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Discussion in 'Medical Topics' started by Rushie, Jan 5, 2017.
From where does this money come?
That's what makes the problem difficult, and why we have no viable solutions.
I'm one of those who is going to be penalized when I go off my employer's plan at an age too young to collect medicare, but with an income too high to qualify for a subsidy. I had researched it and figured it would cost somewhere in the neighborhood of $10,000/year for premiums. Now I am not sure what to expect.
Taxes, of course. But that being as it may, the money at this point in time has been appropriated. Availing himself of it might have saved his life.
Many years in insurance, primarily P&C, but some health exposure. Some experience with a self-funded health plan manager for a NYSE company. Then making a payroll and providing benefits. All of this prior to enactment of the PPACA. So yes, I know some of the tricks from the coverage side. Pretty much had a front-row seat at the start of the spiral.
From the health care provider side, both parents died of cancer, with all that ugliness entails, including billing review.
You can expect to have maternity and sex change coverage Oh, and coverage for psychiatric care, even if such care is not available where you live.
Maternity would have been helpful if I had wanted a child. I remember back in the early 90s when I was looking at individual coverage, the broker said I could not decline maternity because I was of childbearing age.
I am sure that psychiatric care is available in the area where I am looking. In fact I can't imagine much of anything not being available since it is a large city.
If this was supposed to be some kind of commentary about what coverage I might or might not need or use, I accept the fact that not all people use all the items mandated. I have made a large insurance claim (over $100,000) for a condition that not many other people have or are likely to have. I didn't think I was likely to have it either...
He died in '09.
The nightmare continues. The nice country doctor just canceled my appointment because my insurance lists the big city doctor as my primary. They won't see me unless I switch my insurance to them. Not having decided yet if I'm going to abandon the big city doctor, I don't want to switch my "declared primary" back and forth. So I asked if I can just pay cash and see him once to meet him and the girl said, "We would have to list you as self paying uninsured and that would be insurance fraud."
????? Does she know what she's talking about?
To the best of my knowledge, if you are a Medicare or Medicaid patient, you may not pay cash. The reasoning is that if you can afford to pay cash, you do not need the government assistance and representing yourself as such is a fraud. In the case of Medicare, the Gov. Doesn't wan't the docs to accept cash as a way around the prescribed CMS reimbursements. If you have private insurance, many physician contracts preclude seeing patients for cash, but that's breaking contractual agreement, not necessarily a legal fraud.
If you have private insurance, barring contractual agreement there is no fraud unless the physician also submits a claim to the payor. So, the young lady may be correct or may be mistaken.
"MDVIP-affiliated practices are compatible with Medicare. Your annual fee covers those services not reimbursed by Medicare. Your Medicare Part B coverage will continue to work with your affiliated physician as it currently does."
The operative phrase being "will cover those services not reimbursed by Medicare".
Thanks for the answers. No I'm not Medicare or Medicaid. And this isn't an MDVIP doctor. I don't see how on earth it's fraud unless they make a claim for something I already paid for out of pocket. Right now my opinion of office staff personnel is in the toilet. Is it that they're young? Or are people in general getting stupider? I don't recall office staff ever being this moronic in the past. Is the caliber really going down that much or am I just getting old? Or is it that everything being in an electronic cyber database makes them unable to deal with somebody doing something a little different?
Can't speak to your specifics, but my impression is the system is WAY more complicated than it used to be even just a few years ago. I can imagine its hard for the staff to keep up. Esp around the first of the year when old plans are expiring and new ones going into effect and patients going off and on different plans.
Maybe read your list of exclusions and try to schedule an appointment for something clearly not covered. Can't think of a good example right now. Maybe something cosmetic.
Thanks Van, I think you're right. The system seems to have lost all rationality. At this point it's interfering with my getting care. I was going to talk to this doctor today about a new parathesia from the waist down. No motor function loss, and it's not constant, so not ER worthy, but definitely something I want to consult a doctor for, sooner rather than later. When they canceled today, I'm left with either driving 45 minutes into the city, or seeing the chiro. Since sitting in the car for 45 minutes is agony, I chose the local chiro, and I'm going to self treat with some old prednisone I have lying around. This is unreal. Twenty years ago I would have been in with a doctor and on my way to an MRI by now. I'm gobsmacked how things have degraded. This doctor did reschedule me for next month, to give me time to "name him as my PCP".
The weird thing is, I am under the impression it's not mandatory to name a PCP at all. I get a discount on my premium if I name one. The annual online sign up process didn't say I HAD to name one. If I named one it threw up a note "minus x on your premium" and then when I certified I'm not a smoker "minus y on your premium" and then when I filled out the "health assessment questionaire" yet another deduction. Nothing said I had to do any of that, if I didn't I'd just have a high(er) premium.
No wonder my mother says, "The world is too complicated any more. I'm ready to die." I'm starting to see her point.
