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Re: Is Univeral Health Care the answer?????
Old 05-03-2007, 07:23 PM   #61
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Re: Is Univeral Health Care the answer?????

Quote:
Originally Posted by ERD50
Is there any way we can put this to a test?

Could Rich and MKLD PM each other and give it a go? It seems worth 1/2 hour of time for the chance to help this lady (yeah, easy for me to say - it's not *my* half-hour, but still).

I doubt that Rich would mind 'losing' in this case. Of course, if MKLD was not able to get the deal approved, that does not prove that it can't be done in some cases. But it would be interesting to see if it even got assigned to someone and reviewed past the usual "you are not covered' statement.


Hmm... let's see: 30 minutes for this patient (with poor chance of success in my experience), and about the same for, say, a third of my patients who have some surprise gaps in their coverage. At 15 patients a day, that's 5 hours a day -- unreimbursed, I might add -- waiting on hold, following up with at least some of these appeals with written documentation (another 10 minutes per summary dictated, I reckon).

My patient was crying when she called back about this. It made me sad and I will see what I can do for her. This is not an infrequent situation. As if dealing with her cancer was not enough stress on the poor thing.
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Re: Is Univeral Health Care the answer?????
Old 05-03-2007, 07:34 PM   #62
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Re: Is Univeral Health Care the answer?????

Quote:
Originally Posted by mykidslovedogs
. . .
1.) I would call the insurance company claims dept and ask if a "care coordinator" could be assigned to the insured. I would call back daily to see if it was done yet until I heard back from the claims rep that I was working with the name and direct line for the care coordinator. Most of the time, you'll have a care coordinator assigned within a day or two. Care coordinator's work directly with claims on difficult situations to help with upcoming treatment and prior approval. This helps the whole claims process run more smoothly.

2.) Once a care coordinator is assigned, I would explain the situation in detail and ask if it could be possible to send in a written letter of medical necessity from the attending physician along with a letter of request including the following information, signed and dated by the insured:
a.) Group Number
b.) Member ID or subscriber number
c.) Name of medication needed
d.) Specific rebuttal to the clause in the contract limiting the treatment.
3.) Ask the care coordinator if the request can be sent directly to him/her or if it needs to be sent to a specific address in a specific format. Follow the directions to a "T". Write down names and numbers of anyone who is assisting you with the process.
4.) Follow up until an answer is given by someone in a "higher up" position such as a manager in the claims dept.
Padon me, MKLD, but your descriptions of what to do in order to make sure someone gets appropriate health care are some of the strongest arguments made on this board in favor of universal health coverage.

Let's look at the above example.
1.) I would call the insurance company claims dept and ask if a "care coordinator" could be assigned to the insured. I called my insurance claims department today -- 30 minutes of my life to get through to a human and ask my question. The question was simple and the answer acceptable to me, so it took only 30 minutes. Until I read your post, I would have had no idea that asking for a "care coordinator" was even an option. I doubt that most sick peolpe would know. In fact, I would be willing to wager that not all insurance companies call such people "care coordinators". I'll bet if you called and asked for the wrong thing you would get dumb silence and no help.

I would call back daily to see if it was done yet until I heard back from the claims rep that I was working with the name and direct line for the care coordinator. There goes another 30 minutes or more of your life each day.

Most of the time, you'll have a care coordinator assigned within a day or two. Anyone want to take that wager?

Once a care coordinator is assigned, I would explain the situation in detail and ask if it could be possible to send in a written letter of medical necessity from the attending physician along with a letter of request including the following information, signed and dated by the insured:
a.) Group Number
b.) Member ID or subscriber number
c.) Name of medication needed
d.) Specific rebuttal to the clause in the contract limiting the treatment.
Yeah. Why should every sick person in the US need to have this inside knowledge in order to get health care? This is as ludicrous as if the grocery stores all had a secret set of rules you had to know about in order to buy food. . . "I'm sorry, Sir, without bringing us a letter from your physician telling us you really need those apples, we can't allow you to eat. By the way, that letter needs to include your drivers license and social security numbers as well as appropriate test results that indicate you are not alergic to apples."

3.) Ask the care coordinator if the request can be sent directly to him/her or if it needs to be sent to a specific address in a specific format. Follow the directions to a "T". Write down names and numbers of anyone who is assisting you with the process.Yeah, when I'm in need of medical coverage one of my favorite things is to carefully record and observe minute details that have no bearing on the way I feel or my physical recovery. When I'm physically suffering, I love to concentrate on this kind of thing. I especially love it when I get only 5 of the required alpha/numeric sequences correct and get rejected because I swaped digits on the 6th.

