East View from Mother’s Grave

Originally uploaded by nodigio

http://health.usnews.com/articles/health/2008/08/25/how-crafty-health-insurers-are-denying-care.html

What few Davids know is that insurance contracts by law grant companies the legal right to manage a patient’s care, including denying it, sight unseen, and give them the final say, if challenged.

Doctors and their staff will spend hours trying to get the approvals, but patients should be warned that if the company ultimately denies payment, for whatever reason, it’s the patients who are responsible

The problem is bound to grow as insurers make use of sophisticated data tools dubbed “denial engines,” which are touted to reduce reimbursements by 3 to 10 percent. Bearing brand names like Ingenix Detection Software and Bloodhound Technologies’ ClaimsGuard, they search patient records for any signs that claims have strayed outside company parameters. Weeding out fraud or speeding up processing is one thing; serving up excuses to deny legitimate coverage is another.

Every insurance company is mandated to have an internal appeals process, though there is little openness to help those seeking reconsideration, such as information on similar appeals and their outcome or the data used for denial. Nor do insurers provide much detail about the professionals making decisions. Who are they? What’s their experience? Are they moonlighters denying care from New Delhi?

“Insurers play a game of deny, delay, and deceive.” – attorney Andrew Cuomo of New York.

And now they are going to be assisted not only by laws that grant them the legal right to manage a patient’s care above and beyond – or even in place of – a licensed MD’s care. Insurance companies have the right to deny patients care their doctor feels is essential to the well-being of the patient, and if the patient and doctor challenge the denial, the insurance company often still gets the final say in the matter.

Often doesn’t mean always. Some states allow a patient to have an independent review of the claim and can overturn an insurance company’s decision. Unfortunately for some patients, time is critical, like the young girl who died before the insurance company and the appeals process could decide if they would cover her kidney transplant. Although, I must say, if I was the parent of that girl, I’d have demanded the transplant take place and deal with the insurance company and hospital afterwards. I did that when my daughter was born more than 12 weeks early each and insurance denied coverage for her NICU care because she wasn’t born at the correct time and couldn’t be added to the insurance policy until her due date. Got her added, and it was still a battle as they denied claims for blood tests, oxygen, and even for the bili lights.

I’m not afraid of insurance companies, and I know what a scam they are. I’d rather live without health insurance than live at the mercy of some faceless corporation who cares more about the bottom line and profits than about my well-being.

Armed with an ISD and DRG code book, and customary charges for each code, I can and will and have challenged insurance companies for their payments. I’ve also caught hospitals padding the bills (there’s no way one single preemie infant can use up 2 cases of preemie Pampers a day – at 60 diapers per box and 12 boxes per case, not even if the nurses use the diapers inappropriately, nor would the doctor need to use staple pullers for the C-section stitches every day – the stitches were removed only once) and brought this to the attention of the insurance companies so they don’t pay for unnecessary things. Yet, the insurance companies were willing to pay for the excessive Pampers, but not for the oxygen.

There are doctors who will negotiate with patients over fees if the patient pays cash – often charging far less because they don’t have to deal with the paper work of filing with insurance companies or waiting up to 6 months for the insurance company to pay them – longer if the charges are disputed. Negotiating with your doctor and paying in advance can net you between 30% and 70% discounts, and some charges may be written off entirely. There’s a lot of padding that goes on by doctors in order to get a fair amount out of insurance companies, and if you are honest with your doctor and discuss fees up front along with needed procedures and tests, you may be pleasantly surprised at how inexpensive medical care can be when the insurance company is removed from the picture. When a doctor goes through insurance companies with “managed care”, he may charge $75 for a visit, be reimbursed by the insurance for $40, and spend $20 collecting that $40 from the insurance company. By charging a cash paying patient $50, he’s making much more money without the expense and hassles and delays of being paid by the insurance company – and he and his patient don’t have to worry about the insurance company not paying.

