]

I worked in the insurance industry for 36 years for a reason... (so I would get insurance breaks from the average joe)

Wife is an RN --- same thing

Now the industries do not care if you work for them or not -- -we are all ripped off.
This year I had 27 injections in my back. ($30,000) worth of procedures...
Bill's started rolling in , as well as insurance statements (it was a mess)
Saw something on a statement and questioned how the insurance made an adjustment..
Get this -
My surgeon at the beginning of the year sign a contract with insurance companies (GETS PAID literally 100's of thousands of dollars)
so that adjustment shows up on your statement.
My doc lives close to me , in a million dollar home... Now you know how they get money before they even see a patient.

You're just another confused patient... before you go blasting your surgeon, you should understand what an adjustment is and what anti-kickback laws are.

I highly doubt your surgeon has an illegal agreement on paper with any insurer because if he did, he would lose his license to practice.

[bladefd]

You're just another confused patient... before you go blasting your surgeon, you should understand what an adjustment is and what anti-kickback laws are.

I highly doubt your surgeon has an illegal agreement on paper with any insurer because if he did, he would lose his license to practice.

All these insurance companies have secret agreements with certain doctors/hospitals/health care providers that we are not privy to. It makes it so that the same exact service differs from doctor to doctor/hospital to hospital. They will never tell you how much a particular treatment costs because the amount they charge even differs based on the insurance the patient has (and you won't know what the internal agreements are until they run your insurance for approval). Approval might take weeks so you don't have time to ask multiple providers how much they charge - if you want to know, they would each have to run it through the insurance for approval, each taking weeks. It's a bs system that benefits insurance companies and medical providers (more so the former). It screws over the patients.

What needs to happen is every facility should be required to make the cost of each treatment public. That way you can choose where you want to go. Insurance should provide one rate for each in-network providers and another rate for each out-of-network providers. If treatment costs more than what insurance is willing to pay then you are responsible for the remaining amount (or find someone else who charges less). That way you can choose who you want to go to depending on how much they charge. That's what free-market economics looks like. It would lower costs for everyone, open up the market and give choices to people to decide based on where they can go to save money.

This is a huge problem that needs to change.

[rawimpact]

All these insurance companies have secret agreements with certain doctors/hospitals/health care providers that we are not privy to. It makes it so that the same exact service differs from doctor to doctor/hospital to hospital. They will never tell you how much a particular treatment costs because the amount they charge even differs based on the insurance the patient has (and you won't know what the internal agreements are until they run your insurance for approval). Approval might take weeks so you don't have time to ask multiple providers how much they charge - if you want to know, they would each have to run it through the insurance for approval, each taking weeks. It's a bs system that benefits insurance companies and medical providers (more so the former). It screws over the patients.

What needs to happen is every facility should be required to make the cost of each treatment public. That way you can choose where you want to go. Insurance should provide one rate for each in-network providers and another rate for each out-of-network providers. If treatment costs more than what insurance is willing to pay then you are responsible for the remaining amount (or find someone else who charges less). That way you can choose who you want to go to depending on how much they charge. That's what free-market economics looks like. It would lower costs for everyone, open up the market and give choices to people to decide based on where they can go to save money.

This is a huge problem that needs to change.

You are wrong, there is no secret internal agreement. This is what I do -- I do contracting between providers, networks, policies and insurers for a major hospital system. We also offer our employees a HMO plan which I am responsible for so I see both ends of things.

The difference between any two clinics is the negotiation between the provider and the insurer. Facilities (and non-facilities) have fee schedules. There is a contractual agreement that is written off based on the negotiation and a fraction of that is paid by the insurer if the deductible is met, otherwise it's the patient's responsibility or goes to the secondary insurance.

Two providers cannot charge the same because they're not as good. The same reason you look at reviews when selecting your primary care -- you want the best? You and insurances have to pay them more. Often times you will see top surgeons in a hospital be affiliated with the hospital but part of their own practice. This, again, has to do with pay more for the better physician.

Providers do not benefit from insurance companies. It's a major headache which is why there are more providers that now offer concierge service (my wife who is a physician and myself both are a part of one).

Secondly, the latter part of what you said is illegal. What you are referring to is called balance billing and that alone is enough to get a physician kicked out of a network.

If you want to point fingers at someone, look to the sky scrapers in any city, they're owned by scumbag bankers and insurance companies.

EDIT: Also, if you want to know what a physician makes based on a CPT code, just go look it up on CMS's information. That will tell you medicare reimbursement on procedure codes for all providers enrolled in medicare. It's not a secret, it's ignorance. Reimbursement for medicare is PUBLICALLY accessible.

[bladefd]

You are wrong, there is no secret internal agreement. This is what I do -- I do contracting between providers, networks, policies and insurers for a major hospital system. We also offer our employees a HMO plan which I am responsible for so I see both ends of things.

The difference between any two clinics is the negotiation between the provider and the insurer. Facilities (and non-facilities) have fee schedules. There is a contractual agreement that is written off based on the negotiation and a fraction of that is paid by the insurer if the deductible is met, otherwise it's the patient's responsibility or goes to the secondary insurance.

Two providers cannot charge the same because they're not as good. The same reason you look at reviews when selecting your primary care -- you want the best? You and insurances have to pay them more. Often times you will see top surgeons in a hospital be affiliated with the hospital but part of their own practice. This, again, has to do with pay more for the better physician.

Providers do not benefit from insurance companies. It's a major headache which is why there are more providers that now offer concierge service (my wife who is a physician and myself both are a part of one).

