High Deductible Health Insurance -- Golden Rule

[prubin]

We just signed up with Golden Rule. If you are familiar with the mechanics of GR claim processing perhaps you can help me. I am assuming that I ask the service provider to submit a claim even if we have not satisfied our deductible and this how to track charges. The same for filling prescriptions, correct? Will we be charged 'retail' or a price negotiated by the insurance company.

Thanks in advance.

 

[REWahoo]

Prubin, file all non-prescription claims with the insurer prior to paying for services. If the provider insists on payment up-front, agree to only pay a portion of the amount. The amount your insurer authorizes will likely be significantly lower than what you are initially billed and this will prevent overpayment and fighting for reimbursement. And yes, this is the only way your insurer will be able to track your expenses towards your deductible.

 

[Rich_by_the_Bay]

I agree with REW.

BTW, more and more practices are expecting at least the estimated patient deductible or co-pay at the time of service. It's tough enough for them to accept what insurance "allows" without having to float hundreds of little interest-free "loans" to all your patients as you wait for their carrier to adjudicate the claim.

 

[prubin]

Thanks to REW and Rich for your speedy replies.

Paul

 

[Tesaje]

I have Aetna this year and that's the way it worked for me. The provider charged me nothing, then billed my insurance co. The insurance co. logged the amount that they have negotiated with the in-program providers (about half of the "normal" charges), then the provider sent me a bill. My optometrist did a separate billing - they had it all automated so they knew instantly what my insurance allowed and logged it with them, then had me pay right there. It got onto my account with the insurance co. correctly. On the other hand, my allergist never did bill me at all and that was about 6 months ago. Another handy thing is that they could charge my HSA debit card like a credit card over the phone.

So far, both the medical costs and insurance costs have saved me about 2/3's of what I was paying for the HMO and co-pays. It is strange to walk in and out without paying anything.

 

[IndependentlyPoor]

I have to say that doctors and insurance companies have things worked out now MUCH better than a few years ago. When I was taking care of my Mother's medical bills and insurance, statements from doctors would trickle in for months afterwards, often for the wrong amount, which ended up delaying their payment for another month. Keeping track of it was a major PITA.

I just got off the phone with the billing clerk for a doctor I will be seeing Wednesday. They knew to the penny how much my insurance would allow and I paid with a credit card over the phone and got the receipt via email. Sweet.

I have a sort of weird policy with Aetna that only pays 50%. (Why is for another thread.) Even so, Wednesday's procedure cost $4000 some-odd dollars, the negotiated rate was $500-something and my co-pay was 1/2 of that. Amazing. Pity the poor schlub without insurance. $4K for an outpatient procedure. Can you imagine?

 

[Texas Proud]

I agree with REW.

BTW, more and more practices are expecting at least the estimated patient deductible or co-pay at the time of service. It's tough enough for them to accept what insurance "allows" without having to float hundreds of little interest-free "loans" to all your patients as you wait for their carrier to adjudicate the claim.

I will agree with Rich... but I guess since he is living it he would know...

When my wife had foot surgery... the hospital wanted a 'down payment' that was very close to the final amount that we owed... I think within $100. We did not pay any of the doctors up front, but they were mostly covered by that time... but we still paid a bill here and there...

My biggest surprise was the insurance discount... seemed to be 2/3rd to 3/4s of the bill...

 

[prubin]

I have to say that doctors and insurance companies have things worked out now MUCH better than a few years ago. When I was taking care of my Mother's medical bills and insurance, statements from doctors would trickle in for months afterwards, often for the wrong amount, which ended up delaying their payment for another month. Keeping track of it was a major PITA.

IMHO the doctors and insurance companies have set the bar so low that we are thrilled with the pursuit of mediocrity. When I left California I had to give up my Kaiser coverage and I miss it. The medical care and the patient experience were excellent. No trickling of statements from doctors and labs. One copay, no statements. Doctors request lab tests and meds on-line. When you show up at the lab or pharmacy they know exactly what was ordered. No paper or questionable handwriting. Lab results are emailed to you with links to web pages explaining how to interpret results. On-line appointments scheduling -- no phone calls time spent on hold. Kaiser has squeezed lots of overhead out of the process and the lower premiums reflect it.

