Some things I've learned about medical insurance this year

[geekette]

what a buggered-up system. Yeah, I'd go ahead and pay the cash plan that came down with discounts,but, I would be writing a letter to that facility, copy various dept heads, including ER, Patient Advocacy, and director of medical services. One never knows if it will be ignored or if you get a call to discuss and possibly get your account written off. Complaining CAN work. Regardless, the lunacy of "it wasn't emergency" is a bit nuts and should be challenged higher up the chain. Sometimes, low level staff follows procedure written by non-hands-on admins where the policy-writer doesn't fully Get It. Medical coding is indeed a double-edged sword. sometimes, customer service is empowered to write off or discount, and it sounds like this empowerment did lower your bill. It's something, but, yeah, still A Problem. As a frequent flyer, much of my treatment is written off.

I had a recent ER visit that may be denied, but I have the procedure notes that say "seek help immediately if..." and ER notes can show I hit a pile of those. Honestly, if I still had a PCP, I would have had a different outlet, but still may have had to wait days, when I could not wait days (holiday week). So, it'll be what it will be. Ins co doesn't really care about my larger picture, they care about This Visit, That Visit.

I have taken to getting my recs regularly because you have no control over what someone writes. I was labelled Drug Abuser because someone decided that was appropriate, given that I was a smoker at the time. Seriously??? cigs = Drug Abuse?? So now I have A History Of Drug Abuse. Anyone that knows me knows that's ridiculous. Guess what happens when I am in critical pain? yeah, that's right, Live With It,because someone, once upon a time, stuck me in a category without concern as to its long term impacts To Me. I am no longer with that system and did not have my records ported to new system. All I can do is stop that crap from following me.

Found a new PCP today that I will probably keep. I was listened to (bar is pretty low at this point!). While I was clearly in pain, I made it clear that this was not what I needed help with, I need the cause of other stuff looked into, the cause of other new weird symptoms. Just in case somehow they got word that I am a Drug Abuser, I wanted to be very clear that I am not a pill seeker.

 

[Talent312]

... Found a new PCP today that I will probably keep. I was listened to (bar is pretty low at this point!)...

Finding a PCP who will listen is half the battle. The other half is what they say.
My PCP is anti-salt. He says we get enuff salt naturally and should not add any to food.
He criticized me for doing my own drug research... "That's what you have doctors for."
I took that with a grain of salt.

.

 

[bogey21]

My PCP is great. On A Wednesday night I emailed her thinking I might have a hernia. The next morning she emailed me back with an appointment et up with her Physician's Assistant (who incidentally was super) on Friday. PA examined me manually and had tests performed after which all info was given to my PCP who emailed me back with results (degenerative hip) on Saturday morning. She said we will discuss at my next appointment on Dec 29th. I'm very satisfied...

Incidentally she encourage me to do my own research which we then discuss...

George

 

[magmue]

...told her that because they wouldn't change the coding to emergency that we had to self-pay (without it going against deductible) in order for them to get paid - and that wasn't fair. She said (again) their office uses Medicare and Medicaid guidelines so that's why they had to code it as an office visit.

Teresa, I am a recently retired GYN nurse practitioner, so have a fair amount of experience with coding for outpatient care, and some over-the-shoulder experience with the complexities of emergency care and coding.

I'm thinking they probably never officially admitted you to the hospital, but had you in observation status - most hospitals allow at least 24 hours for care givers to evaluate and decide whether to admit.

And when you are being kept and treated "under observation", you are officially considered an outpatient. Medicare is very clear that consultations services on someone who is in observation status have to be reported using outpatient codes.

While making sure my understanding about this was still correct, I came across a pertinent cautionary story
https://careconversations.org/inpatient-or-observation-knowing-difference-could-save-you-thousands

 

[bogey21]

I'm thinking they probably never officially admitted you to the hospital, but had you in observation status - most hospitals allow at least 24 hours for care givers to evaluate and decide whether to admit.

And when you are being kept and treated "under observation", you are officially considered an outpatient. Medicare is very clear that consultations services on someone who is in observation status have to be reported using outpatient codes.

A number of years ago when I went to the Emergency Room with a TIA event (mini stroke) I experienced this. The morning after they kept me overnight a hospital Administrative Employee came into my room and asked me to sign a form acknowledging that I was on Outpatient Status and had not been officially Admitted. She assured me I would receive the same care. In my case it apparently made no difference. Best I can tell the care I received was the same as had I been an admitted patient and Medicare pretty much covered everything. Bottom line is that I had no problems because of this. Later I was told (correctly or incorrectly, I don't know which) that had I been formally been admitted and later had to be readmitted at the Hospital for the same thing the Hospital would have been on the hook for the entire second admission expenses...

