<p>In case you are wondering what my point is with this story 
ER’s get all kinds of weird medical situations every night and it does not seem feasible to have all of the medical professionals required to deal appropriately with each of these things from gunshot wounds, to car wrecks, to fevers, to ebola sitting around on staff in case someone shows up. That would cost a fortune. </p>
<p>RE the 3D breast tomosynthesis (diagnostic procedure): When I went for a mammogram in July, they had a new type of machine. They told me it was digital and 3D. From the web site, it is the Digital Breast Tomosynthesis. So that’s what I got, and my insurance (Blue Shield of California, exchange bronze plan) paid for it, 100%. </p>
<p>There was a little glitch in payment - at one point there was something online that said it wasn’t covered, but I called BS and the first person I spoke to said that it was an error and had been coded wrong on their end, and that it would be corrected – and it was. But the new-fangled machine could have been part of the reason it was initially miscoded – I don’t know, it’s just speculation on my part. Mistakes happen with data entry for all sorts of reasons. But they didn’t say that the problem was the machine used – they wrote that they needed to adjust their records to pay “at the preventative level.” </p>
<p>But here’s my guess on the insurance-pay issue. Where I live, there’s pretty much one place to go for a mammogram on my plan-- it is the women’s health center tied to the local Sutter hospital. That place bought the newfangled diagnostic machine and junked the old machine. So the insurance pays. </p>
<p>But maybe in another community, the main facilities on the plan don’t have the new machine yet. Maybe the question of whether or not the insurance will pay is a factor in whether the facility pays a zillion dollars to buy the new machine, and maybe the insurance companies are taking a go-slow approach. Or maybe it has to do with how each facility chooses to amortize its costs and bill for the services. The amount of the bill in my case was $446 – which I don’t think is particularly high for that sort of thing. So maybe the problem for the insurance company is that the urban facility with high patient volume is able to invest in the new technology and keep the per-patient cost under $500… whereas other facilities with fewer patients want to charge $1500 or $2500 or who knows what for the same procedure. </p>
<p>Here’s an article about the costs – <a href=“Bloomberg - Are you a robot?”>Bloomberg - Are you a robot?; – the article says that “some hospitals are absorbing the costs” - so another explanation can simply be that the facility I go to had decided to just code the procedure the same as the older type of mammogram and bill it at the same rate. </p>
<p>My notion is that under Fang’s Law no doctor would practice in a hospital if they didn’t take the insurances the hospital took.</p>
<p>Maybe one of the things the exchange plans could demand is any facility considered in network means any doctor who so much as picks up a latex glove on the property is considered in network. </p>
<p>When H was cardioverted I specifically asked the cardiologist if his assigned anesthesiologist was in network. This particular cardiologist made sure this was the case, he was very diligent. </p>
<p>How one can be even close to an informed consumer in this environment is beyond me. Since our government is now heavily involved in the medical care industry, one of the best and most important things it could do is mandate a Net Price Calculator for medical providers- similar to the ones colleges use. That at least would give the interested consumer a fighting chance. Oh, and if your website says the doc is in network, then it’s in network! If a consumer can print an image of the page showing doc in network and present it to the insurance company - well then it should be the end of the issue.</p>
<p>I would put the onus on the hospital: if I go to my in-network hospital, any treatment I get there has to be billed in-network. If the hospital wants to run two or more parallel networks, fine, but it’s their problem, not mine.</p>
<p>And having ER docs that don’t accept insurance is preposterous. Hospitals should not even let them walk in the door, let alone bill patients.</p>
<p>I have health insurance through FEHB as a retired federal employee. I read this clause in my insurance plan booklet -
</p>
<p>I think this is true of all FEHB policies but I’m not 100% sure. I think it should be universal, though.</p>
<p>It’s ridiculous. But, it’s entirely predictable cost-cutting. And, most people aren’t going to notice until it’s too late. I also seem to remember a couple of posters early on warning about this stuff and being told they were mean and that could never happen and they should share more or something. So yeah. It stinks.</p>
<p>It may be entirely predictable that hospitals and ER doctors conspire to fleece unwitting sick and injured people, but that doesn’t mean we should allow them to.</p>
<p>It’s also entirely predictable, Flossy, that you would blame something on the ACA that predates the ACA. ER docs didn’t stop accepting insurance this year. Nothing pre-ACA prevented this slimy procedure, and I recall several posters mentioning that it had happened to them.</p>
<p>Doctors can defend themselves but I doubt they are as a profession conspiring to fleece the sick. That would be a big problem, though. I don’t think ACA caused this issue but it is likely making it worse. Much worse.</p>
<p>It just seems to me the only thing people like about ACA is that it gives everyone an insurance card regardless of their ability to pay. It’s 3000 pages. That’s all.</p>
<p>The network issue is going to get a lot better. A lot better. </p>
<p>This is a multi year program. The overall cost issues are fine. The uninsured rate is dropping. </p>
<p>I am writing about my network issue because I believe in reality and not bs.
