Insurance, Doctors, Government and You

“I’m here to check on authorization for this procedure?” “It’s denied”, “Why?” I asked “Blah, blah, blah” The person just read some pre-determination line given from their standard text. “But it’s important” I said. “Are you a doctor” They replied, “No, but I work for one”, “Well you will have to file an appeal, it can take up to 20 days”

Welcome to the U.S. healthcare system, I might be a journalist, but I also work in healthcare and what I see is a very disturbing trend. Two opposites pulling (Doctor and Insurance) often leaving the person in the middle getting hurt.

Sometimes doctors attempt to do procedures that aren’t necessary, but sometimes insurance denies authorization for things that are. When my boss lost her child because the insurance thought the device requested wasn’t necessary, and no doctors stood up and said we are going to do this anyways, because it’s a matter of life or death, it hit me like a ton of bricks on just how out of place or inhumane our system has become. I’m scared that our health, our lives have become nothing more than a dollar bill for which capitalism to prey upon.

I have expressed my concern of having a healthcare system devoted to capitalism, because it would appear to me that the value of dollar might have impact over a person’s health. I have heard the arguments from both sides, well the doctor wants the patient to be healthy so they will come back when a problem arises, and I hear the insurances argument, if we don’t pay the claims, not only is it illegal, but they will drop us and we will be out of business.

Personally I don’t believe it. I believe that a Doctor can treat patients incorrectly and that patient will still keep coming back, I believe an insurance company can and will deny claims and still that person will have a policy with them. I believe that Governments enforcement is often weak on controlling the issues for many reasons, and I believe people are often not really educated enough to solve the issue if it were to arise, sadly to say for example I doubt that half the population would even understand they are being taken advantage of in many of the situations that happen.

I don’t like huge payouts to Congressman and Senators etc.etc. From either side, and I’m still annoyed to see insurance companies on the stock market and giving huge bonuses to executives based on performance which usually comes at expense of somebody’s health.

When healthcare reform rolled around, many people spoke out; and I really didn’t understand how uneducated Americans are about their own insurance until I began listening to them speak. Many didn’t realize the hell people have to go through in order to get preauthorization for their procedures; they are often unaware that many insurance companies change their prior authorization list monthly.

So things that didn’t require authorization last month, might require it this month, nor is there an explanation for why it now does. Maybe the Chief financial officer is losing money at the track? We might never really know. What we often know is once one insurance company does; the others often join in. I watched this whole preauthorization process change dramatically over the years. It use to be the list was set from January to January, then all of sudden it changed to every six months, and before long it became every quarter, and now it’s monthly. What brought about this change is unknown; but what I do know is that the governments lack to deal with it is very disturbing.

Some of the things people said during the healthcare reform argument made little sense, “I don’t want Universal Government Healthcare, because I don’t want somebody deciding what is covered and what isn’t”. Like private insurance companies don’t do that? Then there was the argument about “I want to get a procedure done right away”, like Universal healthcare would take that away. Well if you don’t need prior authorization there is nothing to stop it from happening right away, unlike preauthorization which can take up to 21 days, however out of fairness most prior authorizations happen within 3-14 days, unless it is denied at least once.

Look at Canada I heard them yell. Look at Taiwan, Germany, and Netherlands I replied, how dare you take one without looking at the others, and by others I mean the rest of the industrial world. Then they argued about people dying in Canada because their healthcare lacks, well I hate to break the news, people die in our healthcare system as well, proof was given when my boss buried her teenage daughter and I watched her grieve and suffer because of it. I was mad at everyone involved, doctors and especially Healthnet Insurance.

People often assume that if an insurance does them wrong, just like a doctor they can take them to court, this isn’t always the case, some contracts with employers have arbitration clauses that won’t allow you to sue an insurance company even when that insurance company is in the wrong.

The next argument is that people want to be able to choose their insurance. Well, here is a fact; unless you receive Medicare (and opt for an Advantage Plan or Supplement) you probably don’t pick your insurance, your employer does. This might change some in the upcoming years. A lot of employers have stated they will do away with insurance for their employee’s; in fact they estimate about 35% will cut it, and to be honest I doubt employers will increase pay to the employee’s in order for the employee’s to buy insurance, more than likely this decision will have economic effects on the recession and if we can ever get out of it. Also something of a personal note: Just a FYI to those old enough for Medicare, because I’m tired of hearing this “I have Med advantage and Medicare” First of all; You don’t have both. Your Med Advantage replaces your Medicare, so stop saying it and stop giving the people at the front desk a copy of Medicare and your Med Advantage plan and please stop calling when you receive a statement asking if we billed Medicare after your Med Advantage plan as paid. Thanks.

I’ve heard it all, “I don’t want anyone telling me which doctor I can see”, and yet they chose a managed healthcare plan that does just that, it certainly doesn’t help having knuckleheads out there selling products they have no clue about, and believe me there are a lot out there!

Today’s modern healthcare is a mess, everything from pharmaceuticals to insurance and doctors. The externalities each of us pay are enormous and expensive, almost beyond understanding, but in this series I will attempt to do so. You might not even know what externalities are? I will explain that as well.

I will explain government’s role in this mess, from Universities doing research for pharmaceutical companies, from lobby money affecting policy. I will talk about the enormous cost of not having insurance in relation not only to healthcare care cost, but taxes. I will discuss Medicare and Medicaid. Talk about Doctors liability cost, kickbacks, and insurance contracts, including hospital cost. I take a close look at Universal healthcare in other countries and compare them to what we have here, discuss what might work better than both currently being offered.

I will speak briefly about insurance company’s responsibility to pay, medical necessity, and bundling procedures and give ideas on how to prevent anyone from taking advantage of you and discuss true reform; for example instead of healthcare reform I seek insurance reform. My hope is by the end of the series, you will have enough knowledge to make a decision about what you want from our healthcare system and better understand how that can be obtained and hopefully motivate you to make that happen.

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