Tips or Links on Avoiding Health Insurance Pitfalls

[KimC]

Hi, everyone. I hope you had a fun Fourth!

I imagine that many people in VR.com have faced the daunting, tedious task of researching how to avoid health insurance pitfalls, or the best possible options for continued coverage of heart-related conditions.

For those of you who've been there, I welcome your tips, HTML links or stories on navigating through our amazingly complex and inhumane health insurance system. (I read Gnusgal's painful situation in "Small Talk," ugh!!! I am so sorry!!!)

I'm also interested in hearing from anyone who has been diagnosed with ventricle dysfunction. Is this a pre-existing condition that you've found potential employers won't cover?

As a side note, today my husband has said that maybe we shouldn't be pressing for a firm cause/diagnosis of my heart failure given the potential financial impact. (Isn't that romantic). I responded in an R-rated fashion.

Has anyone found "rueful" ways of doing what's best for your health, but not announcing to your insurer that you may become increasingly dependent on their support?

Please help if you can. Let's try to make this thread a valuable one for our community.

Best,

 

[Joel]

Hipaa

Hipaa

I'm not sure if you are posting from the United States, but if you are the HIPAA (Health Insurance Portability and Accountability Act of 1996) means that pre-existing conditions are not the problem they used to be.

Also if your insurance is provided by your employer COBRA of 1986 would protect you in case of job termination (Assuming you can afford to pay the premiums.)

Then of course there is the FMLA (Family and Medical Leave Act of 1993). Which ensures job protection while out on medical leave.

These three pieces of legislation have taken the circumstances we are facing and prevented them from becoming financial and family disasters for many of us. That being said, there are exclusions and limitations - read the fine print; your mileage may vary.

Even with all of that, I was reluctant to tell my employer about my condition until I had a date set for surgery. My employer is self-insured meaning that they pay out of their pocket the cost of my surgery. There is a conflict of interest in them keeping me on board, when I will cost them so much. HIPAA prevents discrimination in this case, but I was still concerned. So far they have been very supportive and with the law on my side I assume they will continue.

I haven't had the surgery yet, but when I do I will know more about how my Short Term Disability insurance provider behaves.

Joel

 

[gadgetman]

Unfortunately, no matter how well you think you have prepared for the "insurance issues" they will continue to surprise you. We contacted both my wife's insurance and my Tricare (military insurance) in advance to make sure everyone was ready to do their part. My wife just spent the better part of a day on the phone with her company getting them straight on a $4,000 bill we just received from the Hospital. The insurance company's response was "OOOPS, just have them re-submit". Of course, the two insurances played on each other. Tricare refused to pay "their" part because her insurance didn't pay "their" part. Now Tricare will not take care of "their" part until her insurance pays "their" part. Do you see a circle starting?

We also asked IN ADVANCE about the Cardio Rehab. Both said they would cover the 36 days. However, after they started getting the bills her insurance said this is not covered in my case but Tricare has stepped forward and said they will pay 100 per cent. I bet I'll be getting bills for another year.

Good luck on your quest and,

May God Bless,

Danny

 

[Big-Chuck]

Insurance issues

Insurance issues

I would be flipping out right now if my surgerical costs hadn't been picked up by Uncle Sam. For once in my life I feel lucky and grateful.

 

[Guest]

I imagine that many people in VR.com have faced the daunting, tedious task of researching how to avoid health insurance pitfalls, or the best possible options for continued coverage of heart-related conditions.

Am doing this right now, actually...heh.

Let's just say I'll be watching this thread closely, too. I admit I'm beginning to feel some of the "why me?" syndrome when it comes to feeling like everything is against me. It's a free country, but not so much (it seems) for those of us who have health issues. The "red tape" (and other issues) we have to deal with sometimes I tougher than our actual ailment.

*sighs*

Kim ... thanks so much for starting this thread.


Cort, "Mr MC" / "Mr Road Trip", 31swm/pig valve/pacemaker
'72,6,9/'81,7.hobbies.chdQB = http://www.chevyasylum.com/cort/
MC Guide = http://www.chevyasylum.com/mcspotter/main.html
"I'm not the only person with these things in mind" ... Linkin Park ... 'Somewhere I Belong'

 

[afraidofsurgery]

Pre-existing conditions

Pre-existing conditions

I have worked for several small (<50 employees) companies whose group plans have pre-existing exclusion clauses UNLESS you can show continuous medical insurance coverage for the last 6 months. Early this year was in-between jobs. So I had no choice but to find a way to pay for COBRA insurance, even though it cost me $735/mo for me and my daughter's coverage and I was unemployed (and I'm a single mom BTW). I now (after 3 mos) have medical insurance through my provider but a pre-existing condition clause is in place until I get my certificate of coverage from my COBRA coverage, who would not issue one until my insurance was cancelled. So hopefully I can resolve this soon since cardio is starting to talk about surgery

Also I have applied for individual coverage through BlueCross Blue Sheild of Illinois and was turned down due to my aortic valve insufficiency.

What I've learned is: 1) I need to stay employed full time or enough time to have medical insurance through my employer. 2) I need to maintain medical insurance coverage at all times since any gap in coverage may result in non-coverage of heart-related medical expenses. 3) Forget about being an entrepeneur or independent contractor, I'd never be able to find insurance to cover me. The last point was the toughest for me.

Hope this helps!
Patty

 

[Guest]

...Forget about being an entrepeneur or independent contractor, I'd never be able to find insurance to cover me. The last point was the toughest for me.

