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#16 +LogicalApex

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Posted 13 August 2013 - 15:16

Again, you are looking at the amount covered of treatments actually covered. You can't just get whatever treatment you want and then bill insurance companies. Read the ENTIRE contract, not just the marketing tables.

 

Easy example. I have to test my blood multiple times a day to control my Type 1 diabetes. Insurance coverages materials for 3 tests a day. Doctor wants me to test 6 times a day and my pump manufacturer wants me to test 9 times a days. Because insurance only covers 3 times a day, they pay 80% of the cost of those supplies. For the other 3 tests, I pay 100% of the cost.

Marketing labels? This is the actual contract...

 

I left out the part defining "Eligible Expenses" which makes it seem like they could come back and say "hey 2 venom bags were too expensive and we'll only pay for 1", but that isn't the case and I'll add the definition below.

 

The only area it all gets hairy is once you go "out of network", but that is the case with any insurance product since they can't negotiate a rate "out of network" beforehand.

 

Medical Snippet Expenses.PNG




#17 theyarecomingforyou

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Posted 13 August 2013 - 15:21

Yeah this is just part of the system's structure. Not saying it is good, but the reality is the US healthcare system has an middle man who argues down prices (insurance companies) and medical providers do their best to find ways to not have to lower those prices. The end result is they might agree to take a loss on regular office visits, but make it up by over billing for things like gloves.

It's more than just that, though. The US pays more for healthcare in relation to GDP than any other nation yet internationally it is ranked 37th by the World Health Organisation for the service it provides. Large numbers of people are left with obscene levels of debt (even those who have good healthcare plans), while it is calculated than nearly 40,000 people die a year as a result of not having access to healthcare. People are fired from their jobs in order to save the employer money. The quality of care is high but the system certainly isn't equitable or efficient.



#18 ILikeTobacco

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Posted 13 August 2013 - 15:21

Marketing labels? This is the actual contract...

 

I left out the part defining "Eligible Expenses" which makes it seem like they could come back and say "hey 2 venom bags were too expensive and we'll only pay for 1", but that isn't the case and I'll add the definition below.

 

The only area it all gets hairy is once you go "out of network", but that is the case with any insurance product since they can't negotiate a rate "out of network" beforehand.

 

attachicon.gifMedical Snippet Expenses.PNG

Dude... READ. They cover 80%(assuming yours is the same on the percentage amount) of approved expenses. That means they don't cover anything from non approved expenses. If you get more treatment than what is approved, you pay 100% of that non approved treatment. How are you not getting this? It is written into everyone health insurance contract. Stop cherry picking and ignoring that simple fact. If you do something that is not approved by your insurance company, they have no legal obligation to cover it. That is even in Obamacare. Your insurance company decides what you get covered and what treatments you should get, not you. If only 1 bag is approved, you pay 100% of the cost of the second bag.



#19 theyarecomingforyou

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Posted 13 August 2013 - 15:27

Not many here know this but I was sick in January and I was in the hospital for nearly a week. My medical bill was over $40,000. I ended up owning around $3500 out of pocket. Still paying on some of these bills. I pay some every month. I'm still not sure it's broken, maybe just in need of some work.

That's a lot of money to have to spend for treatment and it will inevitably lead to people to avoiding going to hospital when they really should. I have some relatives that live in Philadelphia and they're facing massive healthcare costs because my aunt has been diagnosed with brain cancer - that's despite my uncle having a decent healthcare policy.



#20 +LogicalApex

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Posted 13 August 2013 - 15:30

Dude... READ. They cover 80%(assuming yours is the same on the percentage amount) of approved expenses. That means they don't cover anything from non approved expenses. If you get more treatment than what is approved, you pay 100% of that non approved treatment. How are you not getting this? It is written into everyone health insurance contract. Stop cherry picking and ignoring that simple fact. If you do something that is not approved by your insurance company, they have no legal obligation to cover it. That is even in Obamacare. Your insurance company decides what you get covered and what treatments you should get, not you. If only 1 bag is approved, you pay 100% of the cost of the second bag.

I'm not sure what you're reading, but the document clearly states that they will pay 100% of any eligible expense* (that isn't a physician billing charge) as long as the hospital is "in network".

 

* Eligible expense is anything they have agreed to a price on with the hospital. It mentions NOTHING about it having to be an insurance approved expense. The only thing this would exclude is in-network hospital services where they don't have a contracted rate with the hospital, such as experimental care.

 

It's more than just that, though. The US pays more for healthcare in relation to GDP than any other nation yet internationally it is ranked 37th by the World Health Organisation for the service it provides. Large numbers of people are left with obscene levels of debt (even those who have good healthcare plans), while it is calculated than nearly 40,000 people die a year as a result of not having access to healthcare. People are fired from their jobs in order to save the employer money. The quality of care is high but the system certainly isn't equitable or efficient.

Yeah we do, like I said, the system has a LOT of flaws that need to be worked out. There is too little information for consumers and too much control in the hands of insurance companies. Then you have the hospitals who blatantly ignore federal law on providing benefits to anyone so long as they receive medicare dollars.

 

I think an overhaul is needed, but one that brings transparency to the forefront.



#21 HSoft

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Posted 13 August 2013 - 15:38

Yet another reminder of how broken the US healthcare system is.

A bit like the UK health system then :-

http://www.bbc.co.uk...health-23612539



#22 theyarecomingforyou

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Posted 13 August 2013 - 16:00

A bit like the UK health system then :-

http://www.bbc.co.uk...health-23612539

Nobody is disputing that the NHS is facing major management and financial issues—a lot of which stem from the privatisation and budget cuts imposed by the current government—but it's disingenuous to suggest the issues are comparable to the problems facing the US healthcare system. There's also a major difference between a few failed NHS trusts and the systemic problems present in the United States.



