There must be a pony in here somewhere.

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Dangerman
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Re: There must be a pony in here somewhere.

Post by Dangerman » 30 Jan 2018, 10:40

I took a friend to the ER with appendix pain, and it turned out to be ovarian cysts. Cysts that required surgery that day because they can actually kill you in certain cases. So I'm double upset for this lady because she probably made the right choice even if she somehow knew what the issue was.

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Fin Fang Foom
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Re: There must be a pony in here somewhere.

Post by Fin Fang Foom » 30 Jan 2018, 11:17

I suspect the Amazon, BerkHath, JPMorgan thing is just them doing in-house insurance admin since I'm sure they self-fund.
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Mo
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Re: There must be a pony in here somewhere.

Post by Mo » 30 Jan 2018, 11:24

Which they already do. It's just creating more efficiencies because it's 3 companies instead of 1. And it's already a thing. It's only news because it has Warren Buffett and Amazon in the headline.
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Fin Fang Foom
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Re: There must be a pony in here somewhere.

Post by Fin Fang Foom » 30 Jan 2018, 11:25

Mo wrote:
30 Jan 2018, 11:24
Which they already do. It's just creating more efficiencies because it's 3 companies instead of 1. And it's already a thing. It's only news because it has Warren Buffett and Amazon in the headline.
As in Amazon employees currently carry an Amazon branded insurance card, not like Aetna or whatever?
". . . even the federalist folk are probably a bit wary, and they're essentially cosplaying the preacher from footloose." - dhex

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Mo
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Re: There must be a pony in here somewhere.

Post by Mo » 30 Jan 2018, 11:30

Amazon/Berkshire/JPMC are not going around to hospitals, doctors and pharmacies for network access, it will stay Aetna or whatever.
his voice is so soothing, but why do conspiracy nuts always sound like Batman and Robin solving one of Riddler's puzzles out loud? - fod

no one ever yells worldstar when a pet gets fucked up - dhex

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Jennifer
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Re: There must be a pony in here somewhere.

Post by Jennifer » 30 Jan 2018, 15:18

JasonL wrote:
30 Jan 2018, 09:28
I have no real problems imposing a coverage differential on unnecessary ER visits.
Had she gone to the ER with something petty like an infected hangnail, I'd agree. But how is a non-medical person suffering debilitating pain supposed to know "Eh, despite the monstrous pain this is not fatal; I can either schedule an appointment with my regular doctor, or wait until the urgent care center opens tomorrow morning"?
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JasonL
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Re: There must be a pony in here somewhere.

Post by JasonL » 30 Jan 2018, 15:47

Agree the particular case is terrible. Just clarifying that penalty for ER abuse in general is good not bad. If you go into the ER look around. My nurse friends tell me it’s like 8 or 9 to 1 unnecessary.

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Fin Fang Foom
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Re: There must be a pony in here somewhere.

Post by Fin Fang Foom » 30 Jan 2018, 15:53

It'd be good if they'd tell people to go to urgent care or not to come back if the fever was below 103 or whatever then instead of charging them then.
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JasonL
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Re: There must be a pony in here somewhere.

Post by JasonL » 30 Jan 2018, 15:55

They tell people. People don't go and they won't go next time either. At least, not many of them. That's where these policies came from.

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lunchstealer
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Re: There must be a pony in here somewhere.

Post by lunchstealer » 30 Jan 2018, 15:56

Our insurance includes a $200 payable-up-front copay plus 40% coinsurance up to the OOP max for ER bills, and a lot of doctors at ERs are out-of-network meaning that part of the bill goes against the high OOP max, not the low one. This is a pretty good incentive not to go to the ER for bullshit that you could do at urgent care or your PCP.
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Pham Nuwen
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Re: There must be a pony in here somewhere.

Post by Pham Nuwen » 31 Jan 2018, 02:47

I'm just going to put this out there and run away.

This story doesn't sound true. It could have happened. I acknowledge that. But it doesn't sound true. And I work for whatever cvs/Aetna calls itself or tells people it is. They are penny pinching to an amazing degree. At least to me*. So it could have happened. But it doesn't really sound right.

Running away now.

