There must be a pony in here somewhere.

User avatar
Painboy
Posts: 3653
Joined: 18 Feb 2013, 11:33
Location: Seattle

Re: There must be a pony in here somewhere.

Post by Painboy » 01 Feb 2018, 02:17

Jennifer wrote:
31 Jan 2018, 23:27
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.
That's not going to happen because that would be absurd. No one is going to worry about that if they feel like what they are going through is an emergency situation. The policy is for people whose default response is to go to the emergency room anytime they get a mild headache or suffer some nausea. It's unfortunate that lady went through that but there is no policy that is going to perfectly sort these situations out. Some people are going to fall through the cracks from time to time, but those are outliers and not representative of the vast majority of other patients. If they weren't outliers you would hear about it constantly not just from a few media sources.

User avatar
Mo
Posts: 22832
Joined: 26 Apr 2010, 17:08

Re: There must be a pony in here somewhere.

Post by Mo » 01 Feb 2018, 02:49

I would be more sympathetic to this if ER practices weren’t shady as fuck by default. Before we were married Mrs. Mo got an infected finger where the tip grew to the size of a quarter. They claimed they were covered by her insurance, but none of the docs were*. When she asked why she wasn’t informed so she could go to another ER, they basically said they couldn’t let her leave since it could have been serious, even though it clearly wasn’t life threatening. So what is it, we need to reduce overuse or fuck you we need to make sure we get paid.

* Which frankly should be considered fraud.
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

User avatar
JasonL
Posts: 22448
Joined: 05 May 2010, 17:22

Re: There must be a pony in here somewhere.

Post by JasonL » 01 Feb 2018, 07:10

That should be fraud.

User avatar
Jasper
Posts: 2828
Joined: 27 Apr 2010, 07:56
Location: Newyorkachusetts

Re: There must be a pony in here somewhere.

Post by Jasper » 01 Feb 2018, 13:42

Jennifer wrote:
31 Jan 2018, 23:27
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.
Image
"i'd like to move toward not combusting except on special occasions like arbor day." - dhex

User avatar
lunchstealer
Posts: 15893
Joined: 26 Apr 2010, 17:25
Location: The Local Fluff in the Local Bubble

Re: There must be a pony in here somewhere.

Post by lunchstealer » 01 Feb 2018, 14:32

Yeah, the intentional obfuscation of literally everything about billing and pricing by all involved makes me have zero sympathy for either insurance companies or doctors or hospital administrators. It's like they all want desperately to end up with the British NHS. If a hospital or main provider is in-network, then anyone they bring on to do work for them for you should be contractors of the main provider from whom you requested service, not completely separate providers brought in with fine-print-technically-it's-consent but no transparency. It's basically impossible for a consumer/patient to do good-faith due-dilligence and expect to not get stuck with a stupid bill.

I feel like doctors are hiding behind the "We're SAVING LIVES so we shouldn't be worrying our patients with something so crass as billing and costs, also we should be paid whatever we ask because we're SAVING LIVES aren't we awesome? Lucre is filthy and we don't want to talk about it and also god damn it I gots to get paid so shell out even though I kinda hid the fact that this would cost 3x what you'd expect."
"The constitution is more of a BDSM agreement with a safe word." - Sandy

"Neoliberalism. Austerity. Booga booga!!!!" - JasonL

"We can't confirm rumors that Lynndie England is in the running to be Gina Haspel's personal aide." - DAR

User avatar
JasonL
Posts: 22448
Joined: 05 May 2010, 17:22

Re: There must be a pony in here somewhere.

Post by JasonL » 01 Feb 2018, 14:37

Agree - in the popular narrative the evil deeds of the insurers are overstated and those of the docs and hospital groups are significantly understated. Somebody somewhere has to be in the business of controlling costs and every single time insurers mount a new strategy to reduce payments, they are outflanked by organized providers who then, to lunchies point, hide behind being the good guys.

User avatar
Jennifer
Posts: 22510
Joined: 28 Apr 2010, 14:03

Re: There must be a pony in here somewhere.

Post by Jennifer » 01 Feb 2018, 15:54

Painboy wrote:
01 Feb 2018, 02:17
Jennifer wrote:
31 Jan 2018, 23:27
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.
That's not going to happen because that would be absurd.
You don't think fear of the cost keeps people from getting medical help when needed?