Many of the network issues are because of the insurance companies, the hospitals and doctors. </p>
<p>Just tell the public accurately who are in the plans. The public will be able to take it from there. </p>
<p>How can an insurance company or a doctor’s office not know who are in the plans? They are making the deals. Signing the contracts. </p>
<p>When my wife asks Anthem what is her share of the hospital costs and she doesnt get an answer, what kind of answer is that?</p>
<p>When a doctor says she takes the plan and she doesn’t, how does a patient deal with that?</p>
<p>These issues do not have to occur. </p>
<p>Edit… By the way, my wife has the codes of the procedures. She gave the insurance company the codes.</p>
<p>You can call it what you want, but $5K for putting five stitches in a kid’s chin counts as “fleecing the injured” in my book. Hospitals contract with the ER doctors, knowing full well that the ER doctors can charge anything they want to the patients, and the patients have no recourse.</p>
<p>And I agree with dstark that hospitals, doctors and insurers need to be more forthcoming and honest with people. The insurers know who they’ve contracted with. The doctors know how much they bill for a procedure when they send out a bill, so how come they can’t tell you beforehand?</p>
<p><a href=“https://www.aamc.org/newsroom/newsreleases/2010/150570/100930.html”>https://www.aamc.org/newsroom/newsreleases/2010/150570/100930.html</a></p>
<p>Statistics on the doctor shortage, which includes emergency medicine. ACA increased the demand but did nothing for the supply. Then the reimbursements try to artificially lower rates, but there is still a doctor shortage, so doctors don’t accept insurance. </p>
<p>1/3 of the country’s current doctors are Baby Boomers and are retiring. A few new medical schools have opened but not enough. Younger doctors, particularly the half that are women, want a better lifestyle, and don’t want to work 80 hours a week. And the number of residency spots has not been increased. </p>
<p>I wonder how many medical schools could have opened with the billions wasted on a website.</p>
<p>I have a friend that is a CEO of a company that manages doctor’s offices. His son had his appendix taken out. The hospital or doctor charged 5 times the normal charge. The CEO knows the proper charges. </p>
<p>The CEO calls up the hospital or doctor. I can’t remember. He asked what is going on here? You charged my son 5 times the going rate? </p>
<p>What do you know? The rate was dropped 80%. Dropped to normal. No ACA involved. Just bs.</p>
<p>I’ve been reading discussions here about healthcare issues for the many years I’ve been on CC, and it still baffles me why so many are against universal care. </p>
<p>Nothing wrong with negotiating the fee; it’s smart. </p>
<p>The ER/anesthesiologist problem is not a result of the ACA (and as some may have intuited, I’m not a big fan of the plan). BUT, when the weight of the Feds gets thrown at something considered to be a bit problem - ie health care, then that weight should not just be thrown around so that it looks good, but actually deal with the details. As far as I know, nothing in the 3000 pages address these past problems, nor forces rectification of new ones such as truly bogus in network listings. I was one of those people who checked, double checked and then made three phone calls to ensure I got the same answer at least twice. You would get a straight answer as to who was and who was not in network. </p>
