<p>I made the mistake of citing a specific recent example from my own experience to illustrate a more general point. When I say that insurance companies have the right and the power to make coverage determinations and deny procedures they do not deem to be medically necessary, I was speaking from my legal knowledge. It’s a whole lot of years now, but I believe that they did cover insurance in law school. In any case, I’ve had plenty of experience reading insurance policies and understanding what they mean, and what the respective obligations of the parties are-- as well as knowing what legal rules of interpretation govern the policy.</p>
<p>Obviously an insurance company would be on shaky ground if they denied a procedure that conservative medical professionals would tend to recommend and support --so when there are guidelines issues by public health agencies, the insurance companies are going to tend to abide by them. </p>
<p>But insurance companies can and do deny specific procedures – they do it regularly, and I have never seen nor heard of an insurance policy that would bind them to paying for whatever service that the patient and doctor decided, irrespective of circumstances. Obviously this tends to come up when patients have unusual needs or are seeking newer and less well-established procedures. An example of a new procedure that many insurances will not pay for is virtual colonoscopy --it is less invasive and generally less costly than the standard colonoscopy, but many insurance policies won’t cover it. My point isn’t to address the merits of the virtual procedure vs. the standard one – but to address the issue of patient choice. The fact that the patient opts for the newer procedure does not mean the insurance company has to pay for it.</p>
<p>"In some cases, doctors do know which treatments would be covered by insurance, and which not. "</p>
<p>Good doctors have people in their office who smooth the process with the insurance companies on your behalf. This is how they come up with numbers for out of pocket so one can arrange the payments when they end up being large. When we were having kids, the doctor gave us the cost, the expected out of pocket and a nine month scheduled payment plan through delivery.</p>
<p>Again, it might be just my experience and not the universal rule.</p>
<p>I’ve never been asked to prepay anything other than the standard office co-pay for anything covered by insurance. The process has always been that the claim is submitted to the insurance company first and my payments are only due after the insurance has provided an EOB reflecting patient responsibility amount. </p>
<p>Obviously we have very different experiences, but I would be very unhappy with system such as what you describe. I always knew what my plan deductibles were so I could plan accordingly.</p>
<p>"The process has always been that the claim is submitted to the insurance company first and my payments are only due after the insurance has provided an EOB reflecting patient responsibility amount. "</p>
<p>Not true in my office, nor what is recommended in “practice seminars” . Many smaller practices say the portion you owe, however estimated, is due at the time of service. Yes; smaller practices may be doomed. </p>
<p>My d saw someone who didn’t figure out what was due until it was too late to file, and the whole bill was denied! Sort of a mental health “chain”, as in restaurant chain, but seemingly making its money on psychopharm and not therapy. It can survive for awhile, but I’m not sure how a practice like that will survive. Not sure how many small practices will survive for that matter.</p>
<p>My office manager says this ACA exchange deductible piece will be a bit of a nightmare for billing. Even now, so many folks don’t seem to know they have a deductible, or what their co-pay is.</p>
<p>You may need 30 sessions of PT according to your PT and your doctor, but you might well have an insurance plan that allows only 20 per calendar year. Period. </p>
<p>You might need PT, but you might well have an insurance plan that decides that if you’re not showing improvement fast enough – or you’re a lot better – that further PT is unwarranted and won’t be authorized, no matter what your doctor and PT think.</p>
<p>And if you’re on single payer (that’s a joke) Medicare, you might find that whether or not a procedure is covered depends on where you live, because while you’re covered by Medicare, many actual coverage decisions are made on a local basis by the “intermediary” Medicare has hired in your area, and different intermediaries have different rules for what they will and won’t cover. (We hit this with my mom where a pain treatment covered where she used to live wasn’t an allowable procedure once she moved here.)</p>
<p>If you’re insured by one of the behemoths in your area (like United Healthcare around here, or Medicare) lots of practices seem to be familiar with what they will and won’t cover. If you’ve got some relatively infrequently seen coverage, I doubt they have much idea at all. </p>
<p>And despite there ostensibly being on-line instant estimates of what my out-of-pocket should be (I have a deductible, not a copay) I have yet to be asked for payment at the time of service, since apparently none of my doctors uses the on-line system. I don’t know why. (My dentist’s office, on the other hand, collects at time of service and is usually accurate to within a few dollars of what will be owed.)</p>
<p>Shrinkrap, I should have clarified – I have had a different experience with mental health counselors – but at least in the past the benefits for that have been structured in a different way. Generally I would have a policy that would permit a certain number of outpatient visits per year, and specify pretty clearly what the insurance would pay – for example, we would know that we could have 20 visits and the insurance would pay $40 per visit. Then we would work out the difference with the provider. </p>
<p>But that’s very different than a situation where I get physically sick and go to the doctor; maybe the doctor orders up some tests, writes a prescription, and perhaps there is one follow up visit. There it has generally been that there’s a fixed co-pay that is charged up front – let’s say, $20 – then the rest is submitted to the insurance, they pay whatever they are going to pay, and I get a bill down the line for the balance.</p>