If you give up comprehensive health insurance (with premiums on average about $400 a month) to a catastrophic health insurance plan (averages $75 a month), you can put the $375 into savings that will pay for the cash-only doctor bills and cover the $2,000 deductible if you need catastrophic health care. Even if you can’t afford the $375 to sock away into savings each month, you can probably afford to set aside something. If you approach your employer – especially a small business employer who wants to give you health insurance but can’t afford it either, maybe the two of you can match funds into a Health Savings Account – $50 each a month would cover the catastrophic policy and put some into savings. If you’re healthy, that small amount will build up over time, and if you get pay raises, promotions or change jobs – that money is yours for your health care. You also won’t have to worry about meeting the COBRA charges if you’re between jobs – you’ll have that Health Savings Account to draw from if you must have medical care until you’re re-employed.

Young, healthy people are the best candidates for doing this, but I started my Health Savings Account when I was 50. I’ve paid $62,400 into the account over the last 13 years – a good chunk of which came from employers who were thrilled not to have to pay huge premiums to insurance companies. I’ve paid$8,000 in catastrophic healthcare insurance premiums, leaving me with $71,505 after compounded interest. In those 13 years, I’ve used it a few times, but I spent less than $1,000 altogether, so I have more than$70,000 still available. By the time I’m ready to retire, I’ll have close to $150,000 in there if I continue relying only on compound interest. Rolling half over into a higher interest earning CD will practically double my earnings from interest. If I remain as healthy as my forebears and as my current health indicates, when I die, I may well have more than $400,000 left in that account. If I have to spend some of it – or even all of it – on healthcare, so be it. The purpose for this account is to pay for health care; anything left in it when I die is a bonus for my descendants.

If you’re young and healthy (or old and healthy), consider starting a Health Savings Account. Contribute to it every month. When it reaches a certain dollar amount that you believe exceeds what you will need for 5 years health care, roll over the excess into long term higher interest earning CDs or investing part of it to earn more money. By the time you reach an age where you’ll need costlier health care – you’ll have it available. Just don’t spend the money in this account on anything other than medical expenses. Not ever. Not for any reason.

Opting for cash only doctors and medical care is a hot debate, but personally, I find cash only medical care liberating. You don’t have all the additional worries of some uncaring stranger coming between you and your doctor and forbidding you to have medical care., nor do you then have to pay for the medical care you need on top of the hefty insurance premiums you’re paying. The money you would have spent on insurance premiums is earning interest in a Health Savings Account you can draw on for you medical expenses, and if you don’t spend out all the money you save, you have that much more to earn interest, and after you die, it becomes a part of your estate for your heirs. That’s something that will never happen with insurance premiums. That money is lost money if you don’t need to spend it.

That’s the downside to insured health care – you pay a lot of money every month, expecting it to be there to pay for the bulk of your medical care (30-40 years ago, it paid for all of your healthcare if you were insured), only to discover when you really need it that the insurance won’t pay for what you need, or if they do pay for it, they will deny and delay for so long you may die before you get approval – and you have to wait for that approval because all your health money is tied up in the insurance.

There are downsides to going to cash-only. If you mismanage your money, you won’t have any for health care. If you tap into your Health Savings Plan to pay your electric bill or fund your vacation, you won’t have it when you get sick. If you have a chronic ailment that is expensive to treat, you will never be able to save up enough to provide for it. If you become catastrophically disabled at a young age, you won’t have enough saved to provide for your healthcare.

But, if you are among the relatively healthy and are willing to take greater responsibility for your finances and health care, a Health Savings Account plus a low cost catastrophic health plan can keep you healthier with a doctor who is more concerned about you than misfiling some insurance form, and you may live your life with the knowledge that your good health will benefit your heirs – and you’ll be a role model for them to strive to be healthier, too.

Check out Cash Only Doctors http://www.cbsnews.com/stories/2004/04/05/health/main610269.shtml
http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=108870
http://www.simplecare.com/
http://www.ama-assn.org/amednews/2003/02/10/bisb0210.htm
http://www.orthosupersite.com/view.asp?rID=26705