 

[ERD50]

IMHO the doctors and insurance companies have set the bar so low that we are thrilled with the pursuit of mediocrity. When I left California I had to give up my Kaiser coverage and I miss it. ..... Kaiser has squeezed lots of overhead out of the process and the lower premiums reflect it.

So simply breaking down the state-by-state insurance regulations so that all ins would be competing nation-wide could be a big step in cutting costs. And it wouldn't require any big major overhaul of the present system, which scares a lot of people.

It wouldn't solve everything , but it would be a start. And if it worked well, it would build some confidence and maybe the govt could bring in some "phase II" project? At least we'd save money in the meantime.

The cynic in me says that the *last* thing the govt wants to do is make private ins more competitive. That softens the demand to have the govt do it all, so they can have more control and have more people indebted to them and have more cushy jobs to hand out.

-ERD50

 

[youbet]

The cynic in me says that the *last* thing the govt wants to do is make private ins more competitive. That softens the demand to have the govt do it all, so they can have more control and have more people indebted to them and have more cushy jobs to hand out.

-ERD50

Yes, there's a bit of cynicism there........

 

[ERD50]

The cynic in me says that the *last* thing the govt wants to do is make private ins more competitive. That softens the demand to have the govt do it all, so they can have more control and have more people indebted to them and have more cushy jobs to hand out.

-ERD50

Yes, there's a bit of cynicism there........

Turns out I was not cynical enough

A First! Wolf Blitzer asks David Axelrod Some Tough Questions | Chicago Daily Observer

Hot Air » Blog Archive » Video: Axelrod not comprehending what “competition” means

AXELROD: ... But what is very important is that we have the kind of competition and choice that will help consumers. In many states in this country, there’s one insurer that dominates the entire market. In Alabama, one insured dominates 87 percent. In North Dakota, there’s one insurer that dominates…

BLITZER: So why not break down…

AXELROD: …the market almost completely.

BLITZER: Why not break down the state barriers and let all of these insurance companies compete nationally without having to simply focus in on a state by state basis?

AXELROD: Because we are trying to do this in a way that advances the — the interests of consumers without creating such disruption that it makes it difficult to to move forward.

BLITZER: Why would that be disruptive? If Blue Cross and Blue Shield or United Health Care or all of these big insurance companies, they don’t have to worry about just working in a state, they could just have the opportunity to compete in all 50 states?

AXELROD: But insurance is regulated at the — at this time, Wolf…

BLITZER: But you could change that. The president could propose…

AXELROD: …state by state.

BLITZER: The president could propose a law…

AXELROD: That is not…

BLITZER: …changing that.

AXELROD: That is not endemic to the kind of reforms that we’re proposing or that…

IOW - that is NOT what we want to do. Period.

They don't want to help people, they want control (or make 50% of the people dependent on them, which brings control). No cynicism, just appears to be the facts.

-ERD50

 

[Gotadimple]

As I said in another thread when discussing the public option to encourage competition: why not just change the law at the federal level and require the state insurance commissioners to administer the 'competitive law?'

Would be cheaper, and easier, but then my tax dollars would have no place to work!

But then the competitive option smacks of restraint of trade. You can't compel a company to do business in a state, so the only way to give the impression of competition is to start your own company (public option).


-- Rita

 

[Tesaje]

I'm sorry but that Blitzer-Axelrod dialog was so incoherent it is hard to glean any real conclusion out of it. It sounded more like both parties were trying to get a sound bite and dodge any real statements. Until we have an actual bill to examine, it is all sound and fury signifying nothing.

Oh yeah, you give the govt way too much credit - it isn't conspiratorial or organized enough to have any real conspiracy to take your rights from you any more than social security or medicare has. Now insurance companies and big pharma - they do!

