I have to admit, we have been pretty fortunate so far in getting claims resolved pretty well with our insurer and not having too many hassles or arguments. We don’t even have to get pre-authorizations to get 2nd opinions or get care out of state. I’m very grateful that we are able to access the care we need and only have to fight from time to time (prefer never, but oh well).
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So many physician’s offices are now owned by hospital systems or private equity.
Their business model is to cut costs and increase profits.
So when the office staff isn’t competent, many times that is out of the physicians hands. The group they work for hires staff. Has control over hiring and firing. And as long as they reach some metric, customer care isn’t what is important. They are also very short staffed. Billing is outsourced, not in house as it used to be.
That’s the hard honest truth of medicine today. I don’t know how it’s fixed when profit becomes objective number 1.
For the hospital, the practices they own and the insurance companies.
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My previous PCP’s billing dept was terrible. They never coded the wellness visits correctly. We actually had the doc put in our medical record what our insurance wanted. He would code it correctly and the biller would change it. We’d get a call from collections, tell them to check the codes, they’d resubmit and it was paid. Every. Year. For 17 years!
Doc was great but that was very annoying.
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That’s great, but plenty of peoples’ employers choose United plans with copays and relatively high deductibles ($5K+)…often because those cost less. Obviously companies could also purchase/subsidize supplemental insurance for their employees that covers any OOP costs from the main policy (like Armadacare, Aflac, etc)…but most don’t because those are expensive.
Employer budget limitations limit employee benefits, of which medical insurance is just one.
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Different sort of story (yes, we have many)
8 months pregnant, my boss tells me I can quit (and keep my healthcare benefits for 90 days, per law at the time) or I can be fired and lose them along with my job. He didn’t want to give me maternity leave of any length, getting insurance within a month, with a PEC (pregnancy) was impossible. To be covered by DH’s work was more expensive than COBRA but we did switch after the baby was delivered.
So I “quit” . All of this was absolutely legal at the time.
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Make it so that’s no longer the number one objective. Patient outcomes and efficiency should be rewarded. The only thing remunerative now is production on the physician/hospital side and denying care on the insurance side.
My response was to a completely off the mark assertion that I was denied because my employer chose a poor plan. They did not. Strategic, but unjustified denials are part of the business model for every commercial insurance regardless of its “quality.”
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This is a very viable alternative and many people do it this way. Often suggested because of price and short supply of epi pens.
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I agree, in the circumstance, but does any other developed country have to explore this “viable alternative.”
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Since “EpiPen” is a specific brand of epinephrine injector, people looking for “EpiPen” are by default facing a monopoly supplier, which some years ago decided to extract monopoly rents by raising the list price from $60 to $600 for a two pack.
There are some competing brands of epinephrine injectors, although they can still be priced fairly high, although lower than EpiPen prices. However, many who are used to EpiPen usage do not want to risk making a mistake in an urgent situation if the competitor has slightly different usage instructions.
What they are selling is not just the inexpensive epinephrine, but convenience and accuracy for those not trained or practiced in giving injections with generic syringes.
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My two stories about hospital billing:
When my middle kid was seven, he had a tonsillectomy and then post-operative hemorrhaging. He was in the hospital for several days. When I looked at the itemized bill, I saw, “OR Prep.” Huh. I called and said, “My son didn’t have surgery, what’s up?” and they had the nerve to say, “Were they THINKING about doing surgery?” Uh, no…
We found out the bleeding was from Factor XI Deficiency - even though there’s only a 50% change of having it if it runs in the family, all three of my kids and my husband have it, yay. Whenever any of them is hospitalized, all the medical students come trooping through to talk to us because it’s so rare.
Then when my oldest had hernia surgery at the age of 12, they needed to give him Recombinant Factor VIIa before surgery to prevent bleeding. It’s supposedly one of the most expensive meds, tens of thousands of dollars for one dose. They gave him one dose, and then there was an emergency in the OR so his procedure was delayed. “Oops, we’ll need to give him another dose.” OK, whatever. He had one dose after the operation, also. When I got the bill, they had charged us for THREE doses. I was ripped. “I’m sorry there was an emergency in the OR, but that was NOT our fault.” They removed the charge. So yes, look at any hospital bill with great scrutiny!
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You’re looking at it the wrong way. Given that there is no public option, of course they are in it to make money. The real question is, given the long term average of UHC making roughly a nickel per premium dollar, are they making an excessive amount of money for the services they provide? Just for comparison, P&G makes about 22 cents for every dollar of product you buy from them, yet nobody complains about them.
