If You Have A Perfect Health Insurance Company, You Don’t Need To Read This, but . . .

if like most of us, you’ve had to fight for a health insurance benefit and lost the fight, read on. And if you’ve fought for your benefits and won the battle, recall the headaches, the heartaches, and the family financial crisis it caused. Also, read on. Sue Meadows [medicallife@uskoa.com], an independent health benefits expert (and, thanks only to my dumb luck, my wife) is a Guest Poster whose many years of experience within the health care industry will help you navigate those rough waters. Her article below will:

— first, introduce and dissect the health insurance system, and

— second, in the other articles she’s authored and linked to, she passes along tips about the methods used by health plans to deny your claims, or to try to provide less coverage than you’re entitled to.

And now, here’s Sue.

Medical Mire. The U.S. medical care system is a mire. The trudge through it – accessing, receiving, and worst of all, paying for medical care is a torturous process for patients, family, and even for your doctors, hospitals, and other health care providers. It wasn’t always like this. It isn’t like this in other wealthy countries. And there’s no need for it to be this way here. Change is now an active plan in the federal government, but it will take years before most people will directly benefit from changes, and I didn’t write this to grapple with the politics of healthcare. My goal here is straightforward: What do you do for your family in the meantime?

Access to Medical Care. Getting your family medical care presents two problems. One, many areas of the U.S. don’t have adequate facilities or physicians to fill the needs of the population. Two, far too many people cannot afford the care that is available.

As you know, anyone uninsured or underinsured is at risk of not finding needed medical care. Frequently practitioners will not accept Medicaid-covered or self-pay patients; they can’t take the financial risk. Doctors, emergency rooms, and hospitals who are willing to treat this group often have overfull schedules, and dedicated as they are, quality of care suffers. The unemployed, self-employed, part-time employed, and those working for a small business that cannot afford health insurance benefits all suffer from want of medical care. Healthcare reform cannot be effective without improving access.

Receiving Medical Care. As you may have experienced, those who can access care – get through the front door – are not necessarily able to actually receive care. Problems here are commonly functions of time and money.

• You or your family must coordinate care, especially if it involves more than one doctor or other health care provider, like rehab, dialysis, or clinics.

• There are doctors orders, tests, and schedules that must fit in with your work schedules, daycare availability, care for aging parents, and more.

• Mobility due to disability, as well as regular transportation, can be a serious problem, for you or your family, nuclear or extended.

• Mental health services may be available at a long distance from the patient’s home.

• Providing the prescription medicines your family needs at a reasonable cost can be a tremendous burden.
  

• Some care is not covered at all, or only in part, and that makes it unaffordable even if you have insurance. Hearing aids, diabetic test strips, mammograms, allergy shots, imaging studies such as CT or MRI scans, can all fall into the impossible-to-receive arena.

Paying for Medical Care. Then there is the most elaborate, crazy-making maze: paying for it all. Medical care is expensive was at one time true, now, however, we all know it’s beyond expensive. And who pays for what part of it is less certain than ever. It’s no joke anymore that you feel worse after you get you medical bills even if your actual medical condition is improved . . .

• Services and technologies commonly used now, such as MRI scans and laparoscopic surgeries, were not available in decades past, and more expensive tests are coming every day.

• Medications are being developed at a high rate and for a steep cost, but now permit treating illnesses and injuries that would not even have been addressed before.

• The basic cost of an doctor’s office visit has gone up due to inflation, specialist training, and the doctor’s staff costs (ironically, often due to multiple insurance company paperwork the doctor must provide) . Although the basic office visit cost is not unaffordable for most of us, it these additions to the visit that have really driven costs beyond affordable.

Health Insurance Coverage. Make no mistake: The U.S. rations healthcare by economic means. You and your family get what they can pay for. This is not a “conservative” or a “liberal” criticism. YOU know well: if you cannot pay, you cannot get adequate health care, if any at all. And if you have insurance you pay monthly premiums, copays, and deductibles. Without insurance, of course, you’re billed for everything. Only the wealthy can reasonably afford the bill if it includes a serious injury, illness, or any chronic condition, like diabetes and heart disease. (For details about the three basic kinds of health insurance available in the U.S., see the special section “Types of Health Insurance Plans” at the end of this article.)

Getting Insurance To Pay. And, if you have health insurance, it’s no magic bullet.

• Plans are set up with restrictive rules on what care is covered.

• There may be limits on where you may receive treatment (no in-home treatment or nursing home care, for example),

• or frequency (only twenty visits per year),

• or prior approval required (hysterectomy, back surgery),

• or there may be complete exclusions (no coverage for neuro-muscular disorders, or medical devices like crutches, or medications that are not on the plan’s approved list.)

