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Old 03-28-2010, 05:09 PM   #11
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Default Re: Lessons in Healthcare 101

So let me make sure I got this right Indo. First a little background on my situation. I recently was playing catch with my son and he managed to throw the football just right, I half missed it and it dislocated my finger. It was pretty bad, the front of my finger was actually under the back half, like this. Tip of finger____---------Knuckle at the hand. I hope that makes sense. So I know by looking at it that it's pretty messed up, cause it's pointing off to the right as well. It hurt like a bitch, so I decided the best thing to do was pull it back out(reset it?). At first it wouldn't go, but about 5 minutes later I was able to really pull on it and it popped back into place. Of course the swelling started a couple of minutes later. I took some Aleve and prayed it wasn't broken. Two days later I couldn't stand the pain anymore and decided to go the ER, doc wouldn't see me cause he had no X-Ray and it was Saturday. So I go the ER get an X-Ray a shot of lanacane(sp), get told it's not broken and get a script for a painkiller. Perkaset(sp) I think it was. I was in and out in 45min. Okay a month goes by and my insurance decides to use our FSA to pay for it. They sent us a check and we had to pay the doc. All is good except our FFA is drained now. 900$ bill. Now two months later I am getting bills from the Er and the orthopedic doc. It appears that these bill are the remainder of what the insurance didn't pay.

Okay since the background is somewhat laid out, here is my question. Based on what you're saying, am I not liable for the remainder of those bills because the doc already has agreed upon a certain price and that's what the insurance company paid?
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Old 03-28-2010, 05:11 PM   #12
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Default Re: Lessons in Healthcare 101

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Why are you trying to derail this thread with mindless rhetoric? Seriously, there are other threads for that crap. KEEP IT THERE!
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Old 03-28-2010, 05:27 PM   #13
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Default Re: Lessons in Healthcare 101

It's a FREE world you damn Commie!!
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Old 03-28-2010, 06:22 PM   #14
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Default Re: Lessons in Healthcare 101

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It's a FREE world you damn Commie!!
Typical.
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Old 03-29-2010, 04:32 PM   #15
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Default Re: Lessons in Healthcare 101

OK, I'm back. Busy weekend...
I'll try to answer these question as best I can, but let me throw this disclaimer out there-----I'm just an average run-of-the-mill Steelers fan and not privileged enough to have had the opportunity to read the new healthcare legislation. With that being said, I will answer the questions as best I can, and post the info that is trickling out thru the med societies, etc., as I get it...




Quote:
Originally Posted by tony hipchest View Post
thanks indo for starting this thread. i went to college for pre-med with aspirations of being a sugeon and even took a few courses at UNM's medical college. the most compelling and thought provoking was Sociology of Medical Practice.
You, obviously, were intelligent enough to turn towards a different career!


my final term paper was coping with stress and i was amazed how little research there was on how those with such intense, time consuming jobs dealt with or were taught to handle the stress of having ones life in their hands.

We were not specifically taught how to cope with the stress but, being in New Orleans, we rapidly discovered the benefits of large quantities of Beer and other such beverages!


to put it in football terms, a surgeon either has 'it" or they dont.

point being i really respect your opinion on this topic and hope you can add a real life perspective to us on this board.

can you tell us how this is gonna affect you first hand (and i understand that, at this point, you may be as much in the dark as the rest of us)?

As I said, I haven't read the document----but I have a good idea what will happen...We will all begin to see healthcare rationing. Of course it won't be called "Rationing", but that is what it will be. As a physician, I will be told what tests I can order, which procedures will be approved, and what will be denied. This ALREADY happens to an extent. But that extent will be extended! It is already VERY difficult to get a CT scan or MRI approved for patients that have Medicaid (and the new "insurance" will be an off-shoot of Medicaid. For example: suppose Mr. Smith needs a CT scan of his abdomen. Approval for a CT scan is denied by Medicaid ALMOST 100% OF THE TIME now. And there is little recourse for the patient's MD to appeal the denial. Yes, we can write a letter explaining the situation, but it generally results in a second denial. Now, if I call a private insurance carrier (like BlueCross/BlueShield) there is a human-being who is generally a doctor (the medical director) of the insurance Co. who has a clue what I'm talking about. I can explain the situation and get approval (I can generally get 100% APPROVAL on tests that have been denied IF THERE IS A PERSON WITH A MEDICAL BACKGROUND TO TALK TO). When one calls the Medicaid office to get an approval you generally get to speak to someone who can't spell N-F-L----even if you spot them any two of the three letters!