The policy is for people whose default response is to go to the emergency room anytime they get a mild headache or suffer some nausea.
And yet it was applied to a woman with an extremely painful ovarian cyst, too.
Some people are going to fall through the cracks from time to time, but those are outliers and not representative of the vast majority of other patients. If they weren't outliers you would hear about it constantly not just from a few media sources.
Alternate interpretation: the fact that such horror stories are fairly commonplace is exactly why so many Americans call for the government to Do Something about it.
"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

User avatar
Jennifer
Posts: 22510
Joined: 28 Apr 2010, 14:03

Re: There must be a pony in here somewhere.

Post by Jennifer » 01 Feb 2018, 15:56

And -- referring to Mo and Lunchstealer's comments -- the insurance companies and ERs and the like have been pulling stunts like this long enough that they do NOT deserve the benefit of the doubt, here.
"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

User avatar
Mo
Posts: 22832
Joined: 26 Apr 2010, 17:08

Re: There must be a pony in here somewhere.

Post by Mo » 12 Feb 2018, 10:43

Former Aetna medical director tells the truth that many suspected. Now Aetna is, rightly, under investigation. Aetna's defense is odd. They are saying the doctor's judgement of the patient's medical history is correct, but the doctor never reviewed the medical history.
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

User avatar
JasonL
Posts: 22448
Joined: 05 May 2010, 17:22

Re: There must be a pony in here somewhere.

Post by JasonL » 12 Feb 2018, 11:03

What strikes me about that is Aetna's defense - no equivocation just "yup here are the published guidelines that say this is how we do review and no we would not expect that guy to review cases directly".

User avatar
Warren
Posts: 24244
Joined: 26 Apr 2010, 17:03
Location: Goat Rope MO
Contact:

Re: There must be a pony in here somewhere.

Post by Warren » 12 Feb 2018, 11:28

Back in the last millennium I knew a guy that worked in our HR dept. He told me that coverage was denied based on how readily an employee could be replaced.
THIS SPACE FOR RENT

User avatar
JasonL
Posts: 22448
Joined: 05 May 2010, 17:22

Re: There must be a pony in here somewhere.

Post by JasonL » 12 Feb 2018, 11:40

There are an awful lot of regulations and lawyers involved for it to be exactly that. Maybe marginal cases or something like they would approve more stuff for high value employees, which is not to same saying they would deny coverage in violation of the plan summary for more easily replaced employees. I dunno though. There are a ton of coverage lawsuits and systemic violations of terms would be class actions for sure.

User avatar
Warren
Posts: 24244
Joined: 26 Apr 2010, 17:03
Location: Goat Rope MO
Contact:

Re: There must be a pony in here somewhere.

Post by Warren » 12 Feb 2018, 12:00

JasonL wrote:
12 Feb 2018, 11:40
There are an awful lot of regulations and lawyers involved for it to be exactly that. Maybe marginal cases or something like they would approve more stuff for high value employees, which is not to same saying they would deny coverage in violation of the plan summary for more easily replaced employees. I dunno though. There are a ton of coverage lawsuits and systemic violations of terms would be class actions for sure.
The way it was explained to me was like this. Routine stuff that was in the plan summary was routinely covered, but the thing is that in the full fine print of the plan basically nothing was covered. Even so they paid for a lot of stuff they could have contested so that they could deny payment when they wanted to. If they wound up in court they'd have tons of history of paying out to show that they weren't systematically denying coverage. Valued employees with chronic health problems would be covered and the cost partially recouped with low compensation. People in such circumstances would be loath to give up their health care to go in search of higher salary. OTOH if a drone from sector 7g started racking up medical bills they'd start denying payment and the text of the plan gave them coverage in court. People in such circumstances were poorly situated to mount a legal challenge.
THIS SPACE FOR RENT

User avatar
JasonL
Posts: 22448
Joined: 05 May 2010, 17:22

Re: There must be a pony in here somewhere.

Post by JasonL » 12 Feb 2018, 12:50

Can't say that doesn't happen but man there are a lot of consequences to doing something like that and getting caught. Even having a plan summary materially different from full plan description / plan document is a big no no.

