Medical Billing Errors - WTHELLO

[JimFromTN]

Not entirely true depending upon the care needed. I had dislocated jaw that Medicare first said wasn't covered since they interpreted it to be "dental" then after I paid thru my cheeks to get it resolved, it was then determined it was covered. But at a doctor that was 92 miles away. The "helpless" desk for medicare is staffed third party staffed that frankly is clueless. They cost me a ton of money. Recently I had shoulder surgery and the ice therapy machine should have been covered but was denied. I was able to find the specific code that proved it was covered and I finally got reimbursed 8 months after surgery. No explanation of the refund check just shows up exactly what it cost. My experience with medicare after 2 shoulder surgeries is become fluent in coding which isn't hard to do and double check all the codes and approvals. Even had "fight" with ortho clinic on correct coding and won that as well. You just cannot believe the level of incompetence out there on total medical billing management until you audit the work provided. Don't back down if you believe you have correct coding and ratchet it up the food chain to get resolution.

I was told I "didn't understand" the coding until I explained I retired after 40+ years in EHS and Occupational Health for 100B global company for North America and routinely evaluated workers compensation coding with various plant locations. I was also told I was not allowed to have the Medicare coding manual since they don't have one. WTHELLO!!! I explained the Medicare coding manual is readily available to anyone to download off the Medicare website. The Medicare Helpless desk stated they did not know that. WTHELLO!

So you really need to be totally aware you are dealing with Medicare Helpless desk and medical clinic incompetence on a routine basis and I truly believe everyone needs to be their own auditor of every line item relative to validation of coding and payments. Yes, it takes time but you cannot trust the government or the private sector one iota to get it right first time.

That's my ongoing experience in last 5 years.

The article said overall that it was easier than people using private insurance, It also said overall people on medicare are more satisfied with their insurance. Depending on whether you needed a specialist, its not uncommon to have to travel to see one. With private insurance, your providers need to be in network as well. I live in the country and have to travel 80 miles if I need to see any kind of specialist and I have private insurance. I am not saying medicare is perfect by any means but private insurance ain't all they great either and they would be a whole lot worse if the government didn't regulate them. My first job out of college 30 years ago provided HMO insurance which was really cheap. The reimbursement on those HMO's wasn't a whole lot higher than medicare and much more likely to reject a claim. I think some of them rejected every claim and made people fight to get their claims paid. One weekend I had an accident and needed stitches. My in network doctors office was not open and I did not want to go to the ER. There was a clinic close by so I called my insurance company to verify that they were in network. That said they were so I went. My claim was rejected for out of network. I called the insurance company and they told me their people never would have told me the clinic was in network. In your case they were ignorant, in my case it was intentional. I had a girlfriend that went in for the flu and was rejected for a pre-existing condition. Its because of government regulation that those HMOs don't exist anymore and occurrences like that are far less frequent, I also mentioned earlier my brother being an ER doctor and insurance companies putting them on hold when he is needing preauthorization so that he would perform the procedure at the patient's expense. We have a choice between lazy ignorance and pure evil driven by greed. Which one is better? I would rather have a system that allows private insurance as well as a public option. A public option would drive insurance rates down and more people in this country would be insured. What no one seems to mention is that if everyone can pay their bills then everyone's bills go down because providers don't have to deal with bad debt.

 

[Muddyboots]

What no one seems to mention is that if everyone can pay their bills then everyone's bills go down because providers don't have to deal with bad debt.

Nailed it!

 

[snox801]

people paying bills is about as likely as the government doing the right thing.
But yes. We need to allow people to make choices for care with knowledge of side effects.
Why if someone has terminal cancer they can't try a experimental treatment.
If you know the risk why not allow stem cell blood therapy.
What we do know is that every time the government gets involved in healthcare prices always go up. So why not try the opposite? Free market.

 

[snox801]

I have to say this is why I love this site. We all have different ideas and outlooks that we discuss but nobody takes it to far or gets to bent out of shape. I don't have to agree with you on it but doesn't mean I don't respect your views. I just wanna try and win you over to the good side

 

[PBramble]

The wife says it should be completely paid for that we are under a public health emergency don't let them screw with you! You should contact your insurance commissioner they will get it straight

Thank you very much.