So, it is my belief that this will become MUCH worse...it doesn't really affect me, but it greatly affects the patients if I can't order the proper tests, x-rays, etc.



i keep hearing how everybody will no longer be "free to chose" which doctor they see.

when does the government ship you and all the other doctors out and bring in all the new doctors that will not be of the peoples choice?

I'm not sure----what I can tell you is that about 2-3 years ago the govt. started keeping tabs on all of us as far as performance goes. For example, if the complication rate of a particular operation is, say 1%, but a particular doc has a complication rate which is outside the "average", say 8%, there is talk (don't know how accurate that "talk" is) that the doc with the high complication rate will no longer be able to perform that operation (he will still be "allowed" to perform it, he just won't get reimbursed for it----which affectively takes away his/her ability to perform it)

Scary, ain't it


when i was a kid applying for the ROTC to be a doctor (because i wanted to be a field medic saving the lives of soldiers), i was amazed to learn that military doctors were paid according to their rank, not according to their education or free market value.

Yes. I have posted something about this in another thread a while back (don't have time to find the post right now)----If one decides to opt for the military to pay for their medical education (they pay for 4 years of med school, then you owe them 4 years, sometimes 5 or 6, after you graduate). You graduate from med school and immediately are given the rank of Captain---and are paid according to your rank. I know a girl who finished med school as a Captain and then finished Surgery Residency and was promoted to Major. She then spent a year in Iraq running a MASH unit (like Colonel Blake or Potter). After 8 or so months in-theater the MASH unit was pulled back off of the front lines...she then came back to New Orleans and gave a lecture (complete with some really cool photos) of her experience



are you going to get a rank? is our new socialist regime gonna eliminate "private practice"? will we eliminate all elective surgeries or will the elite such as nanci pelosi still be allowed to reconstruct herself to look like a 110 year old joan rivers?

Hopefully Pelosi will ALWAYS be allowed to reconstruct herself, or we're all in serious trouble! I don't know if we will all get a rank, but I do think we will all be govt employees...


i live in a town where the choice of doctors is about as varied as mcdonalds vs. burger king. sometimes the line for one is longer than the other. is that preparing me for the socialism i am about to endure or will it pretty much be more of the same ol same ol?

Good question.
I think that what has been happening in Massachusetts is a good model for what will happen across the US----I remember reading that the average time to see a physician in Mass. increased from around 16-17 days to around 60 days because so many physicians left the area. I have a feeling that this is what will happen across the country. Look at Canada and England, for example. The waiting lists for procedures (heart bypasses and others are MONTHS long; I don't know the data specifically, but I would bet that a fairly large percentage of people die while waiting for their procedures)

i know some of these questions are sorta tongue in cheek, but most of the concers we have heard on this board are from the patient/payers POV.

i am really interrested in the provider/earners point of view.

oh and another question... theoretically, if you were to catch an STD, are you legally able to diagnose and write yourself a precription to get rid of the itch w/o an outside consultation?


Yes, actually. I have baaaad allergies and I typically write my own prescriptions for the meds. But I WOULD NOT AND DO NOT write any prescriptions for myself or The Girl (same household) for any controlled drugs (like narcotics, sedatives,etc). That practice just raises all kinds of questions with the DEA
Here is something else that concerns me:

Think of an Insurance Company (any insurance co.----car, home, life, health) like a Casino. They are (in the case of Health Insurance) Gambling---putting up a Bet--- that you WON'T get sick. They charge you a fee (your premium) for them to make that bet. If they are correct (and, statistically they are for a high percentage of the bets they place), they win and get to keep the fee they charged you. For a small percentage, they are Wrong and you get sick and they have to pay out the bet at a loss. But if they place a high enough volume of bets, they will, in the long run, Win (make a profit).

So here is what concerns me-----insurance companies will now be forced, by the new legislation, to cover dependent "children" until they are 26 years old on their parents policy. Their will be many more bets placed without effectively increasing the fee for betting.The Insurance companies will be forced to cover many more people without increasing what is in their coffers to pay out when they lose. Now, I will grant you that the 18-26 year old age group typically does not have many sick people. But, when they do have a health issue it is usually a BIG and EXPENSIVE one because people in that age group are the most prone to motor vehicle accidents and other stupid behaviors which lead to accidents.
How does an insurance company continue to pay out claims to this age group (which typically has very expensive claims) without increasing the premiums to cover the losses? In my estimation, it doesn't. This will, IMO, contribute to the eventual replacement of all private insurance with govt insurance as the private coompanies are forced out of business---thereby completing the circle of completely Socialized Medicine.
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Old 03-29-2010, 04:38 PM   #16
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Default Re: Lessons in Healthcare 101

that was very interesting to read your point of view Indo! This is off topic but what do you think about the "boutique" medical practices popping up?
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Old 03-29-2010, 04:51 PM   #17
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Default Re: Lessons in Healthcare 101

