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mail order to slow but made to use it made cost higher to use retail
Mr. Getzen, I believe that what you are saying is basically true. I think of health insurance along the same lines of automobile insurance or homeowners insurance. People who live in flood zones pay higher premiums than those who don't. Young males pay higher premiums than other drivers. The reasons for this are along the same line of reasoning as yours. I think that Americans tend to think about health care insurance as different economically than other forms of insurance. I'd pay more if I lived in a flood zone, because losing my home would be disastrous. I think high-risk drivers should be paying higher auto insurance: they are a risk to my life and that of everyone on the road. Of course there are homes that don't get flooded and young males who are excelllent and careful drivers, but insurance is a pool that everyone pays into in the case of needing it. Health insurance is no different: you may be paying for someone else but, one day, someone else may be paying for you.
I agree Jim. I consider my doctor to be very ethical. He told me that B-12 injections help some people, but not most. He gave me one in the office to see if it helped with the problem that I had at that time. It didn't, and he said that there was no reason to continue. He directed me to take B-12 vitamins when I have specific symptoms or every day, depending on how they affect me (they can have a stimulant affect on me). He gave me the in-home option at a later time, but with the same advice: if it doesn't help, don't take it. Similarly, my allergist has me taking a break from allergy shots, since I may not be benefitting from them.
Andea, I find my EOBs confusing in a similar way. For example, my physical therapist bills each service at the same visit separately. When I receive my EOB, it'll list service after service and I wonder what it means. I realized, at some point, that they were all on the same service date. I'd like EOBs to be more reader-friendly so that, in your case or mine, the date shows up and you see everything that was charged for that date. It's okay if the charges are billed separately, but they should all be listed under the same date. You can also see, sometimes, that there'll be every possible item listed, such as the disposal fee for the syringe -- but there'll either be no charge (since it's included in the lab draw) or you wonder why they're charging you $10 to throw away the needle when it should be a part of the blood work. I think one of the issues is that of knowing what services are bundled together when you have a lab or imaging tests, or B-12 or allergy shots. Some services are bundled together; some are a-la-carte. It can be hard for the patient to know if they're being overcharged. If I remember from my last EOB, if I have a doctor's visit with blood work for 4 lab tests, regardless of how many vials or syringes they use, it'll show up on my EOB as five separate charges: the visit and then each lab test individually. If that's how it has to be itemized on an EOB, then I think the insurance companies should teach people how to read them so that their customers can know what they're being billed for and if the charges ar correct. It may not be that you've been overcharged: it's that you'd expect it to be all one thing and it's been broken down. So, the charge might be the same either way but it doesn't look that way.
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I read an article in the news today about a clause in the health care reform act that would allow insurers to charge smokers premiums that are almost double that of the non-smoker. Even for smokers, the cost of the premium can rise according to age. The comments on this article were 'all-or-nothing' for the most part. Is it possible for insurance companies to offer a supplemental policy (like flood insurance on to your homeowner's insurance policy) for health issues that are specifically related to smoking? Would it be possible for insurance companies to charge higher co-pays to patients or pay a lower percentage for services that are related to conditions due to smoking? It doesn't seem right that, in order to have a broken leg treated, your premium be so much higher than that of other people; on the other hand, smoking is a risk, much like living in a flood zone, and the health care costs associated with smoking are a drain on the overall resources available and the rising costs in general. There seems to be some truth to both sides: it doesn't seem right to discriminate against smokers across the board when their premiums ar set; on the other hand, there are direct links between smoking and some serious illnesses -- and it's hard to not hold people responsible to some extent for the consequences of that behavior. How does Blue Cross anticipate handling this issue when it arises next January?
My physician's practice works along the same principle. It is a fairly large practice, and they have an in-house lab. Some of the tests can be done on-site, and some are sent out to labs or the medical center in the city. When I have my visits, if I need lab work, then my doctor orders it and I have it right after the appointment. If I need fasting work for an annual exam, he puts in an order for the lab work, I got to the office fasting, have the blood work drawn, and then have the exam. If there is something abnormal, then I have a follow-up exam. I rarely go to the lab outside of a physician visit. That has happened only when I needed follow-up lab work for an abnormal result. I think that, for people who live in areas where either the PCMH or a physician practive that has well-organized services is available, this is the best way to go. One of my concerns is for people in rural areas or small towns. My parents go to the small medical center in town for their lab work. Typically, they have to go see their doctor; then they have to go to the medical center, register for lab work and have it done. Then they have to wait for the lab results to get to the doctor's office. Then they have to wait for the doctor's office to call them with the results and to find out if they need a follow-up. Most people in their town assume that if they don't hear back, then there's likely nothing wrong (no news is good news). However, that's not always true and patients are entitled to the results of their lab and imaging exams even if it's all normal. My parents are retired, and it's a good thing: they spend a lot of their time chasing down lab results, trying to find out if they need a follow-up visit, and then actually getting the appointment if they do need one. Are there plans to bring the kind of PCMH set-up to rural areas that need more structured and timely services?
If you believe that you have been given mistaken charges because of a coding error, you can contact your doctor's office or the provider (hospital, clinic) and ask to see the code that they have used and what it means. There are a few ways that thing can go wrong: the coder/biller might have assigned the wrong code; a diagnosis may be ambigous, hard to code, or have two possible codes depending on what it is supposed to mean (for example, 'elevated glucose,' one of my old favorites); the doctor may have written down a diagnosis that doesn't match the exam or test properly; or the doctor has given a diagnosis that doesn't support the test in terms of what is considered 'medical necessity.' For example, if you take a medicine for depression that can cause abnormal kidney functions and your doctor writes only 'depression' on your lab slip, then that may be rejected, simply because depression doesn't fall under the codes for kidney function tests. There is an additional code that is needed, which is a code called 'long-term use of high-risk medications.' When that code is added, tests are typically covered. That's because it's the medication use, not the condition, that is a risk and requires the lab work. With respect to routine exams with labs and preventative exams with labs, if the doctor doesn't explicitly state the nature of the exam, then the coder cannot change that. By law, coders must code what the doctor has written as the reason for visit. It gets complicated, because a person with diabetes may be going for their preventative or yearly exam, but the lab work should have a diagnosis of diabetes rather than a screening. Many physicians try to keep up with using the proper codes, but their main concern is to provide care. The problem you mention is hard to resolve quickly because a coder cannot ask the doctor for a diagnosis that will pay the bill. That's fraud. The coder/biller must go back to the doctor and ask for clarification. I worked as a coder in a small medical center, that had an inpatient hospital, a nursing home, as well as clinics, a physical therapy unit, and other outpatient services. It's a hard job to do. Many patients don't understand what codes are and how they relate to the bill. I'm glad that you do. If a bill/EOB appears incorrect you can first look to see if it was coded properly and if the doctor gave the coders/billers the right diagnosis for the visit and the lab work. If so, and it's been rejected, then that's because your insurance company doesn't consider your diagnosis to be a reason for having the test. In that case, though, you can file an appeal with your insurance company, stating why you needed the test. You can ask your doctor for his/her progress note to support your appeal. I hope that I've been of some help to you. I explained in detail some of the issues, because coding/billing are technical and complicated work. Everyone can do things pretty much right and yet the bill doesn't come out as it should for the patient. However, often the issue can be fixed. It's a matter of locating where the process went askew, which takes time.
Eddy, look up the word "monopoly" and you'll find out how your hospital and many other hospitals are able to charge whatever they want.