Medical Care (Insurance) Rant

[Brando]

Professionals in the medical industry, feel free to contribute. You can skip to the TL;DR if you have ADHD.

So... Over the last few years I have been receiving regular 'maintenance' care. Chiropractic visits, routine checkups, etc. This year has been turning over a whole new leaf. I found a new chiropractor. They take my insurance (PPO), which is great. My 'explanation of benefits' will cover up to 25 treatments within 1 calendar year. "Sounds great" I say, until we get to visit #7.

Apparently my insurance carrier goes through a 3rd party whom evaluates my condition and makes a determination on how much care I really need - AKA how many treatments they are willing to cover. Once we approach the limit my doctor and I both have to make a case to get more treatments. "But my plan says they cover X." I say to the doctor. "That may be true, but buried in the fine print and in our service agreement with that insurer, we can only bill them for what is approved," he says. Shady. Much like those letters they mail to you asking "How did this injury happen? Is it work related? Accident related? Supply the responsible party's insurance info!" I don't even respond to those.

Fast forward ahead to this week. Somehow I injured the 'fat pad' behind my knee pretty bad. Swollen, sore, limited movement, etc. I go to an orthopedic specialist whom does an X-Ray (no out-of-pocket cost) and an MRI ($546!!!), determines that I need physical therapy for the next 6 weeks at 3 visits per week. I get to the PT office yesterday and they tell me my co-pay, and that my plan covers up to 20 visits in a calendar year. "That's good" I think, since I'll only need to do 18 of them. Then the therapist tells me "Well the first visit is just an assessment. We have to get approval before we begin any treatment because your insurance has to review everything and see if therapy is necessary."

Wait, what? The specialist I saw made a prescription for therapy, based on the injury. Is that opinion now invalid because some idiot behind a desk didn't look at a form? A paper-pusher makes the determination to whether I need treatment or not? What the f***? I ask for the "cash" rate and it's usually 1/2 to 1/4 the "Insurance discount" price.



I'm sure some of you are experiencing the same issues in this regard. For what I pay every month for my wife and I, it does not seem to be of any real benefit. Looking at the cost my wife and I pay every month and comparing it to what my insurance is costing me for the year, those whole fiasco without insurance would cost me 1/2 of what my "insurance" care will be for a year. Crazy. I am very tempted to drop insurance, pocket the money from my co ($120/mo), and pay cash for everything. At least then I won't be limited by 'network' restrictions or limited treatment authorizations.

TL;DR: Insurance-based care is stupid-crazy. F'd up my knee, now my provider has to 'approve' care my doctors prescribe. "Insurance" is the roadblock to health care, not cost.

/rant

[Tobra]

I will say this, paperwork is really a B****


There were a couple times when I was treating work comp patients that I told them, fine, find someone else to take care of them if you won't let me do it. They caved.

[Hugh R]

Not surprised, rationed care...No there will never be death panels.

[flatbutt]

I live with a damaged spinal cord due to lateral hyper-flexion at C5. It has all been very clearly documented and is permanent. The accident occurred 14 years ago and periodically the insurance company makes me go through hoops to prove I'm still messed up. They almost always challenge treatment claims saying that they're not sure why they're being billed for a treatment. I have had neurogenic bladder since the injury. They claim that the treatment isn't due to the accident so they aren't responsible. Right. My bladder has been atrophied for 14 years but the treatment isn't due to the nerve damage suffered in the accident. But the effort to get it paid for is worth it since I'd go broke otherwise. Hang in there Brando.

[wdfifteen]

Originally Posted by Brando

Shady. Much like those letters they mail to you asking "How did this injury happen? Is it work related? Accident related? Supply the responsible party's insurance info!" I don't even respond to those.

That's not exactly shady, they're just trying to find out who is financially responsible. If you slipped and fell on someone's broken steps, his liability insurer is responsible. If it's work related, workmen's comp is responsible. Of all the screwed up things health insurance companies do, this is one that makes sense to me.

Originally Posted by Brando

Wait, what? The specialist I saw made a prescription for therapy, based on the injury. Is that opinion now invalid because some idiot behind a desk didn't look at a form? A paper-pusher makes the determination to whether I need treatment or not? What the f***?

I'm sure some of you are experiencing the same issues in this regard.

Yep, standard procedure, and I've dealt with it many times over the years. It is infuriatingly absurd to have some "doctor" hundreds of miles away look at a piece of paper and tell you that the treatment the doctor who examined you prescribed isn't medically necessary. It's the shady way insurance companies have rationed care for decades, but in my experience it got much worse about 10-12 years ago.

[jyl]

But we could also have a thread about all the medical insurance fraud, waste, abuse and over use of medical care that goes on.

[Brian in VA]

Yes someone at an insurance co gets to second guess your specialist and the therapists. If they actually pay for things you need, then how will the CEO of Aetna make $36.36 million in 2012? They've created a perverse system refusing to pay for care & incentivizing PCPs to not provide care. And they've got the cash for lobbyists so that it doesn't change despite "reform."

[porsche4life]

Brandon I know it's crazy but you still need to pay for it. Consider if you got diagnosed with cancer or something major. Are you ready to drop 200k? Or 500k? It's not cheap to treat!

[turbo owner]

Originally Posted by porsche4life

Brandon I know it's crazy but you still need to pay for it. Consider if you got diagnosed with cancer or something major. Are you ready to drop 200k? Or 500k? It's not cheap to treat!

The most affordable way is to let nature run it's course. No way am I going to spend 1/2 a million and leave my wife destitute and still going to anyway. All treatment will do is buy you a few more years, miserable one at that.

[flyenby]

I would not cancel your insurance....if you have any assets

[jyl]

Maybe stop drinking before you make big decisions?

Quote de porsche4life

Brandon I know it's crazy but you still need to pay for it. Consider if you got diagnosed with cancer or something major. Are you ready to drop 200k? Or 500k? It's not cheap to treat!

The most affordable way is to let nature run it's course. No way am I going to spend 1/2 a million and leave my wife destitute and still going to anyway. All treatment will do is buy you a few more years, miserable one at that.

[porsche4life]

Originally Posted by turbo owner

The most affordable way is to let nature run it's course. No way am I going to spend 1/2 a million and leave my wife destitute and still going to anyway. All treatment will do is buy you a few more years, miserable one at that.

I know quite a few people who are living very full lives 20+ years after beating cancer that would have cost them a half million plus had they not had insurance.