For next year, if you go to the Medicare.gov account and create an account during annual enrollment, you put in your zipcode. It shows you your current plan and you can compare it with up to 2 others (at a time). You can put in your medications and it will show you the cost under each plan. I discovered that mine will cost about one thousand dollars a year less under the one I switched to than it did under AARP UHC Medicare Advantage. It also let me see what each cost at the 2 pharmacies in my neighborhood. Which of the 2 cost more varied by drug.
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Our United Healthcare policy allows a âfreeâ mammogram for breast cancer screening. But if your screening guidelines also include an ultrasound for dense breasts (which would include almost half the women over 40), they wonât pay for that, and the cost is about $1000! Seems like a sleazy loophole. And a deterrent to proper screening if they think itâs important enough to pay for in the first place.
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My insurance is through my employer and prescriptions go through Caremark. Caremark did not have a tool to calculate the various options and the call center told me there was no way to estimate the cost.
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I guess I will count my/our blessings that nearly all our claims are paid, which must mean that most of someone elseâs are NOT. 
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I think it means that you have exceptionally well trained and ethical providers.
In the last week, I heard about several egregious cases (elderly people on hospice with âdays to liveâ who were advised to have various surgical interventions; a 95 year old woman told that a hip replacement would increase her mobility, etc.) and I can only shake my head at it all.
I think a lot of the anger about claims denial would go away if more people understood how many shady health care practices go on every year. Iâve posted before about a claim which was paid for one of my parents. The medical intervention was allegedly performed the day after her funeral. The doctor billed, was paid, and when I saw the payment I had a fit. It took weeks but I got the charges reversed. The rep from the insurer told me âwe believe this happens frequently, it probably costs billions between Medicare and private insurers, you are the only survivor who has ever called to complain in my experienceâ.
I called the doctors office to explain that the insurer was following up to claw back the payment and was told âItâs too hard for us to track who doesnât show up for an appointment because theyâre dead so we just bill based on the appointment logâ.
Really? Youâre frequently performing outpatient surgery on dead people??? And are you collecting both the co-pay AND the insurance money on the dead patient?
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Sorry!!I guess my answer only helps if you are on MedicareâI was surprised when I discovered the tool when I was desperately trying to figure out how each plan treated cataract surgery.
I find the call centers just lie. If the person on line canât answer, they say thereâs no way to answer. Personally, when there is a chat option, I use that because I can then save the transcript which at least gives me a record of what was said. On chat, the customer service reps seem less likely to lie.
Our neighbors both had cancer at the same time and both got all the recommended treatment without any fights. They were also offered the option of stem cell treatment for the Hâs cancer at their choice of UCLA or Sloan Kettering in NYC. They chose NYC because their D lived in that city. Kaiser paid everything including airfare for patient and wife. It was over $1 million! They were shocked not to have to fight to get care.
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Not comparing costs is a problem with my employer plans. Above, I mentioned how we have 3 plans, one old school plan (2K deductible/co-pays), and 2 high deductibles ($3200 per person, $5K per person). The main reason people donât switch to the HSA plan is because drugs are NOT covered in the beginning, but they go toward your deductible. Once you hit that deductible, then all of your medical costs are free for the rest of the year, and you pay the same costs for drugs as the old style plan.
However, at some point they started offering âmaintenance drugsâ (i.e. blood pressure, cholesterol, etc) FREE, so that got a lot of people to switch to that plan. But the problem is⊠which drugs are covered? All they can tell you at open enrollment are which drugs are currently offered, but come Jan. 1, the list changes and they canât tell you what the new list will be until after the open enrollment window closes! That is just messed up.
We arenât on any medications, so this is fine for us⊠but many people canât afford $3200 up front so quickly, so they stick to the much higher premium old style kind.
And the follow up scans not being covered⊠Apparently that is the most common way of doing it. Fortunately, ours ARE covered. It saved us $3000+ on Hâs follow-up colonoscopy. Before wellness scans were mandated by the ACA, HR told us that only 2 women got mammograms the prior year. We have 1200 employees! But most people around here couldnât pay for it otherwise. (I was too young at the time to do them, but I probably would have not gone too TBH. We were barely scraping by as it was.)
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My father passed away almost 25 years ago, but I remember a time before his passing when he was in the hospital because he had carotid artery blockage, and he was there for almost a week, on heparin, with nothing happening. Finally he had the surgery to clear up the blockage.
We found out later it was because his insurer, UHC, was shopping around to find a surgeon who would do the work for what they wanted to pay! Have always had a low opinion of UHC since then, and have counseled anyone who would listen not to go with them.
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Wowâone would think an extra week of hospitalization would wipe out any âsavingsâ of a âcheaper surgeon.â. Thatâs awful for patient, family & healthcare system! Very wasteful! Patient could also develop more costly medical issues during the wait, including MSRA infection, etc.
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Well, just out of curiosity, I checked claim denial rates of the insurers Iâve had. Aetna is <2% (had that briefly with my employer) and the rest of the time Iâve been bcbs which is just under 5%. Denial include when they require more info, wrong code, etc.
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Here seems to be a list of claim denial rates for various insurance companies:
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My wife owns a medical practice, and therefore I know this is complete BS. For one thing, when she sees a patient, the procedures often change from what was expected.
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Interesting how differently different reporting there is about insurance denials. The AI claimed Aetna and BCBS denial are considerably lower than the article above.
Agreed! To take it a step further, itâs straight up insurance fraud to bill for a patient you havenât seen. Everyone has PM software now to track that stuff.
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All providers I know know whether a patient came or didnât show. Once my parents died or when they didnât show (for circumstances beyond their control), we were never billed. Fraud is more common than it should be.
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On the chart you can see above the head of the doctor speaking about claim denials in the link someone posted above, Kaiser had the lowest rate of denials of all healthcare companies listed. IIRC, it was 7 per cent.
For clarificationâŠeverything I had denied was eventually paid. They were not permanent denials.
Maybe folks can clarify this on their posts (some did).
I often have thought the first answer was going to be NOâŠand as noted, sometimes it has been.
Over the years, I have had many denials that I have appealed, usually successfully. But every time I âwinâ, I reflect on the fact that I am healthy enough to have the energy to pursue the appeal. And that I have the mental acuity/abilty to argue my case in a way that is more likely to work. Not everyone â and especially someone dealing with major illness â has these advantages. In that sense, the system feels rather predatory. Or at least exploitative.
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Every health plan has a documented, formal process for appeals and grievances. The appeals process would apply to patients/members, while the grievance process applies to the providers (i.e., provider files a grievance with the health plan to complain about why something was denied/not paid).
For Medicare plans, there are specific turn-around times that the health plans must meet based on the urgency (standard vs urgent/emergent) of the appeal/grievance. Commercial health plans usually have the same/similar turn-around times.