I keep hearing more and more stories about health insurance companies refusing to pay for a procedure for various reasons like "it's experimental", and etc. So why do we even pay for health insurance, if they won't help us out with the more expensive procedures anyway? Or just the fact that they could deny us at any time as they please? I understand there's smaller but still expensive procedures, but I'd be better off putting my own money away for things like that. I just don't get it. Anyone? Well, first off, your assumption that they can "deny you any time as they please" is incorrect.
Health insurance is a tightly regulated industry with very specific criteria and rules to follow. A person might not *like* it if they can't get covered for something that they want, but it doesn't mean that the denial was on a whim either.
Generally, Medicare sets the standard for whether or not a new type of medical procedure is considered "experimental" or "investigational." (Meaning that if Medicare decides to allow the procedure, eventually most other private insurers make the decision to allow it too.) And that information is available well in advance of you deciding to have something done...each insurer has a specific Corporate Medical Policy (or whatever their company term is for it) about any procedure you could ever want done. And you as an insured member or any of your doctors have a right to see the policy *before* you have the procedure done. Some of the companies put the info right out for public viewing on the web, others will make the info available to you if you ask for it.
Here's an example for one insurance company for one procedure. (Again, all insurance companies have documents like these for various procedures. Just using this one as an example.) http://www.medmutual.com/provider/MedPol... Right in this document, it tells you/your doctor what medical criteria you would need to meet to have coverage for this service, and it tells you that you need prior approval for the service. If your doctor demonstrates that you meet the critiera in the policy, then you get approved. If you fall under a grey area where you're close but not quite, they might request more documentation from your doctor. If you clearly don't meet the criteria, then you get denied. Pretty cut and dried.
Now, I'm not saying that people are going to necessarily *like* the criteria they are being evaluated against, but that still doesn't mean that things are being denied "any time as they please" either. People need to be proactive in their medical care and find out about their rights/responsibilities *before* making decisions regarding planned medical care. (planned as in non-emergency situations)
If you feel your insurer has made a decision in error, you have the right to see the medical critiera (Corporate Medical Policy document, or whatever your insurer calls it) that you were evaluated against, you have the right to see what medical records of yours were used as the basis of the decision, etc. Again...be proactive.
(Aside from adding that info about how decisions are made, I agree w/what mbrcatz said about health insurance being a financial tool, etc.) Like many things, I think the problem is that people don't know for what they are covered.
I have never had a problem with being denied payment for services received, but I was always careful to make certain that the plan I would choose, who cover the services I received. If that's the case, you might want to consider a high deductible plan. This way, you're still covered for most things after you meet your deductible, but the premium savings would allow you to start saving more money on the side for "experimental" procedures out of pocket. Just a thought. People also need to take repsonsibility for their own health care.
Anytime I have went to the doctor for anything other than a normal physical, if it's a test or a treatment for something, I make it VERY clear to them that I will not pay for something if my insurance will not cover it.
One doctor had TWO labs he worked with...one was included under my insurance, the other wasn't...my insurance didn't pay for a test, when they always had before...that is why I discovered he used two labs.
I told the doctor that it was HIS responsibility to make sure his staff made such clearances in advance...I also told him I wasn't paying for it...and I never did. Because there are only a handful of insurers who dominate the market, they can largely do as they please. They frequently contradict themselves in the information they present for you to read and the courts allow them that out even though contract law is clear that when an ambiguity is created it must be held against the party that created the ambiguity.
Jamie Cort's book HMOs Making a Killing reveals the insane ERISA shield that insurers are offered IF the insurance comes through the employer as it does for a huge portion of Americans.
The testimony of Linda Peeno, MD revealed some pretty appalling dirty tricks used by these multi-million dollar generating companies (http://www.thenationalcoalition.org/DrPe...
The list of problems goes on and on, but the bottom line is that for MOST health care providers, they give ridiculous discounts to the insurers and then pass the costs on to the uninsured and the taxpayer. So if you can have health insurance (some are uninsurable), then you should.
I'd recommend an HSA and sock away as much as you can in the plan. Get a physical every year, whether covered or not, and listen to your doctor. Preventing problems is cheaper and sane. Catching them early is always cheaper and better.
Consider also options such as this if it's in your area:
http://www.simplecare.com/
There are docs not in simple care who also have finally said NO! to insurance and charge a reasonable fee which is due at the time of service and life is good.
It's not just elective or experimental things which are refused. They also play games with "caps" on procedures, look to find that you went to the "wrong" provider, etc. You have to be very wary dealing with this business enterprise that was taken over by non-doctors to reap massive profits. I can't speak for everyone (the "we" in your sentence, unless you have a rat in your pocket), but *I* pay for health insurance because with three kids, I have reasonable expectation of needing it. My policy, year in, year out, pays out more for my family than it takes in.
It wasn't always that way, but when I was younger and single, I knew that if I didn't have insurance BEFORE something went wrong, I wouldn't be able to get it AFTER something goes wrong. So, I covered my b*tt, and kept insurance in force for me. It worked.
You can't put enough money away to cover, for example, chemotherapy and radiation treatments for a year. And if you DO manage, then what happens if you have a heart attack six months after that, or need bypass surgery?
The fact of the matter is, health insurance is a financial tool. Smart money managers use money tools - including health insurance - to manage their POTENTIAL LOSSES. The downside of NOT having health insurance is MUCH greater than the downside of carrying it (ie, the cost).
Browse this board. Look at all the people here who had something go wrong, with no insurance in place, and now can't find any. They either are going without treatment, or going so heavily into debt to pay for treatment, that they'll never be able to climb out of it (btw, you and I, and all the other working stiffs out there will be picking up that tab, through our property taxes and federal payroll taxes).
If you don't "get it", you need to start doing more research on financial tools. In the USA, we spend an average of $7,000 per person, per year, on health care. Sure, you might be one of the $50 ones. But that means someone out there is $14,000 to offset you. What if you're the $14,000 guy? That's going to stink for you.
Then YOU will be the guy looking for a foundation, charitable organization, or just an anonymous donor to pay your $25,000 to $150,000 medical bills. |
