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I was hospitalized for a very serious infection. Then my kidneys started to fail. They were down to 40% of function. The possibkity existed that the drugs they gave me for the infection caused the kidney issue. I finally recovered. The doctors decided they wanted to keep me on extra day for observation. The insurance company refused to pay for the day. The hospital ate the bill. I have BC/BS Premier coverage. Please don't tell me about the horrors of the ACA and ignore the horrors of private insurance.
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The doctors decided they wanted to keep me on extra day for observation. The insurance company refused to pay for the day. The hospital ate the bill. I have BC/BS Premier coverage. Please don't tell me about the horrors of the ACA and ignore the horrors of private insurance.

What happened when you appealed the denial of coverage? Did BC/BS explain the basis for the denial?

Albaby
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What happened when you appealed the denial of coverage? Did BC/BS explain the basis for the denial?

They regarded the additional day as unnecessary. BC/BS knows better than a board certified immunologist and the top kidney specialist for Maryland's school of medicince.

BTW: I am sure this is a daily battle between virtually every hospital in America and private insurers.
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They regarded the additional day as unnecessary. BC/BS knows better than a board certified immunologist and the top kidney specialist for Maryland's school of medicince.

Right - but in the appeal process, did they explain to you why they thought the additional day was unnecessary?

Albaby
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Right - but in the appeal process, did they explain to you why they thought the additional day was unnecessary?

They (BC/BS) thought their reading of my chart was more correct than the doctors. This played out over a couple of days. The doctor made the request to BC/BS before he authorized the day. BC/BS denied it. The doctor then went to the hospital and asked them to give me the extra day for free, also knowing his fee would be waived. I had previously experienced a relapse when released. They wanted to monitor one more day without the medications, and BC/BS didn't think it was necessary.

I am not privy to any more information than the BC/BS explanation.
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I am not privy to any more information than the BC/BS explanation.

But didn't you appeal it?

Albaby
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But didn't you appeal it?

That's why I know the reason they turned it down. I'm not sure of yoru point. I appeal everything with the insurance company. I usually win because my employer steps in and they drop their pants. Why should BC?BS be able to argue with a doctor's recommendation? That is the salient point.
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Why should BC/BS be able to argue with a doctor's recommendation? That is the salient point.

Because they're paying for it, and the doctor benefits economically for doing more work. Someone has to double-check to make sure that the medical services that they propose to do for you are really necessary. Whether it's a Medicare functionary, a private insurance company, or you deciding that it's not worth incurring a large expense (an extra day in hospital) for the benefit being offered, someone has to balance the costs and benefits - and since the doctor doesn't bear any of the costs, it can't just be the doctor that makes that call.

Albaby
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albaby1: "Because they're paying for it, and the doctor benefits economically for doing more work. Someone has to double-check to make sure that the medical services that they propose to do for you are really necessary. Whether it's a Medicare functionary, a private insurance company, or you deciding that it's not worth incurring a large expense (an extra day in hospital) for the benefit being offered, someone has to balance the costs and benefits - and since the doctor doesn't bear any of the costs, it can't just be the doctor that makes that call."

Absolutely right - there has to be someone outside of the revenue stream to make that determination or you'll have no chance to have an impartial analysis due to the conflicts of interest.

While you referenced the doctor in your response, I think the hospital would benefit more from the additional in-patient day than the doctor. And the hospital has much more power than an individual doctor in the relationship with the insurer, in negotiating the charges for services and just being "in network", putting the insurers in the tough spot of second-guessing the organizations they rely on to be successful or even in the game at all. And with hospitals merging with other hospitals and buying physician practices, that consolidation is only going to make that oversight and review function of the insurers more difficult in the future.

MotleyFooley
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So you want insurance companies to be the arbiter for your health care. You're way smarter than that, Al.
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So you want insurance companies to be the arbiter for your health care. You're way smarter than that, Al.

I don't want either insurance companies or my medical service providers to be the sole arbiters for my health care. Both have economic conflicts of interest - so any system that strikes an appropriate balance between controlling costs and ensuring care can't have either of those parties be the only one making the call.

