[notme]

While talking with ALASKA on another thread the subject of the complexity of health insurance came up. I was wondering how many people REALLY understand their insurance policies and exactly what you need to do when your doctor suggests a specialist or needed supplies.

I worked for a hospital for years and was really amazed at how many people were unaware of the hoops they needed to jump through to get their bills paid by the insurance carrier. Many times people with HMO's were sent to the hospital to have pre-surgery lab work done when in fact their insurance company didn't contract with the hospital lab and they should have gone elsewhere to get the lab work done. They would end up with a giant bill that they didn't expect. Also, patients would have surgery and the anesthesiologist would bill for his services seperately from the hospital bill and the insurance companies would deny payment because he was not a contracting doctor. (When have you ever had a choice who your anesthesiologist was?).

The insurance companies can change providers without informing us that changes have been made. I ordered my pump supplies this week from MiniMed and was told I could no longer get certain items from MiniMed and I would have to pay with credit card if I wanted those items. I called my insurance company to find out who the new provider was for these items and not a soul knew. They agreed that the contract with MiniMed was changed, but couldn't tell me who the new contract was with. Why can insurance companies make these changes without informing us? If MiniMed hadn't told me that the contract had changed, I could have ordered these supplies and been billed for these items later because they were no longer under my policy.

I was wondering how many of us have been "surprised" by insurance changes and how many people really understand the insurance terms of "out of pocket" "deductibles" "EOB's" and "contracting providers".

I really think some changes need to be made. Insurance companies make it as difficult as possible so we make mistakes and pay full price for services that should be covered at a contracted rate with our insurance companies.

Nancy

[HeatherP]

You're right Nancy - it's all very complicated. Recently, my husband had to go to the ER, and now we're getting bills because they didn't bill the medical group like they should have. The hospital billed our insurance company. I don't understand that, but oooookaaaayy. Fortunately they are working with us to get things settled.

I am one of those probably rare people who actually sit down and read thru most of the stuff I get from my insurance, so I think I'm pretty well informed but they do throw me a curve ball every now and again.

I guess I'm lucky, my dr's seem to be aware of what my ins co will pay for, and where to send me for services so they're covered. I don't think the insurance situation in this country will change any time soon. Do you know that our Senators and Reps have their very own special gov-issued health insurance plan? They don't have to put up with the high premiums and problems we, as the general population have to deal with. Until they are made to experience health care as we do, and continue to take Insurance Lobby (and pharmacuetical) contributions nothing is going to change.

My husband is 10 years older that I am. We have a small business and get our health insurance through it. When he retires, I don't know what I'm going to do. I won't be eligible for Medicare, I won't have our small employer policy, and because of the Diabetes no one is going to insure me, or if they do they won't want to cover my "pre-existing condition". It's very scary - I try not to think about it because I don't know what I'm going to do.

[lgvincent]

I could be wrong but it seems I recently saw a story on one of the network news program about how one hospital (or perhspa chain of hospitals) has several hundred people working in their billing department because of all the different rules set up by each insurance company. It gave the impression that while HMO's were set establised to save money they are actually costing more money because each insurance company has their own unique rules and way of doing things.

[notme]

You are so right vincent. I have the advantage of being one of the people that worked at a hospital doing billing. I understand "most" of what the insurance companies are doing. The key word is "most". They change the rules so often you need a lawyer to keep up with the contract changes.

I think the only way we will ever get reform is for the system to totally disintigrate. We can't count on the politicians because they are backed by campaign contributions from the health insurance industry and pharmeceutical companies. Even if someone uses healthcare as their platform (Clinton) they will back out after elected. They can't afford to lose these special interest groups.

HMO's were not designed to save money for us. HMO's were designed to save money for the insurance companies. Their rules are designed to confuse not only the general public, but the providers themselves. We have more and more good doctors bailing out of the medical profession because they can no longer afford to care for patients. Anyone can be a doctor if they understand insurance rules.

Medical groups get paid a certain amount of money per month by the insurance companies depending on how many members they have. When you and I go to the doctor for a headache the doctor is paid only once a month for each patient no matter how many times they see them. So lets say they get $50.00 per month per patient. If I go to my PCP (primary care physician) once that month or ten times that month he/she still only gets $50.00. Ever wonder why they are booked up two months in advance??? There is your answer. If you tell the doctor ahead of time you have diabetes you will magically find out they are not taking new patients. You will take up to much of their time for to little money. They are also given a certain amount of money per month for specialty care. Lets say that amount is $5,000.00 per month. If one person in the group sends people in for a couple of CAT scans or MRI's that money disapears and the people in that medical group frown at that doctor. This is because, if there is any of that $5,000.00 at the end of the month, it is distributed between the doctors in the medical group. So, they have incentive NOT to send patients to get tests. My numbers were totally arbitrary, but you get the picture.

I am frightened the way things are going. Most people (and rightfully so) have no idea the games that are being played with our lives. They keep us confused and when we start to get it, they change the rules again.

Nancy