Then there’s the next hurdle of the claims process. Health plans kick out claims that don’t meet all the criteria required when the claim is submitted. You must then research the denial, which requires additional information from the doctor, or the hospital, or (Heaven forbid!) correction of computer data. All this, as you probably already know, is incredibly time- and energy-consuming, and often ineffective because you don’t know the insurance system, its jargon, codes, and practices. And, I bet you know this – the insurers don’t want you to their “language.”

After all the initial claims filings, when your claim is denied and you resubmit it, this begins the wait-and-see. The insurers return more forms for you or others to fill out, they offer no payment for the services in dispute, and you are forced to choose care based primarily on cost.

Pinball Medical Care Payment. As we’ve seen, restrictions and denials of medical insurance payment claims trap both patients and health care providers. Every health plan has an elaborate system for identifying and evaluating claims. The process is akin to a pinball game, with the claim bounced from one maze to a tunnel and then to another maze (click on the pinball machine for a clearer image). Claims systems tend to be biased towards denying claims that might in any way be an exception to the rule. The denials are computer-generated.

Some insurance companies then send you the denial without further review, putting the burden on you to prove they should pay your claim. The time involved in documenting claims, treatment decisions, and the claims submission process is a costly administrative burden for health care providers. Also, comprehensive medical care services commonly involve more than one provider, each of which submits its own claim. The medical doctor, the laboratory, the radiology center, the surgeon, the anesthesiologist, the pathologist, the pharmacy, the therapist, each has its own claim demanding payment. For self-protection some medical practices require you to pay the entire deductible up front. Others simply do not submit insurance claims for you, but bill you directly for the full fee, leaving claims submissions for you, in you “free time.”

The result of all this makes a pinball game look sedate and organized by comparison. The healthcare system generates great expense that buys no medical value, not a single aspirin. Without health insurance coverage a family is running the highest risks of untreated serious health issues and financial ruin. There are ways to minimize the risks and reduce costs somewhat, but they are not obvious or easy. For example, if you family is uninsured you don’t benefit from rates that large health insurance companies negotiate with providers. The full, non-discounted rates can be an impossible cost, and those costs are “passed through” to you if you’re uninsured.

The medical care mire in the U.S. is an ordeal with no value. People are trapped financially in its mud, and can’t escape to the higher, dryer ground of solid medical care. President Obama’s healthcare reform initiative offers promise. Until then, everyone needs to pull on hip boots and be careful out there.

As you trudge on in the mire, take a look at the articles below. They’ll help you understand some of the “language” of the health insurance companies, and perhaps the next time you have to discuss a claim with them you’ll know when they’re misdirecting, misinforming, or just plain lying. And please, feel free to contact me at medicallife@uskoa.com for your own questions or for help with a problem you’re having now or foresee down the road. I can help jiggle that pinball machine a bit in your favor.

• For help with medical care payment problems, see Payment Pinball: Your Medical Bills, where I uncover and explain the health insurance company processes used when processing – and denying – your claim.

• For ways to get by with little or no insurance, or to reduce costs regardless of your insurance coverage, see Medical Care During the Recession and Beyond.

• Finally, click here for an interesting and informative historical timeline about medical insurance in the U.S.

People who are eligible for and enrolled in a health plan can frequently choose among two or three plan types.

• One is a managed care, HMO model that strictly limits which providers can be seen by the person / patient. Other providers will not be paid. Even providers within the HMO may be seen only with the appropriate referrals and authorizations. Managed care saves money on the administrative end. People enrolled in managed care plans, who have primary care physicians with whom they are comfortable can avoid frustration and receive good quality basic care, including medications and therapies as needed. The tradeoff is the loss of choice of providers. Even emergency treatment from a non-HMO provider can be denied reimbursement. For physicians the managed care model can be good: they receive a salary for their services and do not have to worry about running a business as well as providing medical care. Yet, managed care can also pose problems for physicians in that it places limits on decisions they make and discourages treatments they may find important for individual patients.

• Another plan type is catastrophic care coverage, where the patient manages and pays all costs for routine care. Hospitals fees are generally covered with this plan type. This plan is the most affordable, but it works well only for the healthy adult. Pregnancy is not covered with this plan type.

• The most commonly chosen plan type, PPS or POS, allows the patient to choose the providers to see. Providers can contract with the insurer, discounting the rate they charge and receiving guaranteed remittance more quickly in retrun. This plan pays most of the fees for medical care after a deductible is met. It has its own restrictions and rules to govern payment.