4.) Follow up until an answer is given by someone in a "higher up" position such as a manager in the claims dept. My DW has been through such battles with insurance only to have that answer be, "NO". Further battles reversed that decision, but each battle takes a toll in time and energy. For people who are sick, or who have to focus on their jobs, this is a ridiculous burden. :P
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Re: Is Univeral Health Care the answer?????
Old 05-03-2007, 09:31 PM   #63
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Re: Is Univeral Health Care the answer?????

Quote:
Originally Posted by teejayevans
Speaking of tort reform being needed: Washington DC JUDGE is suing a
dry cleaners for losing his pants, for ....drum roll please...
$65,000,000.
It goes to trial next month, in my world he would be in order:
1. disbarred
2. pay all fees of the cleaners plus $650,000 (my 1% rule)
3. be prevented from being a party of any lawsuit for rest of his life.

http://www.washingtonpost.com/wp-dyn...502763_pf.html
TJ
Ooo! Great ideas! Plus maybe he should be court-ordered to have his head surgically removed from his..... You probably know.
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Re: Is Univeral Health Care the answer?????
Old 05-03-2007, 10:24 PM   #64
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Re: Is Univeral Health Care the answer?????

Quote:
Originally Posted by Rich_in_Tampa


Hmm... let's see: 30 minutes for this patient (with poor chance of success in my experience), and about the same for, say, a third of my patients who have some surprise gaps in their coverage. At 15 patients a day, that's 5 hours a day -- unreimbursed, I might add -- waiting on hold, following up with at least some of these appeals with written documentation (another 10 minutes per summary dictated, I reckon).

My patient was crying when she called back about this. It made me sad and I will see what I can do for her. This is not an infrequent situation. As if dealing with her cancer was not enough stress on the poor thing.
Rich, this is just another helpful tip - not sure if you are aware of it or not, and this is totally meant to be helpful - not sarcastic or anything...there's this great service my husband and I use for dictation called "Copy Talk". You do your dictations by cell phone to the "Copy Talk", and they type the dictation and email it back to you. It costs about $50.00/mo. If you are currently having to have an employee do your dictations, they could be freed up to help patients who have complicated claims issues instead of typing dictations. Just a thought..

I imagine that, working in a cancer facility, your perspective on things would be that this kind of situation is not uncommon. But, if you were in my line of business, you would see that the real difficult claims truly are few and far between when you take the larger populations of people covered by health insurance into consideration.
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Re: Is Univeral Health Care the answer?????
Old 05-03-2007, 10:28 PM   #65
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Re: Is Univeral Health Care the answer?????

Quote:
Originally Posted by sgeeeee
Why should every sick person in the US need to have this inside knowledge in order to get health care?
Actually, it's not inside knowledge. It's all spelled out to a "T" in the certificate of coverage. Problem is, many people don't take the time to read (or even skim through) the contract that they have made with the insurance carrier when they signed up for their coverage.

Also, There's no reason the sick person should have to do the work, unless they have no outside contacts. They can just call their broker, and their broker should do it all for them. Or if they don't have access to a broker, then, sometimes, it's helpful to get family or friends involved to help if possible. I know I wouldn't hesitate to help any of my family members with things like that if they needed it.

I don't know...call me crazy, but, I guess I'd rather spend a couple days working on a difficult claim than have to spend several weeks or months in excruciating pain while on a waiting list for my hip replacement...
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Re: Is Univeral Health Care the answer?????
Old 05-03-2007, 10:35 PM   #66
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Re: Is Univeral Health Care the answer?????

Quote:
Originally Posted by mykidslovedogs
Actually, it's not inside knowledge. It's all spelled out to a "T" in the certificate of coverage. Problem is, many people don't take the time to read (or even skim through) the contract that they have made with the insurance carrier when they signed up for their coverage.

Also, The sick person doesn't need to do any of the work. They can just call their broker, and their broker should do it all for them. Sometimes, it's helpful to get family or friends involved to help if possible.

I don't know...call me crazy, but, I guess I'd rather spend a couple days working on a difficult claim than have to spend several weeks or months in excruciating pain while on a waiting list for my hip replacement...
Let's apply this reasoning to the purchase of food:

Actually, it's not inside knowledge. It's all spelled out to a "T" in the certificate of groceries. Problem is, many people don't take the time to read (or even skim through) the contract that they have made with the grocery store when they signed up for their food.

Also, The hungry person doesn't need to do any of the work. They can just call their shopper, and their shopper should do it all for them. Sometimes, it's helpful to get family or friends involved to help if possible.

I don't know...call me crazy, but, I guess I'd rather spend a couple days working on a difficult meal plan than have to spend several weeks or months in excruciating hunger while on a waiting list for my groceries . . .

Yeah . . . that's a system we should all embrace and be proud of.
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Re: Is Univeral Health Care the answer?????
Old 05-03-2007, 10:41 PM   #67
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Re: Is Univeral Health Care the answer?????

