Here are my most recent issues.
My husband has had several types of skin cancer, because of this he needs to see a dermatologist regularly for checkups (a few times a year). His claims for these visits kept getting rejected by the insurance company. We discovered they were not being coded as skin cancer follow up (which they were and would be covered). We spent close to 2 years trying to get the dermatologists office to send in his visits correctly coded. We even got the exact code from the insurance company and told them how to code it.
We recently moved and switched from one delta dental to another (each state is a different insurance company). Shortly after our move my husband had a crown replaced. Delta denied it since he was new to their plan. We were able to call and get them to waive the time requirement since he was insured by them the entire time. Took a little while for them to pay the dentist but they eventually did.
Last story is again about moving to a new state. In NJ for the past several years I would get an Ultrasound when I got my Mamo. I was told this was required due to some dense tissue in my breast. I moved to MA and tried to schedule a Mamo with an Ultrasound. Nope, wonât do that because insurance does not cover screening breast ultrasounds in the state of MA. So I get my Mamo, and guess what, they look at it and tell me I need an Ultrasound on my left breast. I had that and they now say I need to get ultrasounds regularly - hey that is what I tried to tell you in the beginning!
Kiddie- in the last 20 years Iâve had my breasts described as âdense and requiring ultrasoundâ, âDense but no follow up requiredâ, and âdensity falls within normal rangeâ. I had non-cancerous cysts aspirated in the office, a âpre-cancerousâ cyst removed surgically, and enough weird scar tissue as a result to send the mammogram operator into a frenzy of marking off the areas.
Every single one of these tests, procedures, biopsies, exams was eventually covered. But it took a LOT of energy, hours put on hold, and I switched radiology practices several times. The one I use now has expensive paid parking (which I canât stand⊠all the others had free or validated parking) but that price is a pittance to pay when I know that their billing people know the secret codes to get everything covered.
I am convinced that this back office, unheralded person should be making three times what she makes (I donât know why Iâm sure sheâs a woman) because she translates whatever the doc scribbles on the order and turns it into a magic code which unlocks the payment fairies.
There are some very savy businessmen (thatâs what they call themselves) that do this for a living - they become quite wealthy and powerful and very visible.
The MA radiologist was telling me to get a biopsy until he read the NJ radiologistâs report (and nothing had changed in those 2 years). So he instead put me on a six month ultrasound schedule.
Apologies if I shared before, but it is often nearly impossible to get advance estimates in writing. Recently I arrived for an OBGyn procedure/test that was scheduled in advance. Before they let me proceed, I was required to sign a form agreeing to pay if Medicare would not (this was specific to Medicare, not a general insurance waiver). The procedure was not uncommon. I asked if it was typically covered by Medicare, or not. Answer: ? I said I would agree to pay if I knew the cost in advance. Answer: ?? OK, the cost range, with a maximum. Answer: ??? So I signed, and under my signature I added I would only pay if I knew IN ADVANCE the maximum cost. It satisfied the front desk, and they let me into the next room.
I was told my 3d mammogram would NOT be covered because it was DIAGNOSTIC instead of my annual screening one (which would have been covered if I had chosen 3D). I called around to get a price estimate, range or max amount I would be charged. It was VERY VERY hard to get any number from the place doing the imaging or the insurer. I reluctantly got the imaging and paidâ believe it was <$40. Now I always get the 3D mammogram & have no copay and no return visits for re-imaging.
Preventive measures are covered 100% by the ACA act but if they find anything, then those procedures would be diagnostic and would be covered by your deductibles of your insurance policy.
Never fear, the preventive clause of the ACA act is going to be argued by the Supreme Court this year and it may be that all medical care will be covered by any deductibles that you have. So you wonât have to worry, every doctorâs visit and every procedure will be subject to the deductible that your individual policy has. No more confusion.
Once upon a time, the logic of having a deductible was that, if you had to pay first, youâd be more careful about spending. That was in the old days of $100 deductibles. Then they hypothesized that a jumbo deductible â $2800 for an individual, say â would really make you think twice before accessing care. And it does. Lots of people with ailments that theyâll have to pay for in full just donât bother to go to the doctor anymore â which is not the way medicine should be practiced.
Yes, when people forgo care, all they do is put off less expensive and easier prevention and management and end up with huge problems and issues that cost them, society the the medical system a ton more. Our system tends to be awful with preventative and well-managed care. Itâs putting out big fires and waiting for more big fires.
Yes, and furthermore, thereâs no evidence that ânot having to payâ makes people get extra or wasteful care. Preventative care? Yes. Cheaper in the long term care? Yes. We have oodles of data from the rest of the world on this.
Iâve had some annoying denials, but nothing life threatening. My brother had a critically low hemoglobin/hct of unknown origin. His doctor sent him to the ER for a transfusion. When I worked ICU, this lab value would have had us scurrying around getting orders for a transfusion. Same happened when my brother got to the ER. After the fact, his insurance refused to pay, saying it was not necessary. I was completely stunned and outraged by this. My brother was hit with a $13K bill that he really couldnât afford to pay. It makes my blood boil to this day.
When I had my appendix out last fall, the bill was around $37K and my portion was 7K. I donât know how people without a big income cope with these kinds of bills. Itâs awful.
Yes, the annual maximum folks are supposed to come up with is pretty jaw-dropping, especially on top of high monthly premiums! We were pleasantly surprised when our OOP max was hit and we had insurer pay 100% a few years when we had high medical bills. Our max was $2500/person, $7500/family. Itâs now $3000/9000, which is still do-able except of course for the things not included.