Understanding Healthcare

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  • ltomanek
    ltomanek Posts: 53 Member
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    jgnatca wrote: »
    I am Canadian and the nuttiness of the American system boggles my mind.

    I am pretty certain however in North America at least, all doctors are working off the same standard health codes. This allows them to cross compare outcomes regionally not to mention allow health care software to be standardized.

    Instead of a network of health care insurers doctors here only have to deal with a dozen across the country (one per province).

    Costs for procedures (using this health care codes) are negotiated with each province.

    I have only ever paid one doctors bill, when I asked for a typewritten letter. Not covered.

    Yes, comparisons! That's one of the things I do for my job, analyze the top Emergency Medicine CPT codes, 99281-99285, 99291-99292, and compare the acuity to the previous months, or other clients in the same region, depending on the similarities in the client's payor mix. Then you can compare the Procedure codes for trends.

    There's a lot of variation to the Payor Mix for each client, I have a list of over 28,000 payors.
    At a high level, it's Government, Commercial, Self-Pay, Charity Care/Financial Assistance.. But then you break out Government into Medicare, Medicaid, Manager Medicare, Managed Medicaid, Tricare/Champva. And the Commercial we break out to look at the BUCAHs...BCBS, UHC, CIGNA, AETNA, HUMANA. Vs all the Auto and Workers comp insurance and the 1000's of small commercial or private plans.

    Because there is a first time for someone to interact with their healthcare system, I am trying to put together a guide of the top 5 things everyone with insurance should know in the US.
  • ltomanek
    ltomanek Posts: 53 Member
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    skctilidie wrote: »
    tinkerhellraiser wrote: »
    Vikka_V wrote: »
    One thing I wonder, and I live in Ontario where basic healthcare is "free" is how the doctors bill things. Is it by problem? Often you see here posted in the waiting rooms (not sure about anywhere else) is "one problem per visit". Is it the time taken for the appointment? The service provided?

    This is in my experience, YMMV:

    You usually make an appointment for a problem or well check, and are seen for one thing. As far as how they bill things, it's a bunch of different codes that are covered (paid for by insurance) differently depending on your insurance plan and your insurance provider. The two main categories are diagnostic and preventative care. So say you go in and get a colonoscopy. It could be coded as diagnostic because the doctor suspects a problem based on symptoms, or preventative if you have a history of colon cancer and need routine screening. One might be covered at 50% and the other at 80%, so it makes a big difference in what you pay.

    And then it gets really crazy.

    The doctor will bill an amount for the colonoscopy, say $2000, and submit it to insurance. Insurance then comes back and says "We'll only pay $1200" and then the doctor adjusts the amount and you owe the difference, in this case, $800. But likely you also usually have a deductible that needs to be met before they pay anything, maybe $4000 a year that you must pay out of pocket before insurance "kicks in". So in the end you pay the full $2000 for the procedure.

    But if you go to a doctor and say "I don't have insurance, I want to do self pay," they will often bill you a special "self pay" amount that is less than what they request from insurance, in this case, maybe $1200. So not having insurance would cost you less.

    Also if you have a doctor or specialist that is "out of network", usually insurance won't pay anything (some plans pay a fractional amount). Its a huge problem because if you go to the hospital in an emergency and then all the doctors you see are out of network, you are left owing a small fortune.

    If you’re me, you spend over a year battling with your insurance company to get them to agree to cover the treatment your medically fragile kid’s immunologist has been saying for several years that he needs and also says he can prove he needs with the enormous file of records of lab values and infection/treatment histories and lung function tests and such. During this time, they require you to subject the poor kid (who has experienced more needle sticks already in his 7 years of life than many people do in decades) to multiple more sticks to be without a doubt sure that it’s necessary. THEN, they approve the coverage but even though the medical insurance and the prescription insurance are through the same company, they pull this stunt:
    1. Send the letter of approval, but for the prescription coverage to be in effect, the medication must be provided by this one specific pharmacy/home health agency.
    2. The medication must be given by a home health nurse every month...but tell the patient AFTER the first infusion is done that while the company the nurse works for is the only one the prescription part of the insurance will cover getting the med from, that same company is out of network for the medical part of the insurance.
    3. Engage in a weeks long battle over one part of the insurance or the other needing to suck it up and either pay for a different pharmacy to provide the med or for this home health company to give it, because this situation is obviously not going to work and they’re the ones who picked this company in the first place.
    4. They luckily did eventually decide to pay for both the drug and the nursing care...but the bag of IV fluids he needs with it? Thankfully only $10/month, because no way are they paying for that, even if it’s necessary unless we want days on end of him not being able to move thanks to horrible headaches as a side effect if they don’t pre-hydrate him - and oral hydration doesn’t cut it. We learned that the hard way the first couple of months. 🙄

    Ouch! That is a lot to work through. I see a lot in my area with the one part in, one part out of Network status. That's one of those areas most people don't know about until they start having to deal with healthcare, your facility (supplies) is in Network, but your provider (services) is not, for the same location for your insurance. Each billing entity has to go out and try to negotiate their own contract with the Payor. And sometimes it really difficult and a slow road to a final in network contract.
  • MrDarsy
    MrDarsy Posts: 2 Member
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    Thanks, that is really great topic. Have been looking for it for a really long while. You know, all your efforts in terms of provide a better healthcare can be ruined by the government officials that are not willing to listen.
  • msbadgurl69
    msbadgurl69 Posts: 1 Member
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    Yes, government officials are not robots, you know. My brother used to work for a healthcare company, and he says that sometimes submissions from healthcare companies to the government can be prepared not so really well. People may forget to collect necessary documents, present vague requests, where from it is not clear what they need, etc. All because they have time constraints too. So a thought came to my mind that a Healthcare lobbying firm can be used in this case to ensure all the needed protocols and procedures are followed, and documents are presented on time.

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