User avatar
Warren
Posts: 24244
Joined: 26 Apr 2010, 17:03
Location: Goat Rope MO
Contact:

Re: There must be a pony in here somewhere.

Post by Warren » 12 Feb 2018, 13:51

JasonL wrote:
12 Feb 2018, 12:50
Can't say that doesn't happen but man there are a lot of consequences to doing something like that and getting caught. Even having a plan summary materially different from full plan description / plan document is a big no no.
Like I said, this was like twenty years ago, but since he clued me in, I looked at the health plan in the three companies I worked at since then. First of all, until you are actually hired, you can't see the plan. Second even after you're hired you can't see the plan. I mean, you can, but you have to push and push and push, HR keeps giving you the employee handouts which isn't the actual plan. And third, he was right. People say they have "health insurance" from work, but they don't. If they had health insurance there would be a policy that spells out what is covered and for how much. What people have is a "health plan" and at the end of the day it doesn't actually obligate the insurance to pay out for much at all.
THIS SPACE FOR RENT

User avatar
Painboy
Posts: 3653
Joined: 18 Feb 2013, 11:33
Location: Seattle

Re: There must be a pony in here somewhere.

Post by Painboy » 12 Feb 2018, 16:36

Mo wrote:
12 Feb 2018, 10:43
Former Aetna medical director tells the truth that many suspected. Now Aetna is, rightly, under investigation. Aetna's defense is odd. They are saying the doctor's judgement of the patient's medical history is correct, but the doctor never reviewed the medical history.
I think there may be some misunderstanding there (or I'm the one that's misunderstanding it). The guy quoted was not the patient's doctor he was just someone who reviewed the treatments given to the patient to see if those were covered by the plan, then approving or denying coverage depending on the procedure and other info. He doesn't need to know what the patient's medical history because he's not determining treatment just review what was done. Despite the term "explosive" being used I don't think this is much of a revelation if that's what the guy's job was.

Also the Aetna case where the guy was testifying reads to me like Aetna is in the right.
Aetna has rejected the allegations, saying Washington failed to comply with their requests for blood work. Washington, who was diagnosed with common variable immunodeficiency, or CVID, in high school, became a new Aetna patient in January 2014 after being insured by Kaiser.
Aetna initially paid for his treatments after each infusion, which can cost up to $20,000. But when Washington's clinic asked Aetna to pre-authorize a November 2014 infusion, Aetna says it was obligated to review his medical record. That's when it saw his last blood work had been done three years earlier for Kaiser.
Despite being told by his own doctor's office that he needed to come in for new blood work, Washington failed to do so for several months until he got so sick he ended up in the hospital with a collapsed lung.
If the guy isn't keeping up with his treatments that are required of him then should Aetna be made to pay for the results of missing them?

From the trial:
In its trial brief, Aetna said: "Given that Aetna does not directly provide medical care to its members, Aetna needs to obtain medical records from members and their doctors to evaluate whether services are 'medically necessary.' Aetna employs nurses to gather the medical records and coordinate with the offices of treating physicians, and Aetna employs doctors to make the actual coverage-related determinations.
"In addition to applying their clinical judgment, the Aetna doctors and nurses use Aetna's Clinical Policy Bulletins ('CPBs') to determine what medical records to request, and whether those records satisfy medical necessity criteria to support coverage. These CPBs reflect the current standard of care in the medical community. They are frequently updated, and are publicly available for any treating physician to review."

User avatar
Mo
Posts: 22832
Joined: 26 Apr 2010, 17:08

Re: There must be a pony in here somewhere.

Post by Mo » 12 Feb 2018, 16:47

I would think that reviewing a patient's medical history is needed to determine if a treatment is appropriate or not. Even in this case, Broseph not having blood work done in 3 years would be found ... in his medical history.
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

User avatar
Mo
Posts: 22832
Joined: 26 Apr 2010, 17:08

Re: There must be a pony in here somewhere.

Post by Mo » 23 Feb 2018, 21:28

Here's a vision into the future of our healthcare system. The Chicago health care economist basically implies this is inevitable once Dems take over Congress after watching Republican tactics on reconciliation. Once Medicare is opened up to the public, it ain't going anywhere.
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

User avatar
JasonL
Posts: 22448
Joined: 05 May 2010, 17:22

Re: There must be a pony in here somewhere.