Secondly, the latter part of what you said is illegal. What you are referring to is called balance billing and that alone is enough to get a physician kicked out of a network.

If you want to point fingers at someone, look to the sky scrapers in any city, they're owned by scumbag bankers and insurance companies.

EDIT: Also, if you want to know what a physician makes based on a CPT code, just go look it up on CMS's information. That will tell you medicare reimbursement on procedure codes for all providers enrolled in medicare. It's not a secret, it's ignorance. Reimbursement for medicare is PUBLICALLY accessible.

Those contractual agreements are private and we are not privy to the exact costs until they run it through the insurance.

I don't think you understood my argument. So I am not saying the provider should charge the same. I am saying the insurance should pay the same. Difference is the Healthcare providers/hospitals would have their rate public so you can compare different places. The insurance will pay the same anywhere you go so you would be responsible for the remaining amount.

So for example.. Lets say an echocardiogram (echo). Insurance would be willing to pay $750 max. Then you research through hospitals with public rates. You might find one provider charges $850 with trash reviews, another with above average reviews charges $950 and another with the very best reviews charges $1200. I would choose the middle one and pay $200.

Under current system, you will not know the contractual agreement. You might go to the one with the best reviews. You will not know what they charge until they run it through your insurance, which will take a few weeks. At that point, you will not have time to ask the other 2 health care providers because it would take weeks more to run each of them. I will end up spending $450 out of pocket when I could have spent half at the other place. I am not going to wait 2 months by running it through different providers to compare different places. I would prefer it be streamlined and straightforward. It is unfortunately not like that because this is a business built on maximizing profits even if it screws over the patient. That is a FACT.

Second, what is illegal? I am confused which part you are referring to. Point it out and if it's illegal, explain why it is illegal.

Third, OK let's stick with the echo example. Show me how much different hospitals get paid for echo in say nyc or whatever other city you choose. You said it's publicly accessible. Link me to it. (I don't have Medicare btw but let's assume I did and also let's assume I had private insurance - are they both publicly accessible?)

[rawimpact]

Those contractual agreements are private and we are not privy to the exact costs until they run it through the insurance.

I don't think you understood my argument. So I am not saying the provider should charge the same. I am saying the insurance should pay the same. Difference is the Healthcare providers/hospitals would have their rate public so you can compare different places. The insurance will pay the same anywhere you go so you would be responsible for the remaining amount.

So for example.. Lets say an echocardiogram (echo). Insurance would be willing to pay $750 max. Then you research through hospitals with public rates. You might find one provider charges $850 with trash reviews, another with above average reviews charges $950 and another with the very best reviews charges $1200. I would choose the middle one and pay $200.

Under current system, you will not know the contractual agreement. You might go to the one with the best reviews. You will not know what they charge until they run it through your insurance, which will take a few weeks. At that point, you will not have time to ask the other 2 health care providers because it would take weeks more to run each of them. I will end up spending $450 out of pocket when I could have spent half at the other place. I am not going to wait 2 months by running it through different providers to compare different places. I would prefer it be streamlined and straightforward. It is unfortunately not like that because this is a business built on maximizing profits even if it screws over the patient. That is a FACT.

Second, what is illegal? I am confused which part you are referring to. Point it out and if it's illegal, explain why it is illegal.

Third, OK let's stick with the echo example. Show me how much different hospitals get paid for echo in say nyc or whatever other city you choose. You said it's publicly accessible. Link me to it. (I don't have Medicare btw but let's assume I did and also let's assume I had private insurance - are they both publicly accessible?)

You can always call and ask your insurance what your responsibility isgoing to be -- This is afterall what you're paying for. Insurance of healthcare payment to provide you that care. There are good billing departments that can also offer similar numbers but are not completely up to date because we don't have live numbers to see if the patient has met their deductible or not.

Okay, so your example is an echo, CPT code for an echo is 99306, like I said you can easily look up the codes on CMS's website. Blade I don't know why I have to be the one to spoon feed information YOU are looking for. I told you how to do look up codes, just google it.
https://www.cms.gov/apps/physician-f...3&H1=93306&M=5

Not sure if that links going to work for you but that's the page that lays out non-facility, facility and Locality modifiers. Insurance companies base reimbursement on various factors, like cost of a facility to run its business. A hospital in New Bern, NC costs significantly more to do an echo compared to a hospital in NYC and i'm not talking about the physician but just the cost to operate. Insurance do not pay FLAT amounts for everything, there are significant number of factors that they use when contracting.

Do I think insurers need to be transparent in their benefits? Of course, but what most people do not know is that it's the insurance company that does not allow hospitals and providers to show their contracted amount. Trust me, physicians do not make anywhere what the average person think they make. That is why the waiting rooms are filled and they see as many Pts as they do.

Most insurances do not want their contracted amount released because they play a thin line -- they pay just enough so that the provider is okay but not too much to where they obviously are losing money. Some providers are enrolled with only X amount of insurers and so they choose based on contracted amount. IF those numbers were visible for other insurers to see, they'd up physician reimbursement and pull that provider away. It's a game set and played by insurances, hospitals and providers are unfortunately the ones that become scapegoats.

To clarify what I was saying is illegal is charging a patient more than the contracted amount.

[rawimpact]

Needless to say I meant cost to run a hospital in new bern NC is significantly less than NYC.

[tpols]

The USA has beyond the means to have a public health insurance buy in. And that would prevent this type of situation. Of course, private is available if you want, but it's elective. That's how it works in the "socialist" countries of Europe, who rank way ahead of us in healthcare.