George

 

[magmue]

Best I can tell the care I received was the same...

Yes. The care will be the same. But how it is billed - in recent times at least - can be very different.

 

[Talent312]

As a hospital admin explained to me:
We can keep someone up to 72-hours as a "patient under observation" without admitting them. That way, you (and we) get better insurance coverage. IDK about that, but all we paid was a $100 E/R copay and insurance paid ~$25K... Nonetheless, the hospital-food was still pretty bad.
No wonder they could afford to build a new wing.

.

 

[Passepartout]

Bottom line- (as I see it)- In the US, we are dependent on the for-profit insurance industry for our health care, while in the rest of the world, health care is left to health-care providors.

Nobody cares more about your health than YOU!

Jim

 

[Teresa]

Teresa, I am a recently retired GYN nurse practitioner, so have a fair amount of experience with coding for outpatient care, and some over-the-shoulder experience with the complexities of emergency care and coding.

I'm thinking they probably never officially admitted you to the hospital, but had you in observation status - most hospitals allow at least 24 hours for care givers to evaluate and decide whether to admit.

And when you are being kept and treated "under observation", you are officially considered an outpatient. Medicare is very clear that consultations services on someone who is in observation status have to be reported using outpatient codes.

While making sure my understanding about this was still correct, I came across a pertinent cautionary story
https://careconversations.org/inpatient-or-observation-knowing-difference-could-save-you-thousands

Thanks Maggie! Great article. Unfortunately, I had no clue that I wasn't 'admitted' even though they put me in a room. Much more makes sense (????) now.

 

[bogey21]

I'm no expert on this subject buy have two observations.

First, many years ago the first thing in the morning after I woke up after spending a night in the hospital room (I came in via the ER) an Administrative Employee had me sign a form acknowledging that I was there on observation status. I don't know what would have happened if I had refused to sign...

Second, I live in a CCRC and we are instructed to make sure we have been formally admitted in the hospital for 3 full days if we plan to return to the CCRC's Skilled Nursing floor to recuperate. Obviously they want to make sure Medicare pays...

George

 

[WinniWoman]

I'm no expert on this subject buy have two observations.

First, many years ago the first thing in the morning after I woke up after spending a night in the hospital room (I came in via the ER) an Administrative Employee had me sign a form acknowledging that I was there on observation status. I don't know what would have happened if I had refused to sign...

Second, I live in a CCRC and we are instructed to make sure we have been formally admitted in the hospital for 3 full days if we plan to return to the CCRC's Skilled Nursing floor to recuperate. Obviously they want to make sure Medicare pays...

George

That is exactly right. In fact, when my dad was in a nursing home they purposely readmitted him to a hospital after his approved Medicare stay was up. They kept him in for a few days and then readmitted him. That is how they got paid and my mom did not have to pay. Crazy- but that is what they needed to do.

 

[Timeshare Von]

But on a better note, ACA compliant plans in Wisconsin have seen a 15-20% decrease in premiums for 2020. There was a slight policy benefit change year to year (our deductible went up about $600 and the max out-of-pocket went up about $1,000) but to see the annualized amount for premiums go down more than that, we'll be slightly ahead for 2020, even if we max out. (I generally max out every year . . . DH rarely even meets his deductible.)

 

[Brett]

Teresa, I am a recently retired GYN nurse practitioner, so have a fair amount of experience with coding for outpatient care, and some over-the-shoulder experience with the complexities of emergency care and coding.

I'm thinking they probably never officially admitted you to the hospital, but had you in observation status - most hospitals allow at least 24 hours for care givers to evaluate and decide whether to admit.

And when you are being kept and treated "under observation", you are officially considered an outpatient. Medicare is very clear that consultations services on someone who is in observation status have to be reported using outpatient codes.