Albaby
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BC/BS wouldn't pay at all or wanted you to pay the office visit deductible? There's a large difference, and the second has happened to my wife (she was in observation for several days yet they didn't consider her admitted so the deductible for ER visits was charged to us... not the entire hospital bill).
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Someone has to double-check to make sure that the medical services that they propose to do for you are really necessary. Whether it's a Medicare functionary, a private insurance company, or you deciding that it's not worth incurring a large expense (an extra day in hospital) for the benefit being offered, someone has to balance the costs and benefits - and since the doctor doesn't bear any of the costs, it can't just be the doctor that makes that call.


DEATH PANELS!!!
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Because they're paying for it, and the doctor benefits economically for doing more work. Someone has to double-check to make sure that the medical services that they propose to do for you are really necessary. Whether it's a Medicare functionary, a private insurance company, or you deciding that it's not worth incurring a large expense (an extra day in hospital) for the benefit being offered, someone has to balance the costs and benefits - and since the doctor doesn't bear any of the costs, it can't just be the doctor that makes that call.


Very naive.

How do you know (and why do you assume) goofnoff's doc is getting fee-for-service reimbursement rather than a case rate? In lots of metropolitan areas Blue Cross and other insurers are paying case rates - approx $300 whether you're in for one night or 100.

Denying the hospital payment for the last night of hospitalization is a well-honed tactic of Blue Cross. You're in for three nights, it should have been two; you're in for 20 nights, it should have been 18. They shave off a day or two of payment to the hospital and always with the reasoning is "We reviewed the records and determined the denied days were not medically necessary". Many times they give that explanation without ever having requested the records!

"Not medically necessary." Let's stipulate that that's their reasoning in goofnoff's case (because that's ALWAYS their reasoning). So the argument comes down to the attending doc's opinion vs BC's medical director's opinion. BC has the luxury of knowing that the kidney blood test indeed was stable on the day of discharge, so in predatory fashion will then argue that the last night of hospitalization wasn't necessary because the subsequent blood test wasn't worse than the previous day's test result. OTOH the attending doc is the sole individual responsible if he/she sends goofnoff home and the kidney blood test result worsens causing a readmission to the hospital.

One side is entirely levered to not being negligent and doing what's right for the patient, and the other side is levered to profitability for shareholders. It's an uneven playing field if there ever was one.

So when you say "double check to make sure...the medical services are really necessary", I think you need to re-think your premise as to who is more likely to have the patient's best interest in mind.
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The biggest thing in the story is the Oops, not the discussion of payment. My late father was the object of a Whoops, which caused him to spend six months in rehab, and almost a decade of some woe after that. They did some battle over payment, length of stay, but two doctors could have had the Porsches sued right off them.

They didn't.

Oh well, the hospital eventually got paid, as did the almighty doctor. I learned a lot about asking questions then, and trying to figure out which doctor was providing the biggest BS answer.

Ask the nurses if you really want to know anything.

Perhaps BC/BS should have protested and investigated paying for anything.
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How do you know (and why do you assume) goofnoff's doc is getting fee-for-service reimbursement rather than a case rate? In lots of metropolitan areas Blue Cross and other insurers are paying case rates - approx $300 whether you're in for one night or 100.

Because goofnoff said so - he noted in his original post that his doctor waived the fee that he normally would have collected for the extra day, and had to go to the hospital to ask them to waive their fee for the extra day.

One side is entirely levered to not being negligent and doing what's right for the patient, and the other side is levered to profitability for shareholders. It's an uneven playing field if there ever was one.

Exactly - and you need both sides if you're going to have any kind of balancing between service and cost. Medical insurance is not some magical "all-you-can-eat health care" device - you (the enrollees collectively) have to pay for those services in the form of premiums. That means that I (like all insureds) have two competing interests - I want my consumption of health care to be unfettered, but since I have to pay for it I also want to make sure that it's worth the expense.

The doctors, hospitals, and other providers lack any economic incentive to try to minimize costs that will be paid for by third-party insurance. Indeed, quite the contrary - their economic incentives go the other way. It's not just avoiding negligence and doing what's right for the patient - they have an economic incentive to be overly cautious and to get paid for more work.

As I noted above, I don't want my health care decisions to be made exclusively by either the insurance companies or the medical service providers. Both have interests that do not completely align with my own.

Albaby
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What happened when you appealed the denial of coverage? Did BC/BS explain the basis for the denial?

There is a fundamental madness behind the need to even ask those questions, and it's this: the idea that you would have to waste your time, and physical and emotional energy, in appealing an insurance company decision over your health care.