Post by JasonL » 23 Feb 2018, 23:09

Ill believe it’s funded by tax s on the rich when I see that. The primary constraint has always been that wonks know you have to fund deep into the tax base. Germans pay like 15% even at low income levels. Medicare EE+ER is 2.9%. That’s a big fucking tax hike.

User avatar
Painboy
Posts: 3653
Joined: 18 Feb 2013, 11:33
Location: Seattle

Re: There must be a pony in here somewhere.

Post by Painboy » 23 Feb 2018, 23:09

Mo wrote:
23 Feb 2018, 21:28
Here's a vision into the future of our healthcare system. The Chicago health care economist basically implies this is inevitable once Dems take over Congress after watching Republican tactics on reconciliation. Once Medicare is opened up to the public, it ain't going anywhere.
Well I guess we're fucked then.

User avatar
Pham Nuwen
Posts: 6543
Joined: 27 Apr 2010, 02:17

Re: There must be a pony in here somewhere.

Post by Pham Nuwen » 24 Feb 2018, 02:04

Oh it's coming Painboy. It's coming.
Goddamn libertarian message board. Hugh Akston

leave me to my mescaline smoothie in peace, please. dhex

User avatar
Jennifer
Posts: 22510
Joined: 28 Apr 2010, 14:03

Re: There must be a pony in here somewhere.

Post by Jennifer » 25 Feb 2018, 18:25

"Patient blindsided by $17,850 urine test that insurer said was worth $100"

https://www.ajc.com/lifestyles/health/p ... 7fVeJADdM/
After Elizabeth Moreno had back surgery in late 2015, her surgeon prescribed an opioid painkiller and a follow-up drug test that seemed routine — until the lab slapped her with a bill for thousands of dollars.

A Houston lab tested her urine sample for a constellation of legal and illicit drugs, many of which, Moreno said, she had never heard of, let alone taken.

“I was totally confused. I didn’t know how I was going to pay this,” said Moreno, 30, who is finishing a degree in education at Texas State University in San Marcos and is pregnant with twins.

Her bill shows that Sunset Labs charged $4,675 to check her urine for different types of opioids; $2,975 for benzodiazepines, a class of drugs for treating anxiety; and $1,700 more for amphetamines. Tests to detect cocaine, marijuana and phencyclidine, an illegal hallucinogenic drug also known as PCP or angel dust, added $1,275 more.

The lab also billed $850 to test for buprenorphine, a drug used to treat opioid addiction, and tacked on an $850 fee for two tests to verify that nobody had tampered with her urine specimen.

Total bill: $17,850 for lab tests that her insurer, Blue Cross and Blue Shield of Texas, refused to cover, apparently because the lab was not in her insurance network. The insurer sent Moreno an “explanation of benefits” that says it would have valued the work at just $100.92.
"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

User avatar
Pham Nuwen
Posts: 6543
Joined: 27 Apr 2010, 02:17

Re: There must be a pony in here somewhere.

Post by Pham Nuwen » 25 Feb 2018, 18:57

Now that I absolutely believe. Lab peeps are terribad.
Goddamn libertarian message board. Hugh Akston

leave me to my mescaline smoothie in peace, please. dhex

User avatar
Jennifer
Posts: 22510
Joined: 28 Apr 2010, 14:03

Re: There must be a pony in here somewhere.

Post by Jennifer » 27 Feb 2018, 15:11

Pham Nuwen wrote:
25 Feb 2018, 18:57
Now that I absolutely believe. Lab peeps are terribad.
Shit like this (or with ERs and insurance companies pulling stunts like "oh, yeah, this ER is totally covered by us -- but none of the doctors or nurses who actually work there are") is exactly why we're going to end up with single payer.
"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

User avatar
Pham Nuwen
Posts: 6543
Joined: 27 Apr 2010, 02:17

Re: There must be a pony in here somewhere.

Post by Pham Nuwen » 27 Feb 2018, 16:36

Well mainly it's because we are okay with our neighbors paying for us. And we have endless reasons why its okay for you to pay for me but not the reverse. But also things like this, yes.
Goddamn libertarian message board. Hugh Akston

leave me to my mescaline smoothie in peace, please. dhex

Post Reply

Who is online

Users browsing this forum: No registered users and 1 guest