Quote:
Originally Posted by Rich_in_Tampa
Saw a patient today who seriously needed daily injections of a powerful blood thinner to prevent potentially fatal pulmonary blood clots. For various reasons, she was not a candidate for the usual pill form of blood thinner (warfarin or 'coumadin').

This will be a 6 month course, possibly lifelong. The injections cost around $70 per day. Insurance covers 15 days. They can't afford it on their own, period.

We are now faced with putting her on warfarin against medical recommendations, having her simply not accept treatment (50% mortality risk), or having them go $12,000 in debt every 5-6 months at a minimum through a home equity loan they can ill afford. She wants the pills and I am torn since I know it will expose her to serious excess risk.

I face these daily. It is very painful and often futile to fix. Regardless of its ultimate structure, a system which covers legitimate, evidence-based treatment within reasonable boundaries is morally necessary.

This is a 55 year old woman, worked and paid for health insurance (plus employer payments) for decades, and basically played by the rules. She's screwed.

The system needs to protect such people. A safety net at $10K or obliging insurers to pay for the legitimate and accepted medical duration of treatment, whatever. This is what it has come to, and your turn may well arise.

Personally, I favor a tax-supported, Medicare-like system covering all Americans with catastrophic coverage over $10K adjusted for inflation, and private or out-of-pocket coverage for the first $10k/y per person, perhaps adjusted for means.
This is an absolutely horrifying situation. Would the shots be covered in a straightforward way if this lady was on Medicare?

I'm also curious if her insurance was an employer-based group policy or an individual policy?
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Re: Is Univeral Health Care the answer?????
Old 05-03-2007, 10:41 PM   #68
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Re: Is Univeral Health Care the answer?????

Your right, sgeeee,

It's much better to have no control over the waiting list for your health services than to be able to take personal control over your bills.

I really mean it when I say that insurance carriers put dispensing limits on certain kinds of drugs for a reason. Dispensing limits are put in as a protection to the insured. Let's look at dispensing limits for Percoset, for example. As the insured, you may only be able to fill the Rx once every so many days. This limitation is put into place to prevent people from being able to purchase more than a 30 days supply and perhaps taking two pills a day instead of one, resulting in an overdose.

I am sure there is a perfectly reasonable explanation for the dispensing limits on the blood thinners. However, with just a little bit of work, I am nearly certain that the insurance carrier will take the person's personal case into consideration with a letter of medical necessity for extended treatment from her doctor.


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Re: Is Univeral Health Care the answer?????
Old 05-03-2007, 10:50 PM   #69
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Re: Is Univeral Health Care the answer?????

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Your right, sgeeee,

It's much better to have no control over the waiting list for your health services than to be able to take personal control over your bills.


Well . . . that's a good tactic for someone who wants to defend our current broken healthcare system. Rather than admit that it is broken and an unreasonable burden on the patient, accuse those who point out the problems of being lazy and unwilling to take personal control.

PSSST . . . MKLD, The US healthcare system is broken and most Americans have figured that out. You can write 40,000 posts defending it, but it doesn't change the fact that it is broken.
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Re: Is Univeral Health Care the answer?????
Old 05-03-2007, 10:54 PM   #70
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Re: Is Univeral Health Care the answer?????

Quote:
Originally Posted by sgeeeee

Well . . . that's a good tactic for someone who wants to defend our current broken healthcare system. Rather than admit that it is broken and an unreasonable burden on the patient, accuse those who point out the problems of being lazy and unwilling to take personal control.

PSSST . . . MKLD, The US healthcare system is broken and most Americans have figured that out. You can write 40,000 posts defending it, but it doesn't change the fact that it is broken.
I never said it was perfect, I just think it's better than the alternative. To me, spending a little time on some complicated bills is a better alternative than having to wait on a waiting list for services while in pain, or perhaps even dying while on a waiting list. And if you don't think there will be waiting lists in any kind of universalized system, you are sadly mistaken. It might take a few years to get out of control, but it always does, eventually. It's not the primary care I'm talking about....It's the difficult, complicated illnesses and disorders (like cancer) that will be a problem. At least here, we can get our treatment and worry about paying for it later. In other countries, the treatment may not even be available. To me, our system is the lesser of two evils.
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Re: Is Univeral Health Care the answer?????
Old 05-03-2007, 11:10 PM   #71
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Re: Is Univeral Health Care the answer?????

I am starting to think that MKLD have an entry describing her in DSM-IV.

Or maybe she is just a really good dead-pan humorist?

Ha
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Re: Is Univeral Health Care the answer?????
Old 05-03-2007, 11:14 PM   #72
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Re: Is Univeral Health Care the answer?????

It is part of the answer (Universal Healthcare). I personally think that this means affordable healthcare that is available to everyone without regard to pre-existing conditions.

I find it amazing that healthcare in this country is viewed as a opportunity to make money - which is exactly the system we have now.