The health care insurance company exists for only one reason: to make money off you when there is nothing wrong, and pay as little as possible when there is. It's pure systemic evil, and it's engrained in the American psyche.
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There is a fundamental madness behind the need to even ask those questions, and it's this: the idea that you would have to waste your time, and physical and emotional energy, in appealing an insurance company decision over your health care.

Why is that madness? They're not making a decision over your health care - they're making a decision over whether they will pay for it.

Look, this is the next part of health care reform if you want to get costs down to what they pay in other OECD countries. We pay more for health care because we pay more for health care. Or, to quote a piece in the recent Atlantic, you're getting too much health care:

http://www.theatlantic.com/health/archive/2013/12/youre-gett...

BTW, they had another interesting piece about inefficiencies in health care delivery:

http://www.theatlantic.com/health/archive/2013/12/three-ways...

You want someone in the process that looks at what the doctor is suggesting and asking whether it's worth the expense. In a perfect world, it would be the patient making that call - but most patients don't have the skills or information to question whether that extra test, specialist referral, or overnight stay is worth the resources necessary to provide it. But since the patients ultimately have to pay for it, someone needs to look at that question.

Albaby
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There is a fundamental madness behind the need to even ask those questions, and it's this: the idea that you would have to waste your time, and physical and emotional energy, in appealing an insurance company decision over your health care.

You don't think this happens with Medicare and Medicaid???

http://www.medicare.gov/claims-and-appeals/file-an-appeal/ap...

The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll be given instructions in the decision letter on how to move to the next level of appeal.

------------

About half of all appeals are approved.
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Because goofnoff said so - he noted in his original post that his doctor waived the fee that he normally would have collected for the extra day,

That was in his third post, not the original post. His statement, "also knowing his fee would be waived," I took to mean the doc would agree to waive any out of pocket patient payment incurred if the insurer declined the entire hospitalization, for example. I agree that goofnoff's statement could have indicated a per diem, fee-for-service (FFS) arrangement.

Side note - in my experience, in a FFS arrangement the doc gets paid on some or all of the denied hospitalization days. The insurer takes their ounce of flesh out of the hospital billing, which is a much higher cost to the insurer than the lower bill for the doc visit.


That means that I (like all insureds) have two competing interests - I want my consumption of health care to be unfettered, but since I have to pay for it I also want to make sure that it's worth the expense.

Yes, balancing costs and benefits is reasonable and necessary, but in the post to which I replied I found your wording suggestive of the idea that the insurance company medical director necessarily was more authoritative on the medical issue in question or had some higher stake in the process. Your statement, "double check to make sure...the medical services are really necessary" is what I'm referring to, thus my "naive" comment.

It's too numerous to count how many times I've said by telephone to an insurance company medical director, "I don't care that the vital signs are normal, if YOU were standing here LOOKING at the patient as I am right now, there's no way you would discharge her home today".

The point is, PATIENT ADVOCACY (ie, doing what's right for the patient). I'd argue that in the balancing of costs vs benefits, the attending doc (more than the insr company medical director) has a higher stake in achieving proper balance because the attending doc has both a legal obligation (malpractice) and cost containment obligation (can be dropped from insurer network if cost-per-case is excessive).

The insurance company medical director has ZERO downside risk in denying a day or two of hospitalization. ZERO patient advocacy is involved.


The doctors, hospitals, and other providers lack any economic incentive to try to minimize costs that will be paid for by third-party insurance.

I think to say "any" is wrong. Cost-per-case metrics have been used for the past decade by insurers to exclude providers, and case-rate arrangements have been increasing each year as well. Also, capitated plans have been around for many years. But, yes, all of those arrangements represent fewer health care dollars than FFS.

Going forward, thankfully with the ACA we have started the process of structurally changing health care reimbursement from incentivizing overtreatment to pay-for-performance (or, at-risk reimbursement).
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Yes, balancing costs and benefits is reasonable and necessary, but in the post to which I replied I found your wording suggestive of the idea that the insurance company medical director necessarily was more authoritative on the medical issue in question or had some higher stake in the process. Your statement, "double check to make sure...the medical services are really necessary" is what I'm referring to, thus my "naive" comment.

Why would you infer from my post that the insurance company director was "more authoritative" or had a higher stake? I merely pointed out that someone has to balance costs versus benefits, and it can't just be the providing doctor.