 

[Muddyboots]

Here is where I am on all of this:

1. Keep Health care as free market place
2. Address prescription costs for EVERYONE
3. Standardize health care procedure cost, the "ES - Extreme Spread" is ridiculous and there needs to be lower "SD - Standard Deviation" on this.
4. Eliminate Pre-Existing condition penalties PERIOD.
5. Eliminate ER and Immediate Care cost penalties for actual emergency services, yes, they still exist in some cases.
6. Establish a reasonable timeline for drug and procedure approval. Remove political and bureaucratic delays.
7. Free up alternative treatments that are not approved but are conducted within specific procedures that provide risks and potential results. The value to a terminal patient and society is greater than the overall risk.
8. Hold medical organizations ACCOUNTABLE for billing errors with appropriate penalties. Gee wonder why I added this.
9. Improve means to hold Doctors accountable.
10. Hold medical organizations ACCOUNTABLE for data security breaches with appropriate penalties. Gee wonder why I added this. Our data has been lost 3 times from medical organizations from irresponsible actions on their part.

Ok, I plan on adding to this list and sending to my reps. Please add subtract.

 

[JimFromTN]

Here is where I am on all of this:

1. Keep Health care as free market place
2. Address prescription costs for EVERYONE
3. Standardize health care procedure cost, the "ES - Extreme Spread" is ridiculous and there needs to be lower "SD - Standard Deviation" on this.
4. Eliminate Pre-Existing condition penalties PERIOD.
5. Eliminate ER and Immediate Care cost penalties for actual emergency services, yes, they still exist in some cases.
6. Establish a reasonable timeline for drug and procedure approval. Remove political and bureaucratic delays.
7. Free up alternative treatments that are not approved but are conducted within specific procedures that provide risks and potential results. The value to a terminal patient and society is greater than the overall risk.
8. Hold medical organizations ACCOUNTABLE for billing errors with appropriate penalties. Gee wonder why I added this.
9. Improve means to hold Doctors accountable.
10. Hold medical organizations ACCOUNTABLE for data security breaches with appropriate penalties. Gee wonder why I added this. Our data has been lost 3 times from medical organizations from irresponsible actions on their part.

Ok, I plan on adding to this list and sending to my reps. Please add subtract.

Boy, that sure is allot of government oversight. The government telling providers what they can charge not to mention holding them accountable. You sure you aren't a liberal? Just kidding. My brother who is a doctor and very fiscally conservative would agree with you completely as do I. Its interesting that if you leave politics out of it and don't use the political buzzwords, most people want the same thing. Everyone wants affordable and accessible healthcare. No one should die or go bankrupt because healthcare is too expensive.

 

[Muddyboots]

Nope not a liberal at all, not even close, but there needs to be some options available to us. They release our data and we have virtually no recourse against them. The charges are in error, we get sent to collections and we have virtually no recourse against them. Doc leaves something in after surgery and it is virtually impossible to hold them accountable with all the sign offs prior to surgery. I had my jaw dislocated by anesthesiologist and I had no recourse. WTHELLO!

Heck, auto shops use standardized rates and we can't get this in medical? I know the complexity of all the procedures but at 71 I am really tired of pushing water uphill against health care. We cannot get reasonable dental or vision care once you are in Medicare. The annual billing is usually close to the max payout. SO WTHELLO!

My prescription for a drug pre Medicare was $40, after Medicare was over $200. Seniors are screwed into ground.

 

[JimFromTN]

Nope not a liberal at all, not even close, but there needs to be some options available to us. They release our data and we have virtually no recourse against them. The charges are in error, we get sent to collections and we have virtually no recourse against them. Doc leaves something in after surgery and it is virtually impossible to hold them accountable with all the sign offs prior to surgery. I had my jaw dislocated by anesthesiologist and I had no recourse. WTHELLO!

Heck, auto shops use standardized rates and we can't get this in medical? I know the complexity of all the procedures but at 71 I am really tired of pushing water uphill against health care. We cannot get reasonable dental or vision care once you are in Medicare. The annual billing is usually close to the max payout. SO WTHELLO!