It’s very easy to forget that insurance companies actually provide useful services. First, they provide a check against medical fraud. Second, they negotiate rates much lower than health providers want to charge individuals without insurance. Separately, these payments also tend to be higher than what Medicare will pay, which is important because many medical professionals cannot survive on Medicare payments alone, but that’s a completely separate discussion.
Given they are a profit making business, I cannot conceive of a situation where they can pay out more than 90 cents per premium dollar, provide the services they do, and provide any positive return for their investors.
Going to a public option may raise the payout by another nickel or so, which is certainly meaningful, and will result in slightly fewer denials of expensive services, but won’t eliminate them.
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Former benefits VP here.
Just be aware of the difference between plans that are insured versus self-insured.
Small companies (fewer than 1,000 people, say, but it’s not a strict number) have insured plans. That means that the employer pays a premium to the insurance company, the insurance company pays the bills. (or not.)
In a self-insured plan – and this is what almost all large employers have – the company pays the insurance company for administrative services and access to their network, only. Because the plan is self-insured, actual claims come from the employer company coffers – not from the insurance company’s. As we used to say in the biz, “claims are claims.” They are going to be whatever they are going to be, and going with UHC or Aetna or Cigna or anyone doesn’t change that. When selecting which insurance company to use, an employer looks at (1) the monthly administrative cost per employee, and (2) the alleged network discount. (That is, Aetna may claims 50% off an in-network hospital’s “standard” rate of $2,000 per day, while UHC will claim a 45% discount off of the Medicare-approved rate. It’s very difficult to make an apples-to-apples comparison.)
The actual plan design in a self-insured plan – low v high deductible, low v high annual out-of-pocket max, etc. – is completely up to the employer. The insurance company just codes their system to handle it.
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Thank you for that inside explanation.
Do you think people notice a difference between an insured plan vs a self insured plan with regards to claims and reimbursement?
Thanks for that explanation.
Who decides what claims to accept in a self-insured plan? The employer or the insurance company?
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To add to @hebegebe’s question, if they use the insurer’s published “criteria,” that could make a difference. E.g. BCBS allows breast MRI annually for moderate to high risk of breast cancer but UHC does not.
Presumably both. At the high level, the employer says “X is covered, Y is not covered” etc… When a claim for X is made, the insurance company bureaucracy decides whether to cover it based on its policies and procedures (in or out of network, pre-authorization, fraud check, etc.).
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I worked for three very very large employers during my career, all of whom were self-insured. At the first company, we were very very “high touch.” Any significant or iffy denials were to be shared with us (anonymously) first and – since it was our money – we the employer had the final determination. However, we almost always wanted to know what the “standard” insurance company decision would be, so we could make sure we weren’t going too far out of the norm.
[Sidebar: I remember one claim that was for a breast reduction in an adolescent boy. According to the insurance company’s rules, such a procedure would not be deemed medically necessary. The employee – the kid’s father – made a very good point, that having excess breast tissue was detrimental to this kid’s mental health. I remember one of his comments – “My 13-year-old son’s breasts are bigger than my 15-year-old daughter’s!” We, the company, approved the claim and told the insurance company to pay for it.]
At the second company – waaaaaay less “high touch”; they didn’t really care about their employees; their entire focus was on cost-saving – we almost always went with what the insurance company suggested.
And at the third company, there were some key exex for whom we were almost never to deny claims. It was absurd, and not fair, but that’s how it went. (The Chairman of the company was one of them. His name was the company’s name. You’d recognize it in an instant.)
Most employees don’t know the difference between an insured and a self-insured plan, since it’s never been explained to them. IMO, it helps to know which your employer has. If it’s self-insured, you’re more likely to get somewhere by talking to your internal benefits people. If it’s insured, you have to deal w/ the insurance company – and they have very little incentive to bend the rules for you. Note: I’m not talking about insurance companies’ incompetence or reluctance to pay. I’m just talking about something being covered in the first place.
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Thanks again for the detail.
This is one of the reasons I stay on CC–the knowledge shared by so many intelligent people.
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My H was a fed employee so all companies who wanted to offer federal employee insurance had to offer a package of benefits approved by OPM, I believe. The package was quite comprehensive.
This is very interesting and helpful information. We have a self-insured plan at my work. It has never been explained to the employees that anyone inside our institution could/would override the standard insurance company denials.