The point is, PATIENT ADVOCACY (ie, doing what's right for the patient). I'd argue that in the balancing of costs vs benefits, the attending doc (more than the insr company medical director) has a higher stake in achieving proper balance because the attending doc has both a legal obligation (malpractice) and cost containment obligation (can be dropped from insurer network if cost-per-case is excessive).

Again, I wasn't arguing relative importance - merely pushing back on the notion that it was absurd for insurance companies to be involved at all. There are economic factors on all sides (and I shouldn't have been absolute in claiming that doctors faced no economic incentives to limit care). Getting dropped from a panel is a powerful sanction, but up until that point doctors have significant economic incentives to maximize care. On the other hand, while it's fashionable to paint insurance companies as somewhere between Snidely Whiplash and Simon LeGree on the evil scale, they are also in the business of selling a product - and if employers are getting constant complaints from employees about crap coverage, they will lose market share.

My point is that neither the insurance companies nor doctors have their interests exactly aligned with mine, so I don't want either having absolute say to the exclusion of the other.

Albaby
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Why would you infer from my post that the insurance company director was "more authoritative" or had a higher stake?

Well, because you used the phrases "make sure" and "really necessary" in referring to the oversight of the attending doc by the insurance company medical director. If the medical director has the clinical ability to "make sure" something is "really necessary" for your health care, then that reasonably implies he/she is more clinically authoritative (eg trusted, true, reliable) than the attending doc.

I merely pointed out that someone has to balance costs versus benefits, and it can't just be the providing doctor.

Fair enough, but see below.


My point is that neither the insurance companies nor doctors have their interests exactly aligned with mine, so I don't want either having absolute say to the exclusion of the other.

Yes, goofnoff's posts suggested that the process be one-sided, and that's what you were responding to. At the same time, my point is that the attending doc is far more aligned with your interests than is the doc at the insurance company.
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Because they're paying for it, and the doctor benefits economically for doing more work. Someone has to double-check to make sure that the medical services that they propose to do for you are really necessary. Whether it's a Medicare functionary, a private insurance company, or you deciding that it's not worth incurring a large expense (an extra day in hospital) for the benefit being offered, someone has to balance the costs and benefits - and since the doctor doesn't bear any of the costs, it can't just be the doctor that makes that call.

So doctors and hospitals can't be trusted to provide legitimate health care recommendations because they may profit and do not bear costs (except that they both did in this case) . . . but insurance companies can be trusted because they pay? Of course they pay with my premium money and choosing not to pay increases their profits. How does that make them more trustworthy?

I have a number of horror stories similar to this with my private insurance, Humana. They reject virtually every claim these days. Often their stated reason for rejection is not even true. Sometimes they screw up their own paperwork and then reject because the paperwork is incorrect. So far we have won every appeal, but it takes months . . . and months. That means that I still have several appeals in process. I won't know how they go for some time. Because I live in a state with a brain-dead tea-bagger GOP legislature and governor, my state appeals go to an agency that is not really very helpful or much of an advocate for the consumer.

I have to conclude that anyone who actually believes they are better off with private insurance decisions than with doctor/hospital decisions has not really ever experienced the private insurance trends that have been going on over the last few decades.
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So far we have won every appeal, but it takes months . . . and months. That means that I still have several appeals in process. I won't know how they go for some time.

Well in albaby's defense, he did suggest that if enough (what, tens of thousands?) people complained then the insurer would change its ways.


Because I live in a state with a brain-dead tea-bagger GOP legislature and governor, my state appeals go to an agency that is not really very helpful or much of an advocate for the consumer.

Much like Dick Cheney was an oil industry shill who found his way all the way to the White House, state insurance commissioners are usually from the industry and there's only as little consumer advocacy as there needs to be to keep the governor happy.
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So doctors and hospitals can't be trusted to provide legitimate health care recommendations because they may profit and do not bear costs (except that they both did in this case) . . . but insurance companies can be trusted because they pay? Of course they pay with my premium money and choosing not to pay increases their profits. How does that make them more trustworthy?

It doesn't. It may have been later in the thread than the post you replied to, but my point was that I don't want either the insurance company or the doctor to have sole choice in these matters, since neither have interests that exactly align with my own.

Albaby
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The US medical payment system is so cool...

We have companies who's interest is served by denying care controlling our medical treatment. Not the doctors who in good consonance recommend treatment.....

This only helps make the case for a government controlled and tax supported single payer system.
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