<p>I can’t really blame the doctors. Take a look at the Blue Shield EPO offerings Silver 70, Silver 73, Silver 68, Basic Limited EPO, Basic Bronze EPO - I pity the poor front office staff who has to figure out the details. And as it becoming clear…the devil resides there, here is what they are dealing with…</p>
<p>Here is the list which pops up on a particular providers direct link:</p>
<p>Basic PPO/EPO Plans (Bronze) (Covered California)
Blue Shield Access+ CCSF Plan
Blue Shield Access+ HMO Plan
Blue Shield Access+ HMO Plan for Individuals and Families
Blue Shield Added Advantage POS (Point-Of-Service) Plan
Blue Shield Life and Health Insurance Company
Blue Shield Medigap Medicare Supplement Plans
Blue Shield Spectrum PPO Plan
Blue Shield Spectrum PPO Savings Plan
BlueCard Plan
CCPOA Medical Plan
CalPERS - Blue Shield 65 Plus HMO Group
CalPERS Access + HMO
CalPERS NetValue HMO
California Choice Access + HMO
Enhanced PPO/EPO Plans (Silver) (Covered California)
Federal Employee Program (FEP) - PPO
Get Covered PPO/EPO Plans (Catastrophic)
HMO
Indemnity
Local Access + HMO
Major Risk Medical Insurance Program (MRMIP)
Preferred PPO/EPO Plans (Gold) (Covered California)
Shared Advantage - PPO ASO and Shared Advantage Plus - PPO ASO
Shared Advantage ASO - Tiered Network Plan for John Muir
Shared Advantage PPO ASO - Adventist
Stanford EPO - Self-Funded ASO
Ultimate PPO/EPO Plans (Platinum) (Covered California)
Vital Shield 900 & Vital Shield 2900 Plans </p>
<p>Now, when you go to the BS website the following plans pop up. It is not possible to tell if these are all the plans BS ever dreamed up, or if these are only the ones the provider accepts</p>
<pre><code>0 Cost Share EPO AI-AN
0 Cost Share PPO AI-AN
Access +HMO
Access+HMO
Access+HMO Savenet
Access+HMOSavenet
Active Choice Plans
Basic EPO (Bronze level)
Basic EPO for HSA (Bronze level)
Basic Exclusive PPO for SHOP
Basic Exclusive PPO for Small Business
Basic Full PPO for HSA for Core Accounts 5500
Basic Full PPO for HSA for Small Business 3500
Basic Full PPO for HSA for Small Business 5500
Basic Full PPO for Small Business 4500
Basic PPO (Bronze level)
Basic PPO for HSA (Bronze level)
Blue Shield of California PPO Network
Bronze 60 EPO
Bronze 60 EPO AI-AN
Bronze 60 HSA EPO
Bronze 60 HSA EPO AI-AN
Bronze 60 HSA PPO
Bronze 60 HSA PPO AI-AN
Bronze 60 PPO
Bronze 60 PPO AI-AN
CCPOA Medical Plan
CalPERS 2015 Access+ HMO
CalPERS 2015 NetValue HMO
CalPERS Access+ HMO
CalPERS NetValue HMO
CalPERS Supplement to Original Medicare plan
Core Flex Basic HMO 45
Core Flex HMO 20
Core Flex HMO 30
Core Flex HMO 40
Enhanced EPO (Silver level)
Enhanced Exclusive HMO for SHOP
Enhanced Exclusive HMO for Small Business
Enhanced Exclusive HMO for Small Business 55
Enhanced Full HMO for Core Accounts 55
Enhanced Full HMO for Small Business 55
Enhanced Full PPO for Core Accounts 1250