<p>I think the mental health coverage will be structured differently under ACA, though I haven’t really looked into it.</p>
<p>I don’t know how different mental health will/should be given parity laws. ( I am a physician, not a counselor, and often use the same codes my husband the FP does).</p>
<p>I’m pretty good about documenting, knowing my patients be benefits and formularies, but I have, and have known doctors who have had payments for labs denied, prescriptions denied ( or time consuming authorizations requested) , and LOT’S of claims denied, even when we’ve dotted all the I’s and crossed all the T’s. </p>
<p>I think the bigger problem is when an insurance company is known for that sort of thing (I’m looking at YOU Anthem Blue Cross), and soon few provider’s will take it. Same might be true for very difficult, very complicated problems that just don’t make sense to take on, unless you just love that sort of thing. </p>
<p>But I’m sure it will all work out in the end. :D</p>
<p>Well, I’m not likely to find out, as I don’t anticipate a personal need to know in the near future. Personally I think I’m going to stick with the insurance I have, which is an HSA plan so I simply write checks from the HSA for whatever the insurance won’t cover. My main interest in this thread has been more along the line of making sense of the premiums and subsidies, not so much worrying about the other end of the process as to what the insurance will actually pay for.</p>
<p>I have an HSA plan too. In fact, I am finally moved to bite the bullet, and eat the cost of taking HSA and other credit and debit cards In my practice.</p>
I’m sure it is, as the taxpayers are contributing towards both Sue’s and her son’s policy. Take a look at some non-gov’t policies, Sue, and you will feel fortunate with yours. For one thing, there are often steep increases based on the employee’s age. That doesn’t happen with the fed plans, does it?</p>
<p>Taxpayers receive a service from government employees. Government employees are compensated with wages and benefits. Please don’t start with the “makers and takers” stuff.</p>
<p>It astonishes me how people would rather direct their resentment toward others who have something they wish they had, rather than try to advocate that everyone deserves the same benefits. This is the race to the bottom in a nutshell.</p>
<p>^^^sally, you put this into words far better than I. The only thing that I would add is that some people seem to forget that government employees are ALSO taxpayers.</p>
<p>A pet peeve of mine: When you ask the doctor what course of treatment they recommend, and they ask you what insurance you have before answering. </p>
<p>I’d much rather know their MEDICAL opinion regarding treatment. Then if that’s not covered, we can move on to the next best thing. I can never tell if they’re offering me Option 2 because my insurance doesn’t cover Option 1, or if they’re offering me Option $$ because my insurance does cover it, even if Option $ would also work.</p>
<p>Next time, I’ll ask them to explain ALL my options.</p>
<p>Let’s try this thought experiment: Ignore insurance. Suppose you were paying out of pocket for all your health treatments. Would you want your doctor to tell you about every possible treatment/test for your condition? Would you even want to hear about a treatment/test that costs a million dollars, and is a tiny bit better than the treatment/test that costs a hundred dollars?</p>
<p>It’s naive to pretend that money is no object. Money is an object, no matter who is paying.</p>
<p>Fang, good questions. Don’t forget I also said “or if they’re offering me Option $$ because my insurance does cover it, even if Option $ would also work.”</p>
<p>I want to know if there’s a treatment that’s not covered by my insurance that will be better for me physically/medically. Then it would be my decision whether to spend the money. </p>
<p>I’ve sometimes chosen to take a non-covered medication because the covered medication isn’t effective (enough) or has side effects I can’t handle. Sometimes insurance agrees with my appeal to cover it, sometimes not.</p>
<p>What my docs say is along the lines of: “what I think would be most appropriate” or “what I’d like to try, first.” Sometimes: “I think this is as simple as-” Then with the caveat that they will run it by the insurer, see how much they will support it and pay. I’ve also had docs tell me why they advise against more expensive treatment. Eg, why it’s probably a bust for me to have knee surgery. </p>
<p>I bring this up because I think we each have different specific experiences, varying by our areas, our particular situations and the docs involved.</p>
<p>Same goes for the earlier argument about the elderly. Doc recently insisted my mother not have a particular surgery, based on problem x being slow to pose problems, the availability of an Rx that would do the same and the awfulness of the recovery.</p>
<p>I understand your point, axw. I don’t love insurance companies. I think they have engaged in evil practices like throwing people off insurance because they get expensive diseases.</p>
<p>However, my issue with doctors is, I don’t think they know which treatment is better, in situations where the state of medical knowledge is changing. They are far too swayed by anecdotal evidence of small numbers, and far too ignorant of statistics.</p>
<p>For just one example, look at the stents we’ve been discussing here. We’ve known since at least 2007 that stents for non-acute cases of angina are no better than alternative non-surgical treatments. We know why, too-- because heart disease is systemic, and fixing just one little place isn’t going to stop a blockage somewhere else. And yet, year after year, doctors keep putting those stents in, because that’s what they’re used to doing. The only way to get rid of that treatment is to stop paying for it, or to wait for the doctors who are doing it to retire.</p>
<p>Suppose insurance companies stop paying for the stents, as they should. Some damn doctor is going to sit there and whine that the right way to treat you is with a stent, but the evil insurance company won’t pay. But he has no idea what he is talking about.</p>