Quote:
Originally Posted by 43Hitman View Post
So let me make sure I got this right Indo. First a little background on my situation. I recently was playing catch with my son and he managed to throw the football just right, I half missed it and it dislocated my finger. It was pretty bad, the front of my finger was actually under the back half, like this. Tip of finger____---------Knuckle at the hand. I hope that makes sense. So I know by looking at it that it's pretty messed up, cause it's pointing off to the right as well. It hurt like a bitch, so I decided the best thing to do was pull it back out(reset it?). At first it wouldn't go, but about 5 minutes later I was able to really pull on it and it popped back into place. Of course the swelling started a couple of minutes later. I took some Aleve and prayed it wasn't broken. Two days later I couldn't stand the pain anymore and decided to go the ER, doc wouldn't see me cause he had no X-Ray and it was Saturday. So I go the ER get an X-Ray a shot of lanacane(sp), get told it's not broken and get a script for a painkiller. Perkaset(sp) I think it was. I was in and out in 45min. Okay a month goes by and my insurance decides to use our FSA to pay for it. They sent us a check and we had to pay the doc. All is good except our FFA is drained now. 900$ bill. Now two months later I am getting bills from the Er and the orthopedic doc. It appears that these bill are the remainder of what the insurance didn't pay.

Okay since the background is somewhat laid out, here is my question. Based on what you're saying, am I not liable for the remainder of those bills because the doc already has agreed upon a certain price and that's what the insurance company paid?
The answer is----it depends.
Going to the ER is a whole different animal altogether.
You have to look at your specific policy and see what kind of co-pay you must pay to the hospital. An ER visit can cost $100, sometimes even up to $250 in co-pay. Think of it like a "deductible" over and above your yearly deductible.
Remember that ALL insurance policies (car, home, health, etc) have a deductible.
Generally, if you choose to pay a low(er) premium(monthly fee), you will have a higher deductible----again, it's a gamble. You're gambling that you WON'T get sick and therefore choose to pay a lower monthly premium at the risk of having to pay a Higher deductible if you do get sick.
On top of that, ALL healthcare policies have the "co-pay". Your policy may cover 80% of the bill and you owe 20%. Or it may cover 100%, but you still owe the co-pay...etc
Co-pay for a visit to the ER is typically high, as I said

So you need to look at your policy and see if your yearly deductible has previously been paid...if not, your ins. co. may be saying that you still need to pay because the deductible hasn't been met. Or, the hosp. is billing you the ER co-pay, for which you are responsible. A call to your insur. co. can usually clear it up.

Now, the payment to the Ortho. guy can be explained in the same way----he/she has billed for a service provided in the ER. First question, is he a provider of the type of insurance that you have? Has he signed a contract with them and agreed to "Accept Assignment" of what they will pay? Or is he "Out of Network" , as they say. In that case he is under no obligation to accept anything that they will pay and CAN bill you directly. If he is "In Network", he must accept what they will pay as he has signed a contract saying that he would. Again, your insur. co. can tell you.

Hope this makes sense...let me know if it doesn't
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Old 03-29-2010, 05:04 PM   #18
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Default Re: Lessons in Healthcare 101

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that was very interesting to read your point of view Indo! This is off topic but what do you think about the "boutique" medical practices popping up?
Again, It Depends

Some of these facilities are run by very good doctors that have simply said, "I have had enough!" and they choose to stop accepting insurance altogether. Instead, they set up payment plans with their patients or they require that the service to be provided is paid in full prior to the procedure---

for example, I knew a guy in New Orleans who was a Plastic Surgeon who did only Cosmetic surgery and had his patients pay 10 days in advance for any procedure that he did. They wanted the procedures, so they paid. Sometimes as much as $25,000! Crazy, isn't it.

The problem occurs when someone less-than-ethical opens one of these "boutiques" because they are not really held to the same standards as hospitals, etc. The JCAHO (Joint Commision on the Accreditation of Healthcare Organizations) does not survey/inspect them and does not accredit them.
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Old 03-29-2010, 05:50 PM   #19
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Default Re: Lessons in Healthcare 101

thank you for your reply, much appreciated. I heard that some of the boutiques also charge a membership fee,
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Old 03-29-2010, 07:07 PM   #20
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Default Re: Lessons in Healthcare 101

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thank you for your reply, much appreciated. I heard that some of the boutiques also charge a membership fee,
Membership might be something like keeping a lawyer on retainer. Build up some bank in case you need it.
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