*I'll never be able to understand how we lost 6 million in revenue over 300k in labor but we did. I saw it happen.
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Jennifer
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Re: There must be a pony in here somewhere.

Post by Jennifer » 31 Jan 2018, 03:07

Pham Nuwen wrote:
31 Jan 2018, 02:47
I'm just going to put this out there and run away.

This story doesn't sound true. It could have happened. I acknowledge that. But it doesn't sound true.
Based on what? Medical sticker shock (a la "You were quoted X price before the procedure, then got a bill for 10X or even 100X") is a thing, unfortunately.

And I work for whatever cvs/Aetna calls itself or tells people it is. They are penny pinching to an amazing degree. At least to me*. So it could have happened. But it doesn't really sound right.
The insurance cmpany mentioned in the article is Anthem, not Aetna.
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Pham Nuwen
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Re: There must be a pony in here somewhere.

Post by Pham Nuwen » 31 Jan 2018, 03:14

Doesn't. Sound. True.

Signing a policy and reneging is real. But an actual visit? Supported by prescribed notes and orders? It's begging for a settlement much higher than what was denied.

And I work for an insurance ... thingy ... whatever they are calling it. They all basically do the same thing. Because i work for one and have perspective.
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Re: There must be a pony in here somewhere.

Post by Jennifer » 31 Jan 2018, 03:56

An insurance company refusing to cover something doesn't sound unbelievable to me at all, unfortunately. How many hits would you get if you Googled "health insurance company denies claim" without the quotes? [Checks] Ah, it's 1,580,000. And Google offers the additional recommended searches for "insurance company denied my claim now what" "how to fight health insurance denial" "health insurance claim denial reasons" and "what to do if health insurance claim is denied."
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Re: There must be a pony in here somewhere.

Post by JasonL » 31 Jan 2018, 09:12

To be clear, what you care about is health insurance denying valid claims. There are lots and lots of reasons, spelled out in the coverage, why a given claim would be denied. It seems like settlement bait to have to coverage documents say one thing then do something else, or even to leave the terms of ER refusal that nebulous.

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Re: There must be a pony in here somewhere.

Post by Jennifer » 31 Jan 2018, 14:43

JasonL wrote:
31 Jan 2018, 09:12
To be clear, what you care about is health insurance denying valid claims.
Exactly. Such as happened to the woman in the story, because Anthem insurance apparently expects ALL of its customers (at least in Georgia, Kentucky, Indiana and Missouri) to be as knowledgeable as your typical medical school graduate, regarding such matters as "This excruciating pain I suddenly started feeling -- can it wait until standard business hours for treatment, or should I go to the ER now?"
There are lots and lots of reasons, spelled out in the coverage, why a given claim would be denied. It seems like settlement bait to have to coverage documents say one thing then do something else, or even to leave the terms of ER refusal that nebulous.
One could say similar things about (for example) "Oh, yeah, this ER is totally in your insurance network -- but not a single goddamned physician in this ER is." Yet THAT shit happens too.

I know you're very resistant to the idea "People who complain about large companies sometimes have legitimate reasons to do so, and the company in question is in the wrong," but even with the alleged "protections" of Obamacare, it's still all too easy for people to act responsibly and STILL get screwed: "Yes, I have insurance -- fuck, the insurance refuses to cover anything." "I asked my doctor the price BEFORE I consented to the procedure -- fuck, the bill I actually got is three orders of magnitude than the original quote I got."
"Myself, despite what they say about libertarians, I think we're actually allowed to pursue options beyond futility or sucking the dicks of the powerful." -- Eric the .5b

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Re: There must be a pony in here somewhere.

Post by JasonL » 31 Jan 2018, 15:36

I know you're very resistant to the idea "People who complain about large companies sometimes have legitimate reasons to do so, and the company in question is in the wrong,"
Not to re-litigate this, but this is not what I'm resistant to. My resistance is to the suggestion that this case of claims rejection is a common flavor, which is what happens when you say things like we can be informed about such abuses by googling "insurance claim denied" or whatever. I'm saying that when you do that, the vast majority of complaints are for contractually legitimate claim refusals.

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Warren
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Re: There must be a pony in here somewhere.

