<p>^^Which is another way of saying the same thing. :)</p>
<p>Yep. (10 char)</p>
<p>For our State plan parent/child is less expensive than family coverage. I am surprised it is not the same for the federal plans.</p>
<p>Re post #1630:
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<p>Er no, you don’t. The screen you are talking about is NOT the same as the DEXA scan which I am talking about - [url=<a href=“http://www.webmd.com/osteoporosis/guide/dexa-scan]DEXA”>DEXA Scan (Dual X-ray Absorptiometry): A Test to Measure Bone Mineral Density]DEXA</a> Scan to Measure Bone Density<a href=“Price:%20$885”>/url</a>. You are talking about a heel screen (price: ~$50) – which I will pay for out of pocket. </p>
<p>My point was merely to give an example of something that is “covered” under an insurance policy only when the insurance company says it is covered. </p>
<p>As Hayden pointed out, there is always the possibility of negotiating with the insurance company. My d’s doctor at her college recommended a minor outpatient surgical procedure that was “covered” under the student health plan – my d. had the medical appointment in December and then took off for study abroad in Russia in January. I spent the next 6 months debating the insurance company over coverage. They ran me through all sorts of hoops – the matter was settled only after I got the person at my d’s college who coordinated the benefits plans involved. </p>
<p>I think the insurance company was acting in bad faith – I caught them outright lying to me about what procedure codes meant – and the following year my d’s college changed carriers – but the point is, if a procedure isn’t approved by the insurance company, it won’t get paid. ACA doesn’t change that. </p>
<p>I think the company I was dealing with followed the practice of purposefully denying legitimate claims on the assumption that most people wouldn’t persist. Because of my legal background, I’m not easily deterred in those circumstances. That practice of bad faith denial is well known among some companies – it is not legal but it’s hard to prove and the ACA doesn’t do anything to really address that. People are still going to have to do battle with their insurance companies in some circumstances.</p>
<p>Insurance policies generally only cover treatment deemed medically necessary (including preventive care). The insurance company will make a determination in every case. Obviously there are many cases where there is no room for dispute – when my d. broke her foot, there were xrays. But the point is that the insurance company has ultimate say over whether or not they pay for it, just as a college which meets 100% need has the ability to decide exactly what the student “needs”, no matter what the student and family think they need. </p>
<p>Of course that is not the same as treatment being denied – it’s simply a determination of who pays. But it is why that for any sort of costly, non-emergency treatment, the standard practice is to seek pre-approval from the insurance company before scheduling the treatment.</p>
<p>"Er no, you don’t. The screen you are talking about is NOT the same as the DEXA scan which I am talking about - DEXA Scan to Measure Bone Density (Price: $885). You are talking about a heel screen (price: ~$50) – which I will pay for out of pocket. "</p>
<p>Unless you know you have a problem, why do you need the bigger screen than the smaller one? The point of the smaller screen is to see if there are issues so more tests are warranted.</p>
<p>I am assuming if an issue is identified at the basic level, more testing gets approved by insurance as warranted without any age check.</p>
<p>You are missing the point. You wrote that insurance companies have to pay whatever the patient and doctor decide on – which is not the way it works. I gave you an example of a situation where my doctor’s opinion as to a procedure is not enough to satisfy the insurance company. You are assuming that the results of an inexpensive screening correlate well with the more expensive test, but that is not established. See: [Usefulness</a> of quantitative heel ultrasound compared with dual-energy X-ray absorptiometry in determining bone mineral density in chronic haemodialysis patients](<a href=“Usefulness of quantitative heel ultrasound compared with dual-energy X-ray absorptiometry in determining bone mineral density in chronic haemodialysis patients | Nephrology Dialysis Transplantation | Oxford Academic”>Usefulness of quantitative heel ultrasound compared with dual-energy X-ray absorptiometry in determining bone mineral density in chronic haemodialysis patients | Nephrology Dialysis Transplantation | Oxford Academic) </p>
<p>Because of my age, I have not opted to explore this particular issue right now – I’ll be age 60 in 6 months so we can revisit this soon enough.</p>
<p>But the point isn’t to debate about bone density screening. The point is that an item is only “covered” by insurance if and when they say it is. ACA has mandated expanded coverage in some areas, but it doesn’t micromanage the determination as to each procedure or service.</p>
<p>Must be since I have never had insurance refuse me anything. </p>
<p>There have been some expensive tests done in my family to isolate issues where the only suggestion ever made was to go to a preferred screener vs out of network screener for MRIs. So I am not familiar with the issues you point.</p>
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<p>I’m not sure what any legislation could even do to address this practice. After all, it’s already illegal. Maybe step up enforcement?</p>
