Before I retired, I routinely told patients that a commercial insurance company’s job is to not pay. That’s how they make money. It’s bizarre to me that there isn’t a broader and louder outcry.
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Me too.
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My anesthesia was not covered either! Several very long phone calls, they said it was covered at the end of each, but kept receiving bills from a third party, I finally paid to reach our deductible last month, received a check back.
29 years ago my hospital stay for an induction (42 weeks pregnant) was denied because the induction failed and I went home for 12 hours (my water finally broke at home so I went back to the hospital). It wasn’t considered pregnancy related because I didn’t have a baby (at the time you were supposed to call insurance before being admitted to the hospital except childbirth, you were told to just call Aetna after the child was born, so we didn’t call before the induction). It took an entire year, my mom was a legislative aid for an assemblyman at the time so she finally got involved.
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My dad told me to never not have health insurance, even if it meant living in my car. I have passed on that advice to my kids.
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About 12 years ago my company had switched to United Health Care. My wife had an ambien script for 4-5 years. First time trying to fill with United they wouldn’t and wanted her to try other things first. She had already done that previously. Luckily United bolted from IL for a period of time and we went back to BCBS.
Also the hoops my wife would go through to get our daughter’s epipens at a reasonable cost has been crazy. Trying to find manufacturer coupons or programs that would make it affordable.
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I live in fear of the dismantling of the ACA because I know the insurance companies would be all too happy to dump those of us with pre-existing conditions. And then what?
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Our former legislator was a big supporter of the insurance industry. His advice for families was to purchase vials of generic epinephrine and bulk syringes, draw up the same dosage, and manually inject the dose instead. (We voted him out)
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Had a mammogram with a bit of “can’t see that part super well” result.
I can have a follow up MRI, but if it isn’t cancer, the insurance won’t pay for it, $885. If it IS cancer, insurance will cover.
This is my perfect example of why poor people cost more in healthcare systems – a poor woman is NOT going to run the risk of a $885 cash procedure that probably isn’t necessary (if she can even find a clinic that will do her mammogramin the first place, or follow up) . Then, if she has cancer, she won’t know it until it is either financially expensive to the system, or she just is killed by the cancer. This is no way to run things, or treat people.
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That’s interesting. We haven’t had a single problem with DH’s Advantage plan. We never have to do anything and they pay almost everything. Plus give him $600/year for fitness (downhill skiing, in his case).
Many people certainly express the same. The fact though that it is a commercial insurance that is incentivized to deny claims means there is always risk there. I can eliminate that risk by choosing straight Medicare and a supplement. Plus, there’s no balance billing for Medicare. Thus, no surprise billing.
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I had to haggle with regular Medicare and a very costly supplement to get some of my mother’s bills paid. A large number were denied, and the doctors or therapists needed to resubmit. This was NOT a MA Advantage Plan. It was regular Medicare with a very expensive BCBS supplement. And I have to add…the supplement folks were very difficult to deal with.
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Just out of curiosity, if you don’t mind sharing, what were the services? That’s atypical of Medicare. Certainly it’s not atypical of the supplental which is just a mini-me of advantage, but forced to follow the Medicare rules. Experiences are variable for sure.
Certainly one of the main takeaways from this thread is that our system is broken. Other systems aren’t perfect, but denial of payment after service really isn’t a thing.
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Our friend’s brother died because his MA plan would not allow the doctor to perform tests and procedures that, had he been on Medicare, would have been covered without hassle. You better believe that our friend is telling everyone he knows who is turning 65 to go with a supplement if they can afford it.
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Devil’s advocate here: back in the 90s, a California jury awarded millions of dollars against Healthnet for denying coverage. The patient had metastatic breast cancer and wanted a bone marrow transplant which she thought would cure her. It was major news in the legal community and the patient’s attorney was viewed as a hero. (The woman died before trial but her husband got a lot of money).
30 years later, that’s not a cure for MBC. So the insurance company was correct.
This is not equivalent though. At that time BMT was experimental for Breast Ca. Companies now are denying things that they already cover, things with deeply rooted medical evidence.
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D had a blood test (CBC panel) at Quest. They billed her and she paid. Just got our benefits statement from insurer. She didn’t owe anything and wadjy supposed to pay anything! Now we have to fight to get her money back. Quest has contract with BCBS to accept their tiny payment for lab services as payment in full.
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Can you explain more about what has happened so I know what to look out for in the future? So far I’ve just seen bills submitted to Medicare which pays what they’re supposed to and then the supplement company automatically pays their part.
The best part about choosing a good Medicare broker is that if something is denied by Medicare, as it was for @thumper1’s family member, they will go to bat for you. Nothing should be denied if it’s covered by Medicare.
H had his pneumonia shot denied, but we only know this because we saw it in his Medicare account online - his doctor resubmitted it immediately & it was covered before we ever got a bill. I actually googled billing codes when I saw the denial in the system, and I could tell immediately that the doctor had used the wrong administration code for Medicare for this particular vaccine. A less proactive billing office might have billed us rather than resubmitting.
Also, it’s important to note that not everything is covered by Medicare. If it is, it should be paid; if not, it won’t. For example, H has a CPAP from before Medicare. I looked up coverage & saw that while it would be covered, he needed to work with the doctor to make sure they did whatever they needed to do on their end so that his supplies would be covered.
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Well, it will be interesting to see what our insurance pays for D’s jaw surgery, which they have pre-authorized. I’m told the cost will be $50k. If insurance covers a big chunk of that, I will definitely be delighted, otherwise I will fight them to get them to pay their share.
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