 

[ziggy29]

But then the competitive option smacks of restraint of trade. You can't compel a company to do business in a state, so the only way to give the impression of competition is to start your own company (public option).

True, but you can allow the purchase of insurance across state lines as an alternative way to get more competition. Seems to me that's well within the interstate commerce powers of Congress. I don't think that's a cure-all for the competition issue, but it's a down payment...

 

[Gotadimple]

True, but you can allow the purchase of insurance across state lines as an alternative way to get more competition. Seems to me that's well within the interstate commerce powers of Congress. I don't think that's a cure-all for the competition issue, but it's a down payment...

I agree Ziggy, but most states have two components that affect interstate commerce: (1) licensing the carrier to do business in the state -- a tax impact on premiums charged, and consumer protections over operations if they sell to a resident of the state, and (2) legislation that sets the minimum coverage and regulations for oversight.

So, not as simple as buying coverage from a carrier in the next state. What eliminating the state barriers looks like, then, is a common set of law regarding benefits and consumer protection.

Wait!!! What!!! We have that already: Medicare Supplement plans all have common benefits and oversight -- also no oversight by the states and no premium taxes to collect (uh oh )

-- Rita

 

[M Paquette]

It wouldn't solve everything , but it would be a start. And if it worked well, it would build some confidence and maybe the govt could bring in some "phase II" project? At least we'd save money in the meantime.

Call me cynical ("OK, you're cynical"), but I am not so sure that having BCBS Oregon competing with BCBS California, or United HealthCare of Arizona competing with United HealthCare of New Mexico will accomplish that much. I can't see these companies engaging in cutthroat competition. Their national holding companies wouldn't permit it.

I'm pretty sure the insurers would love to have that change in place, though. Something about Federal interstate regulation trumping state regulatory boards comes to mind.

Beware of unintended side effects. Dizziness or nausea may occur.

 

[ERD50]

As I said in another thread when discussing the public option to encourage competition: why not just change the law at the federal level and require the state insurance commissioners to administer the 'competitive law?'

-- Rita

What do you mean by the "competitive law"? Laws to make things competitive seldom work, but the govt can set up a competitive "environment", then let competition do its thing.

I'm sorry but that Blitzer-Axelrod dialog was so incoherent it is hard to glean any real conclusion out of it.

That is the nature of spoken dialog/interview, but this seemed clear to me:

AXELROD: That is not endemic to the kind of reforms that we’re proposing

In response to creating more competition in the private sector. It just isn't in their game plan. But why not?

True, but you can allow the purchase of insurance across state lines as an alternative way to get more competition. Seems to me that's well within the interstate commerce powers of Congress. I don't think that's a cure-all for the competition issue, but it's a down payment...

Exactly. And if it doesn't work, it doesn't work. But how can it hurt? And if the public option is truly "pay as you go", the ins cos either compete or close up shop. If they can't compete, then good riddance (though I think we need *something* to keep the public option 'competitive'). And if the public option isn't "pay as you go", then any sense of "competition" is meaningless - no business can "compete" with one that can rob future generations and not even account for it on its books.

-ERD50

 

[Gotadimple]

The BlueCross Blue Shield Association licenses plans and guarantees a territory. So in a state where there are two Blues, there are distinct geographical areas where they may market their plans.

HOWEVER, those blue plans that have common ownership do compete with each other where practical in landing large multi-state accounts (megacorps). Examples of Blue plans with common ownership are Wellpoint (based in Indiana but owning several other plans in 12 states), Regence (based in Oregon, with plans in Washington, Idaho, and Utah), Health Care Services Corp (based in Illinois, with plans in New Mexico, Oklahoma, and Texas).

The result is really negligible, as they are competing to cover megacorps and pricing on these policies is not the same as for a small business or individual.

I'm sure that United Health Care and Aetna also compete with themselves for megacorp accounts and those premiums are customized for the account and consider what the competition is likely to offer.