<p>The ACA did, however, get rid of a similarly sleazy practice by bad-faith insurance companies, who would happily take people’s payments when they were well, but trump up some reason to throw them off coverage when they got sick. Oh, you got the sniffles when you were six, and didn’t tell us about that when you applied for your insurance? Sorry, we’re cancelling your policy now that you have breast cancer. OK, they didn’t cancel for the sniffles, but they did cancel for a previous condition of acne, and they did cancel in at least one case when a subscriber didn’t tell the insurance company about a minor condition that her doctor had noted on her medical records but hadn’t even told her about. The insurance company execs, in Congressional testimony, admitted to this practice, and would not agree to stop it in the future.</p>
<p>I took a look at the paper you referenced, calmom. Judging by the paper, you might want to think about having the heel screen if you haven’t already, as a pre-screen. According to the paper, a positive screening result is not dispositive-- you might or might not have the condition-- but a negative screening result means you don’t have the condition.</p>
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<p>And you’d rather not have any more X-rays than necessary. If you take the heel test and get a positive result, you’d still have to have the X-ray test, but if you take the heel test and get a negative, you’re done.</p>
<p>[This comment has nothing to do with the issue we’ve been discussing, about whether insurance companies deny treatments that doctors have recommended to their patients. Texaspg must be lucky indeed, and have lucky friends, if he doesn’t know anyone who has been denied by an insurance company. Texaspg, has no one in your family had a medical treatment that had to be pre-authorized by the insurance company? Not even medications? Never? That’s amazing.]</p>
<p>“Texaspg, has no one in your family had a medical treatment that had to be pre-authorized by the insurance company?”</p>
<p>There is a difference between preauthorization and denial. I am saying if a doctor said a specific test is needed, insurance does not say no. They may specify where to go to get a negotiated rate but do not turn down the test. I have had nuclear stress test a few years ago because the EKG was flaky. I was surprised by the bill but I paid the out of network percentage per contract and nothing more.</p>
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<p>Why on earth are you saying this, when calmom has just told you that her doctor said a specific test was needed, and her insurance said no?</p>
<p>You asked me about my experience. It is not the same as Calmom’s.</p>
<p>Oh, sorry, I misunderstood. When you said, “*f a doctor said a specific test is needed, insurance does not say no,” you meant, “In the past, when my doctor recommended a test, the insurance company paid for it.” I thought you were making a more general statement.</p>
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Aging runner here with bum knees. Discussion with HMO doctor about approaches to increase the activity level my knees will allow me to do … physical therapy, minor surgery (smooth out rough rough cartilage), injections to lubricate knee (my layman’s description), or knee replacement. Next conversation … my HMO will pay for option #1 (PT) … I’m on my own paying for any of the other options. I certainly am not in position of pursuing any viable medical option under my insurance.</p>
<p>I am stating that our insurances have not denied to pay for a test recommended by a doctor. It is possible they keep track of what is covered before recommending them. </p>
<p>Hopefully it stays that way. It is quite possible that within our own company people who chose HMO or another plan have similar experiences as 3togo.</p>
<p>I believe there is still some misunderstanding. There is no real way for your physician or you to " keep track of what is covered". The health insurance policy does not list procedures which are covered and ones which are not. It’s somewhat subjective. </p>
<p>If your insurer has never denied coverage for anything, then you and your family have been incredibly lucky. I hope that continues.</p>
<p>My wife’s doctors office kept putting the improper code for a treatment so the claim kept getting denied so she now gets the treatment as an inpatient at the hospital where it costs more and the claim is always paid.</p>
<p>In some cases, doctors do know which treatments would be covered by insurance, and which not. A number of times during discussions between me and a doctor, the doctor has said, “What’s your insurance?” <looks over="" at="" my="" record=""> “Ah, then we can/can’t do XYZ, your insurance will/won’t pay for it.” If that same doctor were talking with a person whose insurance definitely didn’t cover XYZ, they probably wouldn’t even have brought it up, even though they believed it would be the best treatment.</looks></p>
<p>That’s probably from experience, not from reading the policy. </p>
<p>Although I am pretty jaundiced in my view of health insurers I will say that most routine and even tertiary procedures will be covered if for no other reason than that they have to cover some basic levels of health or consumers would have been up in arms before now. And in other cases where they initially deny, you or your physician can argue / negotiate coverage.</p>
<p>The practice of rescission which Fang discussed in #1648 was one of the very worst abuses prior to ACA (and there were plenty of candidates for that title). Blue Cross of California was famous for it, and happily paid fines to the state which were negligible compared to the money they saved by booting subscribers after they got sick. Here’s another example of the complete and utter immorality of the pre-regulated insurance industry:</p>
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<p><a href=“http://www.truth-out.org/archive/item/74331:health-insurer-tied-bonuses-to-dropping-sick-policyholders[/url]”>http://www.truth-out.org/archive/item/74331:health-insurer-tied-bonuses-to-dropping-sick-policyholders</a></p>
<p>And Fang is quite correct; insurers never committed to stopping this despicable practice even when it was publicly exposed. They would still be doing it today if it weren’t prohibited by the new law.</p>