My prescription for a drug pre Medicare was $40, after Medicare was over $200. Seniors are screwed into ground.

Not being able to hold your anesthesiologist accountable is a result of tort reform. Allot of that is at the state level. I know in TN its very difficult to to sue for malpractice.

As for pricing, that is totally controlled by the providers and insurance companies. It is the free market to some extent. The private sector is determining the prices. People say they want a free market but you can't cap pricing or regulate pricing in the free market or put any regulations on penalties. You also can't protect pre-existing conditions in a true free market. In our current system, you can shop around all you want if you don't have insurance. If you have insurance then you are restricted to shopping around in network if you want your insurance to pay and most of the providers have agreed with the insurance company what they are going to charge. There can be major differences when it comes to radiology, even in network. I watched the Ben Shapiro video that was posted and it made me curious so I went out online and watched some others. He mentions that you can't shop around for xrays. I have found that to be untrue. You can shop around for xrays but everyone pretty much charges the same thing for an xray so thats not really a good example. You can save some serious money if you shop around for MRI's even if you stay in network. His stuff sounds good but once you really dig down into it and think about the relationships between providers and insurance companies, it doesn't make sense. In the perfect free market world, everyone is competing and the prices are driven down. Thats not reality when it comes to healthcare and really does not work out that way always in other markets. Coke and Pepsi are both raising their prices even though they had huge profits. Kind of blows the whole free market will cause prices to drop because of competition theory. You have to either get rid of insurance companies or get rid of their networks and their contracted pricing and get them to agree to pay whatever the market determines they should pay. Good luck with that. I also have a hard time believing that neurosurgeons and heart surgeons are going to get in price wars with their competitors. Are you really going to go to a heart surgeon that advertises on tv at 3am in the morning?

 

[snox801]

First you can't have pre existing conditions. That's no longer insurance if you can buy it afterwards. What they need to do is make sure the person who covered you when you got the illness pays. Many times they use the example of someone getting sick long term and being dropped form health care. That's not right and they lump that into pre existing conditions
You honestly think doctors are the only professional occupation on earth that won't compete for your business. Lol I bet you use the same argument about public schools
If you would like another good spot to find some info about it check out Steven crowder.
He breaks down the facts many use like higher Indians mortality rates. Those don't hold water if we use the same metrics. Same as our mass shooting stats.
Lastly no matter what points are made how can you pay for this? Or have can you be ok with forcing me to pay for it?
As for coke and Pepsi from what I gather they made more profits by increased sales so without a good look at the books they may have kept the same profit margins. Free market works I can still go buy a soda for less than a dollar juts not cola or Pepsi. I ah e a cheaper option. That's free market. I have a cheaper option whether I do or not is different.
Again a free market is the only way to determine a true cost of things. Problem is regulation can really throw it out of wack .
So do insurance companies. Think of the stuff a contractor decides to toss in when you have a claim. Or the body ship we cover deductible. They don't do that, they just know they will bill that to and insurance company and because the guy is not writing a check out of his pocket and has the policy owner on the other side.

 

[JimFromTN]

So if you are born with a pre-existing condition, you are SOL? If you develop a pre-existing condition under your parents insurance, that insurance company has to cover you for the rest of your life? What if they go under or get bought out? Also, companies that provide insurance to their employees change their insurance carrier all the time. How exactly does that work? Then you mention not allowing them to drop them. Thats government regulation.

Your argument about doctors not competing throws out your whole argument for a totally free market.

The reason it is ok to make you pay into the system is because eventually unless you die outside of the system and all that needs to be done is plant you in the ground or no one finds your body, you are going to use the system and if you don't have the money on hand to pay for it yourself then you are the freeloader. It happens every day. You can say that it won't happen but statistically its practically inevitable. If I live in a safe area where there is no crime, why should I pay for the police? If I have no kids, why should I pay into the education system? If I don't own a vehicle then why should I help pay roads, stop signs, or traffic lights? My house has never burned down, why should I have to pay for the fire department? If I don't support the wars we have been in, why should I help pay for the military? Why should I help pay for the FBI or CIA? Why should I pay for anything that I don't directly use?