It wouldn't surprise me, though, to find that the Blue Cross Blue Shield Association is working on an inter-plan method to make coverage seamless regardless of state lines -- they have that now when it comes to claims. They are a big player in DC in designing benefits that can be sold and administered by any of their licensee plans (again for megacorps, but I imagine they are already studying the 50 state insurance laws for ways to comply).

-- Rita

 

[Gotadimple]

What do you mean by the "competitive law"? Laws to make things competitive seldom work, but the govt can set up a competitive "environment", then let competition do its thing.

My point is an underfunded federal option will not create competition, it will create a marginalized population receiving sub-standard service. I object to the public option on the grounds that it will not achieve competition. The reason for the public option is that in many states there is only one large insurer. At least that's the reason the need for a public option has been presented.

There are probably good business reasons why other insurance carriers (large, small, or mid-size) have chosen not to enter the marketplace in a particular state. To encourage competition the various state legislators and the insurance departments can make changes to encourage entry by other players. It just hasn't been worth it to a particular state to encourage the competition.

-- Rita

 

[ERD50]

The BlueCross Blue Shield Association licenses plans and guarantees a territory. So in a state where there are two Blues, there are distinct geographical areas where they may market their plans.

HOWEVER, those blue plans that have common ownership do compete with each other ...

Two entities "competing" with each other in a territory is not a "free market", it is a duopoly. Cable/Satellite, Dems/Repubs, Visa/Mastercard....

Duopoly - Wikipedia, the free encyclopedia

-ERD50

 

[ERD50]

My point is an underfunded federal option will not create competition, it will create a marginalized population receiving sub-standard service.

Maybe I'm just misunderstanding you - but this seems like double-speak to me?

What do you mean by an "underfunded" public option regarding "competition"? It seems to me that you are saying that ins cos are charging too much (I don't disagree), but then you say that the public option needs more money than that to be "competitive"? I don't get that.

The reason for the public option is that in many states there is only one large insurer. At least that's the reason the need for a public option has been presented.

That's the whole reason for dropping the state regulations - let's get more insurers in a territory. I have plenty of car ins cos to choose from.

To encourage competition the various state legislators and the insurance departments can make changes to encourage entry by other players. It just hasn't been worth it to a particular state to encourage the competition.

-- Rita

I suppose they could, but it would probably be like herding cats. Wouldn't this be better done at the national level?

-ERD50

 

[Gotadimple]

Maybe I'm just misunderstanding you - but this seems like double-speak to me?

ERD: The House version of the health insurance bill will establish a fund of $2,000,000,000 (trillion) for a public health option. There will be no other funds, and as you've said it would be pay as you go. As I've said in other threads, $2Tr is not a lot of money to compete against United Health Care (who can go to the market to get more money, and can do things to sustain a profit by investing in other businesses to generate profits).

My experience with a mid-size not-for-profit insurer is that to pay claims and provide services that cover 3,000,000 people takes in excess of $500,000,000 per year. If there are 45,000,000 uninsured people who enroll in the public option, then, it would take $7.5 trillion to pay claims and provides services.

* 45,000,000 uninsured is 15 times more than 3,000,000
* $500,000,000 claims/customer service/advertising/marketing costs per year * 15 = $7.5 trillion
* So $2,000,000,000 can only provide services to 4,000,000 people for a single year. Who covers the other 40,000,000 people?

What do you mean by an "underfunded" public option regarding "competition"? It seems to me that you are saying that ins cos are charging too much (I don't disagree), but then you say that the public option needs more money than that to be "competitive"? I don't get that.

See above for my reasoning on underfunded.

That's the whole reason for dropping the state regulations - let's get more insurers in a territory. I have plenty of car ins cos to choose from.

Talk to your regulator and legislators. Just like any other regulated industry (think electricity, auto insurance, cell phones), the state needs to make a business environment that encourages these business to want to do business in the state.