Post by Warren » 31 Jan 2018, 17:16

JasonL wrote:
31 Jan 2018, 15:36
I know you're very resistant to the idea "People who complain about large companies sometimes have legitimate reasons to do so, and the company in question is in the wrong,"
Not to re-litigate this, but this is not what I'm resistant to. My resistance is to the suggestion that this case of claims rejection is a common flavor, which is what happens when you say things like we can be informed about such abuses by googling "insurance claim denied" or whatever. I'm saying that when you do that, the vast majority of complaints are for contractually legitimate claim refusals.
Which is another way of saying FYTW. "Contractually legitimate" means "we put language in the fine print that only a lawyer can decode and misled the client about what it said".
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Re: There must be a pony in here somewhere.

Post by JasonL » 31 Jan 2018, 18:31

It is a more accurate way of viewing the arrangement than the common construction “insurance writes me a check in any amount no matter what”. That’s not how it works. You are agreeing to payment under specified terms. There are regs governing the complexity and prominence of key feature language. Most disputes are not about fine print they are about the nature of the thing you are buying written in 5th grade English.

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Re: There must be a pony in here somewhere.

Post by Andrew » 31 Jan 2018, 18:54

JasonL wrote:
31 Jan 2018, 18:31
It is a more accurate way of viewing the arrangement than the common construction “insurance writes me a check in any amount no matter what”. That’s not how it works. You are agreeing to payment under specified terms. There are regs governing the complexity and prominence of key feature language. Most disputes are not about fine print they are about the nature of the thing you are buying written in 5th grade English.
Wilful disbelief is a helluva drug. Same thing that happened to homeowners who claimed they "didn't know" they had an ARM that switched to 495% interest after 3 years despite a form saying that in 24 point font.
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Pham Nuwen
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Re: There must be a pony in here somewhere.

Post by Pham Nuwen » 31 Jan 2018, 19:13

Andrew wrote:
31 Jan 2018, 18:54
JasonL wrote:
31 Jan 2018, 18:31
It is a more accurate way of viewing the arrangement than the common construction “insurance writes me a check in any amount no matter what”. That’s not how it works. You are agreeing to payment under specified terms. There are regs governing the complexity and prominence of key feature language. Most disputes are not about fine print they are about the nature of the thing you are buying written in 5th grade English.
Wilful disbelief is a helluva drug. Same thing that happened to homeowners who claimed they "didn't know" they had an ARM that switched to 495% interest after 3 years despite a form saying that in 24 point font.
Yeah. And its kind of why I disbelieve the story. It could be real. But a lawyer would be all over that shit. So I'm of the mind that something else is afoot.

And I'm not a heartless bastard Jen. It just checks to many boxes of what people expect to hear and read about an insurance denied story. And I grew sensitive to that real quick in retail pharmacy.
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Re: There must be a pony in here somewhere.

Post by JasonL » 31 Jan 2018, 19:44

Andrew wrote:
JasonL wrote:
31 Jan 2018, 18:31
It is a more accurate way of viewing the arrangement than the common construction “insurance writes me a check in any amount no matter what”. That’s not how it works. You are agreeing to payment under specified terms. There are regs governing the complexity and prominence of key feature language. Most disputes are not about fine print they are about the nature of the thing you are buying written in 5th grade English.
Wilful disbelief is a helluva drug. Same thing that happened to homeowners who claimed they "didn't know" they had an ARM that switched to 495% interest after 3 years despite a form saying that in 24 point font.
Yes. When it seems like I’m an infinite apologist it’s because I deal with this all day every day. The general systems aren’t exploitative of customers, corrections are generally (universally in my world) applied to legitimate errors, people want to make customers happy. Even insurance companies. You hear about the worst abuses and practices and they should be curtailed- but you f you think this case here is reflective of the average denied claim you don’t understand how customers who have to pay money react in the real world.

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Re: There must be a pony in here somewhere.

Post by Jennifer » 31 Jan 2018, 19:59

Pham Nuwen wrote:
31 Jan 2018, 19:13
Andrew wrote:
31 Jan 2018, 18:54
JasonL wrote:
31 Jan 2018, 18:31
It is a more accurate way of viewing the arrangement than the common construction “insurance writes me a check in any amount no matter what”. That’s not how it works. You are agreeing to payment under specified terms. There are regs governing the complexity and prominence of key feature language. Most disputes are not about fine print they are about the nature of the thing you are buying written in 5th grade English.
Wilful disbelief is a helluva drug. Same thing that happened to homeowners who claimed they "didn't know" they had an ARM that switched to 495% interest after 3 years despite a form saying that in 24 point font.
Yeah. And its kind of why I disbelieve the story. It could be real. But a lawyer would be all over that shit. So I'm of the mind that something else is afoot.