Pepsi and Coke both increased their sales yet they are both raising their prices. What happened to the free market theory that competition drives prices down? Cheap colas are not in competition with them. There is a reason the "cheap" cola companies can't compete. Their products suck in comparison. There is nothing stopping you from getting a doctor that is cheap and sucks in comparison. That exists today.

I have never had a contractor or body shop do me any favors. Its always been, bend over and take it.

 

[snox801]

I'll take these one at a time
First yes if you get diagnosed with a serious condition while insured yes they need to cover that. I can currently wreck my car today cancel my insurance tomorrow and they still have to cover that. So yes you were insured when you got sick they need to cover that.
Now you also put in a lot of what if's. Let's not cherry pick small instances for befall policy. Yes n those instances we would have to hope the social fabric picks up the slack or figure some kind of special way to carry that.

My argument about doctors competing is not off. They will compete. What would cause them to be the only industry not to?

As for forcing someone to pay in. Nope never ok.
What's next I declare jousting my right? Nobody should be homeless. Then they can force you to pay for my home?
The reality is you have absolutely no right to forcefully take money from me to pay for someone else's care.
I agree you should not have to pay for schools, police maybe because who's is to say your area stays safe. But I'd lean towards no. I believe the police have become a major draw on the system and are vastly over funded. Same as schools. Every year we spend more and more on both and they keep getting worse outcome.
House burns down make insurance pay for the depts call. If you are irresponsible live with the outcome of bad choices.
The military is the one you are wrong on.
Government only has a few true roles I. This country. Mainly things the local people can't do. Wars, plagues things like that.
Lastly yes cheap cola does compete. In fact look at my fridge full of rc cola and .99 venom drinks.
Do I prefer coke yep 100 percent I made a choice in the free market to buy cheaper goods. Explain how they don't compete. I just walked into the gas station. Coke, Pepsi, and rc cola along with several others. That's free market. I have a choice many choice cars in fact.

 

[JimFromTN]

The what if's are very real and are quite common. People are born everyday with pre-existing conditions. People develop pre-existing conditions when they are too young to work everyday. I have had my insurance change several times at the job I am currently at. I have also changed jobs and my insurance changed. Making the original insurance company cover it is absurd. My first job was an old HMO that does not exist anymore so what then? Also, if your insurance changed at your company and you kept the original you would no longer get the negotiated pricing and your premiums would soar out of control. You don't address the fact that your premiums could easily become unaffordable and make it impossible for you to pay and as a result you would be uninsurable for the rest of your life. Of course when you mention the social fabric taking care of it, if you mean a public option or medicare then I am all in but you don't get out of paying for it. If you are talking about some magical charity that will cover the hundred million americans that you rendered uninsurable and it get its money from donations then that is as ludicrous as it sounds.

What you don't seem to get about doctors is that if they wanted to be more competitive with their pricing, there is nothing stopping them and insurance companies would love it if they charged less money.

Cheap cola doesn't compete enough to drive down the cost of other colas which I believe was your point in that the free market would drive down prices. If coke and pepsi are raising their prices then RC is having no effect on the free market.

If you don't mind me asking, how old are you?

 

[Muddyboots]

As far as I am concerned the entire insurance and medical field is in violation of the Federal Antitrust laws:

The Sherman Act outlaws "every contract, combination, or conspiracy in restraint of trade," and any "monopolization, attempted monopolization, or conspiracy or combination to monopolize." Long ago, the Supreme Court decided that the Sherman Act does not prohibit every restraint of trade, only those that are unreasonable. For instance, in some sense, an agreement between two individuals to form a partnership restrains trade, but may not do so unreasonably, and thus may be lawful under the antitrust laws. On the other hand, certain acts are considered so harmful to competition that they are almost always illegal. These include plain arrangements among competing individuals or businesses to fix prices, divide markets, or rig bids. These acts are "per se" violations of the Sherman Act; in other words, no defense or justification is allowed.