Enhanced Full PPO for HSA for Small Business 2000
Enhanced Full PPO for Small Business 1250
Enhanced Full PPO for Small Business 1700 (previous 2000)
Enhanced PPO (Silver level)
Get Covered EPO (Catastrophic)
Get Covered PPO (Catastrophic)
Gold 80 EPO
Gold 80 EPO AI-AN
Gold 80 PPO
Gold 80 PPO AI-AN
Local Access+ HMO
Local Access+HMO
Minimum Coverage EPO
Minimum Coverage PPO
Platinum 90 EPO
Platinum 90 EPO AI-AN
Platinum 90 PPO
Platinum 90 PPO AI-AN
Preferred EPO (Gold level)
Preferred Exclusive HMO for SHOP
Preferred Exclusive HMO for Small Business
Preferred Exclusive HMO for Small Business 30
Preferred Full HMO for Core Accounts 30
Preferred Full HMO for Small Business 30
Preferred Full PPO for Core Accounts 0
Preferred Full PPO for Core Accounts 750
Preferred Full PPO for Small Business 0
Preferred Full PPO for Small Business 750
Preferred PPO (Gold level)
Premier PPO 15
Premier PPO 20
Premier PPO 25
Premier PPO 35
Premier PPO 45
Premier PPO 5
Shield PPO
Shield PPO Combined Deductible 25-250 90/60 Foundation
Shield PPO Combined Deductible 35-500 90/50 Foundation
Shield PPO Combined Deductible Value 25-2500 80/50
Shield PPO Combined Deductible Value 35-3500 80/50
Shield PPO Plans
Shield PPO Savings Plus Aggregate 1250/2500
Shield PPO Savings Plus Individual Member Deductible 2600
Shield PPO Savings Plus Individual Member Deductible 3000
Shield PPO Savings Plus Individual Member Deductible 3500
Shield PPO Savings Plus Plans
Shield Saver
Shield Secure
Shield Spectrum PPO 0/500- 90/70 Premier
Shield Spectrum PPO 0/500- 90/70 Standard
Shield Spectrum PPO 0/500- 90/70 Standard Foundation
Shield Spectrum PPO 1000- 80/50
Shield Spectrum PPO 1000- 80/60 Premier
Shield Spectrum PPO 1500 - 80/50
Shield Spectrum PPO 1800 - 80/50
Shield Spectrum PPO 250- 80/60
Shield Spectrum PPO 250- 80/60 Foundation
Shield Spectrum PPO 250- 80/60 Standard
Shield Spectrum PPO 250- 90/70 Premier
Shield Spectrum PPO 250- 90/70 Standard
Shield Spectrum PPO 2500 Value
Shield Spectrum PPO 500- 90/70
Shield Spectrum PPO 750- 80/60
Shield Wise
Silver 70 EPO
Silver 70 EPO AI-AN
Silver 70 PPO
Silver 70 PPO AI-AN
Silver 73 EPO
Silver 73 PPO
Silver 87 EPO
Silver 87 PPO
Silver 94 EPO
Silver 94 PPO
Simple Savings
Small Business Enhanced PPO
UC Care Plan (Blue Shield Preferred)
Ultimate EPO (Platinum level)
Ultimate Exclusive HMO for SHOP
Ultimate Exclusive HMO for Small Business
Ultimate Exclusive HMO for Small Business 25
Ultimate Full HMO for Core Accounts 25
Ultimate Full HMO for Small Business 25
Ultimate Full PPO for Core Accounts 150
Ultimate Full PPO for Small Business 0
Ultimate Full PPO for Small Business 150
Ultimate PPO (Platinum level)
</code></pre>
<p>Alwaysamom, we like to pay more for less. :)</p>
<p>I’m with patsmom 15525. That s exactly what my insurance co clarified to me, when this came up on this thread, months and months ago.</p>
<p>Anyone ask their insurer? </p>
<p>“Nothing wrong with negotiating the fee; it’s smart.”</p>
<p>Why do we have to do this? It’s like visiting the middle east or third world country and negotiating the price of a scarf. </p>
<p>You don’t have to. You could pay whatever they ask. How are you at car buying?</p>