And I'm not a heartless bastard Jen. It just checks to many boxes of what people expect to hear and read about an insurance denied story. And I grew sensitive to that real quick in retail pharmacy.

I'm not saying you're heartless; I'm asking "Given that 'insurance companies denying claims' and 'Just because you have insurance doesn't mean it will actually cover you when you're sick or injured' are actual things, what makes you doubt this particular story? "(If you read to the end, you'll note that Anthem eventually changed its mind .... after Vox contacted them for this story.)
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Re: There must be a pony in here somewhere.

Post by Painboy » 31 Jan 2018, 20:18

Jennifer wrote:
31 Jan 2018, 19:59
Pham Nuwen wrote:
31 Jan 2018, 19:13
Andrew wrote:
31 Jan 2018, 18:54
JasonL wrote:
31 Jan 2018, 18:31
It is a more accurate way of viewing the arrangement than the common construction “insurance writes me a check in any amount no matter what”. That’s not how it works. You are agreeing to payment under specified terms. There are regs governing the complexity and prominence of key feature language. Most disputes are not about fine print they are about the nature of the thing you are buying written in 5th grade English.
Wilful disbelief is a helluva drug. Same thing that happened to homeowners who claimed they "didn't know" they had an ARM that switched to 495% interest after 3 years despite a form saying that in 24 point font.
Yeah. And its kind of why I disbelieve the story. It could be real. But a lawyer would be all over that shit. So I'm of the mind that something else is afoot.

And I'm not a heartless bastard Jen. It just checks to many boxes of what people expect to hear and read about an insurance denied story. And I grew sensitive to that real quick in retail pharmacy.

I'm not saying you're heartless; I'm asking "Given that insurance companies denying claims" and "Just because you have insurance doesn't mean it will actually cover you when you're sick or injured" is an actual thing, what makes you doubt this particular story? (If you read to the end, you'll note that Anthem eventually changed its mind .... after Vox contacted them for this story.)
They changed their mind because the media got involved and they know they can't win that fight regardless of the rightness of their claims.

I worked for a time at large mail order pharmacy doing collections. Much of their clientele were people in nursing homes. Their official policy was that if you didn't have Medicare, Medicaid, other insurance, or family, that was paying for your medications then you would be cut off. The reality was they would continue providing their medications regardless because they didn't want to be dragged into the inevitable media clusterfuck that would happen when they cutoff some grandma with dementia's meds. The amount of money they ate from this was not small change, but the possibility of being pilloried by the media was seen as not worth the risk.

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Jennifer
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Re: There must be a pony in here somewhere.

Post by Jennifer » 31 Jan 2018, 23:27

Painboy wrote:
31 Jan 2018, 20:18
They changed their mind because the media got involved and they know they can't win that fight regardless of the rightness of their claims.

Oh, I know they changed their mind due to media embarrassment. But if Vox's account is accurate (and I've no reason to think it's not, especially since they could be sued by Anthem otherwise), their claim was not right at all. "Pain so excruciating you're doubled over and can't function" damned well qualifies as an emergency even if it can be ignored for a day or two without leading to death or permanent maiming-- and that woman, being a non-doctor, of course had no way of knowing she was suffering the "non-emergency" form of pain.

I was reading a comment thread about this or some other story on Metafilter (whose non-American commenters are already appalled by the notion that Americans can go bankrupt due to medical costs, or that Americans already stressed out by illness or injury must add financial stress to that), and one commenter brought up something I managed to overlook: how many people might very well die, because they need to go to the ER but fear Anthem will pull a stunt like this? Not everybody screwed by insurance companies is lucky enough to get their story picked up by the media.
"Myself, despite what they say about libertarians, I think we're actually allowed to pursue options beyond futility or sucking the dicks of the powerful." -- Eric the .5b

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