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