#23 FlintyV

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Posted 13 August 2013 - 16:09

A bit like the UK health system then :-

http://www.bbc.co.uk...health-23612539

 

And yet regarded as one of the most efficient and highly regarded health services in the World. 

 

Good job HSoft. 



#24 threetonesun

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Posted 13 August 2013 - 16:26

Dude... READ. They cover 80%(assuming yours is the same on the percentage amount) of approved expenses. That means they don't cover anything from non approved expenses. If you get more treatment than what is approved, you pay 100% of that non approved treatment. How are you not getting this? It is written into everyone health insurance contract. Stop cherry picking and ignoring that simple fact. If you do something that is not approved by your insurance company, they have no legal obligation to cover it. That is even in Obamacare. Your insurance company decides what you get covered and what treatments you should get, not you. If only 1 bag is approved, you pay 100% of the cost of the second bag.

 

Approved expenses being something the insurance company is aware of, has set a cost to, and has qualified in your plan. I think you'd have to have a pretty lousy health insurance plan to not have as much antivenom as prescribed by a  doctor covered.

 

I also don't see how $40,000 is expensive, given what it takes to make and store anti-venom. There are conventional made bio-pharmaceuticals which can cost more than that per dose.



#25 HSoft

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Posted 13 August 2013 - 17:38

And yet regarded as one of the most efficient and highly regarded health services in the World. 

 

Good job HSoft. 

lmao - by whom?  I'm sure lots of other countries want to have to have a system that is unsustainable causing them to pump and billions and billions it and that has so many restrictions and rules on who can get what care and when.

Even the people in the UK know it's broken, hence the big increase in people going private.



#26 FlintyV

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Posted 13 August 2013 - 17:59

lmao - by whom?  I'm sure lots of other countries want to have to have a system that is unsustainable causing them to pump and billions and billions it and that has so many restrictions and rules on who can get what care and when.

Even the people in the UK know it's broken, hence the big increase in people going private.

 

 

http://www.telegraph...-the-world.html

http://www.theguardi...health-services

http://www.bbc.co.uk/news/10375877

http://www.independe...ld-1814790.html

http://www.commonwea...e.aspx?page=all

 

Problems? Yes Broken? Absolutely not.  

 

 

I'd be extremely interest if you have any actual facts to back up your claim of a big increase in people going private. Forgive me doubting you but I remember you recently claiming the NHS had gone bankrupt so I'm a little skeptical of your claims.

 

I know you've got a bit of a grudge against NHS so I'm not all all surprised by your reply. I think it's a little rich for someone in the US to be criticising the NHS when you've got a mangling wreck of a healthcare system. Give me the NHS over that mess anyday. 



#27 vetneufuse

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Posted 13 August 2013 - 18:01

I'm not sure what you're reading, but the document clearly states that they will pay 100% of any eligible expense* (that isn't a physician billing charge) as long as the hospital is "in network".

 

* Eligible expense is anything they have agreed to a price on with the hospital. It mentions NOTHING about it having to be an insurance approved expense. The only thing this would exclude is in-network hospital services where they don't have a contracted rate with the hospital, such as experimental care.

 

Yeah we do, like I said, the system has a LOT of flaws that need to be worked out. There is too little information for consumers and too much control in the hands of insurance companies. Then you have the hospitals who blatantly ignore federal law on providing benefits to anyone so long as they receive medicare dollars.

 

I think an overhaul is needed, but one that brings transparency to the forefront.

yep, you are right on how it works... your EOB writes it out clearly, 100% in network coverage eligible expenses, under my EOB for example any eligible expense is anything that isn't cosmetic surgery, or elective cosmetics, and experimental drugs... everything else is covered



#28 HSoft

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Posted 13 August 2013 - 18:11

Forgive me doubting you but I remember you recently claiming the NHS had gone bankrupt so I'm a little skeptical of your claims.

Well your memory is obviously failing you.  At no point have I said it had gone bankrupt.  It's been losing money hand over fist for years and is unsustainable however.


 I think it's a little rich for someone in the US to be criticising the NHS when you've got a mangling wreck of a healthcare system.

pot...kettle black.  So it's not rich at all for someone in the UK to criticize the US healthcare system? 

But if that's your sniff test then yes I can criticize it because I'm British and used the system for years, even worked in it. 

http://www.theguardi...y-nhs-rationing



#29 MikeChipshop

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Posted 13 August 2013 - 18:17

Bejesus, glad i'm in the UK! No snakes (OK one poisonous one and you'd be very unlucky for it to get you) and a decent NHS.



#30 FlintyV

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Posted 13 August 2013 - 18:27

Well your memory is obviously failing you.  At no point have I said it had gone bankrupt.  It's been losing money hand over fist for years and is unsustainable however.

 

pot...kettle black.  So it's not rich at all for someone in the UK to criticize the US healthcare system? 

But if that's your sniff test then yes I can criticize it because I'm British and used the system for years, even worked in it. 

http://www.theguardi...y-nhs-rationing

 

 

I didn't criticize in this thread until you brought the NHS into it.

 

I do remember you saying the NHS was going bankrupt with hospitals closing all over though. 

 

It's interesting to see that piece from the Guardian though it is a little light on actual numbers. 

 

I remember seeing people in the US having to wait for a bus full of doctors to visit them because they couldn't afford it and people in pretty poor health as a result. Yeah, that looks like a much better system.  :rolleyes:

 

I noticed you completely glazed over my links. No surprise there though.