I suppose they could, but it would probably be like herding cats. Wouldn't this be better done at the national level?
Yes it would. I agree with you absolutely!

-ERD50

-- Rita

 

[ERD50]

My experience with a mid-size not-for-profit insurer is that to pay claims and provide services that cover 3,000,000 people takes in excess of $500,000,000 per year. If there are 45,000,000 uninsured people who enroll in the public option, then, it would take $7.5 trillion to pay claims and provides services.

* 45,000,000 uninsured is 15 times more than 3,000,000
* $500,000,000 claims/customer service/advertising/marketing costs per year * 15 = $7.5 trillion
* So $2,000,000,000 can only provide services to 4,000,000 people for a single year. Who covers the other 40,000,000 people?

-- Rita

Either the math is funny, or your insured group is far outside the average (or both)?

I've read (and provided links along the way, could dig them up if needed), that our HC costs are $2.2T (2.2x10^12), which divided by 300 million population ~ $7300 annual per person average.

Your sample 3M people insured at $500M claims/customer service/advertising/marketing costs per year is only $167 annual per person per year?

15*$500M = 7.5 B( 7.5 x 10^9, not T).

But rather than get lost in the numbers and decimal points, let's just level the playing field. Give a voucher for that $7300 and let them choose govt or private, each has to take any/all offers. Either the govt provides better services for the $7300, or they don't. Let the people choose.

Regardless of how badly private ins cos are or are not running things now, it would be crazy to think they would not want a piece of that $7300 * 300M people.

But if your $2,000,000,000 to cover 45M people is accurate, then yes, it is underfunded, that is only $44/person/year. So it isn't really a plan, is it? When do they come back and say they need more money?

BTW, the latest figures are 30M uninsured - this seemed to have changed after someone assured us that illegal immigrants would not be covered:

Obama changes talking points on uninsured | Politics | Reuters

WASHINGTON (Reuters) - Tucked into President Barack Obama's speech to the U.S. Congress was a new talking point -- that his aim is to get health insurance for 30 million uninsured people, not 46 million.

"There are now more than 30 million American citizens who cannot get coverage," Obama said on Wednesday. Back in August, he had said: "We've got 46-47 million people without health insurance in our country."

Why the change?

White House spokesman Robert Gibbs said Obama was making the point that under his plan, illegal immigrants would not get health insurance.

"The proposal that the president outlined covers American citizens," Gibbs told reporters. "His plan would not cover illegal immigrants."

-ERD50

 

[Martha]

Turns out I was not cynical enough

A First! Wolf Blitzer asks David Axelrod Some Tough Questions | Chicago Daily Observer

Hot Air » Blog Archive » Video: Axelrod not comprehending what “competition” means



IOW - that is NOT what we want to do. Period.

They don't want to help people, they want control (or make 50% of the people dependent on them, which brings control). No cynicism, just appears to be the facts.

-ERD50

There are good reasons not to allow interstate competition unless some drastic changes are made. The problem is that states regulate insurance companies. If you can buy out of state your home state's regulations don't protect you. The worry is that the worst companies win or companies mislead consumers into buying a product that can barely be called insurance and states effectively lose any ability to regulate. All it would take is one state with no regulation. Insurance companies migrate there and sell all their policies from that state. Some states already do next to no regulation of insurance companies. Now I can see this becoming less of a concern if the federal government steps in to fill the regulatory gap.



It is somewhat like state usury laws. They became close to meaningless when a credit card company based in South Dakota was allowed to market cards to people in any state. South Dakota had no or very high interest rate limits and other states' usury limits became meaningless.

 

[ziggy29]

There are good reasons not to allow interstate competition unless some drastic changes are made. The problem is that states regulate insurance companies. If you can buy out of state your home state's regulations don't protect you..... Now I can see this becoming less of a concern if the federal government steps in to fill the regulatory gap.

Well, yeah -- I think that would have to be part of the mix. But that would also be a part of the regulation of interstate commerce, so I see no legal or constitutional issues standing in the way.