While making sure my understanding about this was still correct, I came across a pertinent cautionary story
https://careconversations.org/inpatient-or-observation-knowing-difference-could-save-you-thousands

lots of cautionary tales about being admitted to a hospital "under observation status"

"Under Medicare rules, the consequence of being hospitalized under “observation status” rather than being formally “admitted” can be financial ruin." ----- "get a written statement from your surgeon and from the hospital that you will be admitted and not placed under observation status."

https://www.latimes.com/opinion/story/2019-12-20/medicare-coverage-hospitalization-patient-costs

 

[WinniWoman]

lots of cautionary tales about being admitted to a hospital "under observation status"

"Under Medicare rules, the consequence of being hospitalized under “observation status” rather than being formally “admitted” can be financial ruin." ----- "get a written statement from your surgeon and from the hospital that you will be admitted and not placed under observation status."

https://www.latimes.com/opinion/story/2019-12-20/medicare-coverage-hospitalization-patient-costs

A travesty. This kind of thing makes blood shoot out of my eyes!

 

[VacationForever]

lots of cautionary tales about being admitted to a hospital "under observation status"

"Under Medicare rules, the consequence of being hospitalized under “observation status” rather than being formally “admitted” can be financial ruin." ----- "get a written statement from your surgeon and from the hospital that you will be admitted and not placed under observation status."

https://www.latimes.com/opinion/story/2019-12-20/medicare-coverage-hospitalization-patient-costs

If patient has Medicare supplement or Medicare Advantage, is the patient then not be blind sided by the huge bill?

 

[Brett]

If patient has Medicare supplement or Medicare Advantage, is the patient then not be blind sided by the huge bill?

yes, that's what I would think. I didn't read the story completely to see if that person had a medicare supplement plan.
I have a Medicare supplement plan so hopefully won't encounter this situation

 

[VacationForever]

yes, that's what I would think. I didn't read the story completely to see if that person had a medicare supplement plan.
I have a Medicare supplement plan so hopefully won't encounter this situation

No mention of other Medicare add-on plans.

 

[Brett]

No mention of other Medicare add-on plans.

The author of the article did say
"I wasn’t enrolled in Part B, but did have Blue Cross/Blue Shield supplemental insurance, which required me to pay 20% of the allowable hospital and surgical charges"

I guess the $25,000 is part of the 20% allowable patient hospital charges but you would think his Blue Cross supplement plan would have covered those extra expenses

 

[magmue]

you would think his Blue Cross supplement plan would have covered those extra expenses

It may depend on how they define "allowable", as well as their definition of what constitutes a "hospital and surgical" charge.

 

[VacationForever]

The author of the article did say
"I wasn’t enrolled in Part B, but did have Blue Cross/Blue Shield supplemental insurance, which required me to pay 20% of the allowable hospital and surgical charges"

I guess the $25,000 is part of the 20% allowable patient hospital charges but you would think his Blue Cross supplement plan would have covered those extra expenses

True. I forgot about that piece. It must not be a plan f or g.

 

[Talent312]

I'm trying to pick a Plan G provider, sometime soon...
I'm tempted to go with BCBS, since DW has her plan with them.
However, there's no discount for keeping it "in the family."
Humana & United Health Care (AARP) are ~$10/month cheaper.
Someone suggested I ask my doc who they liked working with.
.

 

[VacationForever]

I'm trying to pick a Plan G provider, sometime soon...
I'm tempted to go with BCBS, since DW has her plan with them.
However, there's no discount for keeping it "in the family."
Humana & United Health Care (AARP) are ~$10/month cheaper.
Someone suggested I ask my doc who they liked working with.
.

Doctors don't usually know as their billing folks handle reimbursements.

 

[WinniWoman]

I'm trying to pick a Plan G provider, sometime soon...
I'm tempted to go with BCBS, since DW has her plan with them.
However, there's no discount for keeping it "in the family."
Humana & United Health Care (AARP) are ~$10/month cheaper.
Someone suggested I ask my doc who they liked working with.
.

A lot of people say they like United through AARP.

 

[WinniWoman]

The author of the article did say
"I wasn’t enrolled in Part B, but did have Blue Cross/Blue Shield supplemental insurance, which required me to pay 20% of the allowable hospital and surgical charges"

I guess the $25,000 is part of the 20% allowable patient hospital charges but you would think his Blue Cross supplement plan would have covered those extra expenses

I thought you had to have Part B to enroll in a supplement plan or Advantage plan.

 

[Talent312]

I thought you had to have Part B to enroll in a supplement plan or Advantage plan.

That is weird. If he didn't have Part B, he would not have a Medicare Supplement. Maybe he had some sort of AFLAC or hospitalization plan, which he inartfully describes as supplemental. In any event, his problem wasn't that he wasn't admitted, but that he didn't do his homework to get the coverage he needed.