Update. I spoke with my insurance company. They confirmed that I am not required to enter a PCP as far as they are concerned. I'm covered and that particular doctor is "in" their network. But she told me a lot more doctors are now instituting a policy of not seeing you at all unless you name them as the PCP. She also said the lady was nuts to say it would be fraud if I paid in cash, unless they also filed for reimbursement. And that a lot of doctors are now refusing direct payment.
My sister told me that a dermatologist desk person said, "We don't even know how to process that," when my sister wanted to pay cash to get seen for an urgent skin problem, and the VA was going to make her wait for months. Don't know how to process cash?? You take it, drive to the bank, and deposit it into the doctor's account. What is WRONG with people today?
If their practice is a network provider for your insurance, they are required to bill all services provided to a covered member to the insurance company. In HMO style health plans, only one primary care provider can receive payment at a time (except for emergencies). So unless you switch your PCP with the insurance company to the 'country doctor' practice, they have no way of getting paid. They are required to bill your insurance and their claim will be denied as 'not provided by the designated PCP'. Their network contract in turn precludes them from billing you a reasonable charge for the service. It doesn't sound like your plan requires you to designate a PCP, so that restriction probably doesn't apply, but that's what primary care front desk folks are conditioned to look for these days.
There is really no downside to switching your PCP to the 'country doctor' practice. It's just a designation with the insurance company, it doesn't mean your 'city doctor' will burn all your records and never see you again.
...by paying cash for them.
It was my impression that medical procedures weren't actually included in the concierge model. I was led to believe that the medical concierge will put you at the head of the line should you need care or consultation, or act as a patient advocate if hospitalized, but any actual coded visits or procedures were billed to insurance, or to medicare if the Doc is a medicare provider. Is that correct?
I wish I were. You don't get any bennies with less than 20 years credited.
And I am not eligible for any subisdies. It is $2,492 per month. Silver plan 80/20 with $3,800 deductibles each.
Chip: as for abuse, it's everyplace. The Epi pen debacle is an example. So is that guy with the orphan drug who raise the price 200 fold and got hauled before congress.
Airdale: Robert I Chien Phd (Economics, MBA, Statistics) was a CEO, my dad.It was his second language so I had a lot of input into that book (read it?). The exception to capital allocation in development, is that we have this "bleeding heart" need to develop new drugs- cure hepatitis C (we just did) and to develop new antibiotics to counter the flesh eating bugs and super resistant TB. IT is just like every small town that wants air service- they get a subsidy, which is why CAPE AIR is operating C 402s out of Quincy IL.
This republic refuses to just "bury" our dead. Like Monty Python "BRING OUT YOUR DEAD"......"But I an not DEAD yet!".
These factors distort good old widget competition
Thank you so much for that clarification. That makes it all make sense. I wasn't aware of the terms of the contract that makes them "in network". If it requires that they have to file the claim and at the same time cannot then bill the patient when the claim is denied (as it will be because it's a second PCP) then it all makes sense. Although not sure "insurance fraud", as in, a crime, is what it would be, it would just be them violating the terms and maybe being kicked out of being a network provider.
Yes, you hit my fear of doing it. I don't think the city doctor will "burn my records" (ha ha!) but if they aren't through processing all the claims from my December visit, and I change the name to the country doctor, I'm fearing the city doctor's claims will be rejected if they come through after the name change. The last thing I can handle right now is another conversation with the city doctor's staff, after everything that's gone down with them.
If they haven't sent out their december claims, well ,then they are just a bit slow. Changing the PCP shouldn't affect the processing of claims for past service dates. The downside I could see is your city PCP not taking you back into the practice in the future because he is so swamped in patients that he closes his roster.
Yes, I feel very hesitant to rock the boat after what we just went through to get Mark in with her. We squeaked in right before the door was slammed shut, in fact, they kicked Mark back out and I had to get them to get the doctor to make them open the door and snatch him back in. If I do anything to get us expelled now we have no hope of getting back in.
Just got back from the chiro and I asked him about this country doctor and got a very good report. Not huge enthusiastic warm fuzzies but reasonably big warm fuzzies. Not quite big enough to risk losing the city doctor without yet even meeting him. The city doctor is massively giant warm fuzzies, which explains I guess, her popularity. But you see my dilemma. By the way, by "warm fuzzies" I don't just mean bedside manner, I mean my perception of their professional skill too.
There are reasons that the insurance companies don't want you to go around them (e.g. pay cash). It revolves around "data" and "case management". As I may have noted, I got a letter from my "insurance" carrier about not having a claim (or test results) submitted for certain blood tests that they believe should be done for certain BP medications. They also sent a letter to the doctor. This was sent notwithstanding deductibles or payments received in another manner.
Think of "insurance" companies as paid service contracts, like HOWs. That is what we now have. Electronic medical records pushes us even further in that direction.
Shouldn't this entire thread be in SZ?