The 2008 elections would be all about this issue if we weren't distracted by a meaningless war.

Peace
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Re: Is Univeral Health Care the answer?????
Old 05-04-2007, 12:14 AM   #73
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Re: Is Univeral Health Care the answer?????

Quote:
Originally Posted by mykidslovedogs
I never said it was perfect, I just think it's better than the alternative. . .
What a defeatist and narrow minded attitude!!! It is clearly very imperfect. So why should we settle for a broken system? Apparently you feel we should just learn to live with it because, "It's better than the alternative?"

Do you believe Americans are so simple minded and clueless that they can only think of one alternative to the current mess? We should just accept that no matter how bad the current system is, we would probably only make it worse if we tried to fix it.

We fail only if we don't try to improve the current system. :P
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Re: Is Univeral Health Care the answer?????
Old 05-04-2007, 12:43 AM   #74
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Re: Is Univeral Health Care the answer?????

Quote:
Originally Posted by d
the average federal plus state&local tax collection are about 31% ...
Don't forget to add the cost of health insurance.. that was included in the 'onerous 33% tax'. Maybe you could take half the cost of that insurance.. as the govt policy probably provides basic care, the other half would be what you could use to purchase higher level coverage.

Looks pretty close, financially, to me.
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Re: Is Univeral Health Care the answer?????
Old 05-04-2007, 01:30 AM   #75
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Re: Is Univeral Health Care the answer?????

Just to make it clear, as there seems to be some confusion, the 33% social tax in Estonia is paid by the EMPLOYER. It IS NOT deducted or withheld from the employees earnings.

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Re: Is Univeral Health Care the answer?????
Old 05-04-2007, 06:37 AM   #76
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Re: Is Univeral Health Care the answer?????

Quote:
Originally Posted by mykidslovedogs

I'm just trying to correct Rich that instead of just telling the patient "it's not covered", and leaving her to think she's "screwed", the doctor's office could go a step further and explain to the patient that oftentimes, a simple appeal filed as per the step by step instructions I mentioned earlier could result in coverage for the injections.

Time and again, I have helped people who have been trying to appeal a claim for months or even years, to resolve the issue in a matter of days by bringing in the proper people from the insurance company to help out. When a claim appeal gets sent to the wrong dept or through the wrong channels, it can slow the process altogether and just lead to a lot of dead ends that seem like "the runaround", when in actuality, the claim appeal would've been processed much more quickly and timely if it had been sent to the correct address, with all of the correct information included.

I'm not trying to insult anyone here, just trying to point out that the insurance company is not going to deny a claim just for the purpose of being greedy and insensitive. Oftentimes the problem is that the insured just needs a little help going through the proper channels to get it taken care of quickly, and rather easily.
If an elderly patient can't figure this out easily the process is designed to thwart them. If a doctor like Rich perceives the system as preventing the patient receiving coverage, it is designed to be perceived that way. It is like IRS wanting people to fear them.
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Re: Is Univeral Health Care the answer?????
Old 05-04-2007, 07:03 AM   #77
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Re: Is Univeral Health Care the answer?????

Quote:
Originally Posted by janeeyre

After reading a recent post about differing state requirements for health care, I am wondering how Universal Health Care would work -- like Medicare. More importantly, I do not want the government running my health care. Other than the IRS, the government, by its very nature, is ineffecient and incompetent --- look at Katrini. There must be a better way.

While the government dictates the rules
and pays the bills... services and claims for
Medicare and Medicaid are administered by
the private sector, not by government employees.

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Re: Is Univeral Health Care the answer?????
Old 05-04-2007, 07:29 AM   #78
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Re: Is Univeral Health Care the answer?????

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Originally Posted by FIRE'd@51
This is an absolutely horrifying situation. Would the shots be covered in a straightforward way if this lady was on Medicare?

I'm also curious if her insurance was an employer-based group policy or an individual policy?
Yes and employer based.
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Re: Is Univeral Health Care the answer?????
Old 05-04-2007, 08:07 AM   #79
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Re: Is Univeral Health Care the answer?????

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Originally Posted by Rich_in_Tampa
Yes and employer based.
Perhaps there's an HR person at her employer, who would know how to efficiently work through the "insurance maze".
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Re: Is Univeral Health Care the answer?????
Old 05-04-2007, 08:25 AM   #80
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Re: Is Univeral Health Care the answer?????

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Originally Posted by Beststash
It is part of the answer (Universal Healthcare). I personally think that this means affordable healthcare that is available to everyone without regard to pre-existing conditions.

I find it amazing that healthcare in this country is viewed as a opportunity to make money - which is exactly the system we have now.

The 2008 elections would be all about this issue if we weren't distracted by a meaningless war.

Peace
I guess we could ask the doctors to work for free? That should solve the problem! After all, there's no reason why a healthcare provider should make money. Healthcare is an entitlement.
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