Arg. Not what I wanted to read...lol.

Thanks for your post, Patty ... sure puts some more things into perspective ... and reality....

 

[windsurfer]

lack of freedom

lack of freedom

Though we all enjoy great freedoms in this country few realize that we are not free to live where you may want to if you are an entrepreneur because of the potentially devastating costs of medical care. This discrimination is reprehensible. I didn't realize that until it was too late. I now envy those in Europe who can freely move around and relocate.

I've been covered by medical insurance continuously without even a month's gap since college days yet I am uninsurable (cannot be underwritten therefore pay huge premiums for very limited coverage) because I am self employed and have relocated several times during my life. Sooner or later medical conditions come along and you cannot relocate after that. Even if you pick large insurance carriers with coverages in many states, you will be cut off if you relocate since each region is considered a separate company from a coverage point of view though not separate to the owners of the multistate carriers who benefit financially across regions. Thus they exploit those living the American dream of freedom to live where you want.

Until the laws are changed, either don't be self employed or don't relocate - policies that I view as very un-American with its traditions of freedoms.

Bobco

 

[afraidofsurgery]

Un-American or just practical?

Un-American or just practical?

Yeah, but ther are many many drawbacks to living in other countries that have socialized medicine - like the hospitals are nowhere near the caliber we have here, you have to wait in line for non-emergency surgeries, if you're old, you might not even have your heart surgery approved, higher taxes, etc. I've worked with people from the UK and Poland, and these drawbacks are very real. People from other countries fly here to use our doctors and hospitals because they're not run by our government, and they come here to be educated in our medical schools because they're the best in the world. Even given the drawbacks I'd stay right here.

That said, I recently saw a TV show about US citizens who fly to India for major surgeries since the price is right. It actually made a lot of sense!

I agree, I'm a slave to insurance and there is a very real chance I will deal with the same high cost problems you face. There really is no in-between here

Patty

 

[Guest]

Until the laws are changed, either don't be self employed or don't relocate - policies that I view as very un-American with its traditions of freedoms.

*raises eyebrow slightly*

Don't relocate? Aye ... I didn't even think relocating would be a problem.

So, basically, even if I was on COBRA for a bit before I moved to TN, an insurance company via an employer down there could STILL not accept pre-existing conditions, despite HIPPA?

*shakes head*

I think I'm going to cry now.

 

[baldstuart]

It's all a scam!!!!!!!!

It's all a scam!!!!!!!!

My husband was scheduled to have OHS on June 27th at the only hospital that our surgeon performs surgery at. Mind you the Doctor is 100% in our insurance network. We went into the hospital on the previous Friday for all the lab work and so on. Half way thru the tests some bean counter from downstairs comes up to tell us that they won't accept our insurance but if we would like to give them a deposit of $36,000 they would work out the rest with our insurance.What a blow!!! after going thru all the emotional crap that comes with accepting the fact that this surgery HAS to be done we have this laid in our laps! Now we have had no choice but to go to the ONLY hospital that will accept our insurance and we have had to find a new doctor.He now has surgery scheduled for the 20th of July at a hospital we really didn't want and with a doctor we don't really know. ( but this doctor does come highly recommened) We pay our huge premiums every month without fail and we talked to the hospital at lentgh before the surgery date. We were told Blue cross and Blue shield,No Problem!. Well I guess it was. So what can you do?

 

[Perrybucsdad]

Bald - did you find out whether the hospital was in network? Even if it's out of network, they can't ask for a "deposit." That's usurious. I would call that bean counter's boss or the main hospital administrator and raise cain with them.

I would also talk to the doc about the hospital being out of network. He should have known this from the outset and let you know.

It's all about accountability and being proactive with your healthcare. Unfortunately, we live in this type of world now and you have to check, check again, recheck and recheck again to make sure everything is covered and where it should be.

Good luck.

Pam, I'm not 100% certain, but I think they can ask for payment upfront. I know some docs who do liposuction and facelifts can do that because insurance will not cover it. Not sure what the law is, but I think that is allowed.

John

 

[baldstuart]

We were told one week prior to the deposit issue that the Hospital was not in network but because our doctor only preforms surgery there and his office is in the hospital they could work it out with Blue Cross. They do it all the time, but not this time. I guess the almighty dollar is more important than a human life. We did go to the Hospital Adiministrator as did our Doctor, it all fell on deaf ears. Again it was all about the money, something about the average surgery of this type costs $72,000 and if our insurance only agrees to pay 50% we are on the hook for the other half and would you like to sign up for low interest financing or just write a check for $36,000. This AVR was not considered an emergency therefore we could go elsewhere and the only Hospital that is in network is 35 miles away so we did not qualify for the Hospital 50 miles away rule that will pay 100% to an out of network hospital.The hospital played the insurance out to be the bad guy but when we contacted our insurance they felt that the hospital was being unreasonable in wanting them to guarantee an exact amount without seeing the actual bill.Blue Cross said they do this all the time and out of network Hospitals almost always accept whatever Blue Cross pays as payment in full when approached with this type of predicament. It gets old fighting with these people so thats why we decided to go to another Hospital and Doctor. My husband is really very sick and doesn't need the stress. We have come to terms with it. It is just sad and isn't it strange that the "NOT FOR PROFIT" HOSPITALS are so concerned about their profit?????????
Patti (wife of BaldStuart)

 

[Guest]

I think it's getting a little confusing....

*raises eyebrow*

A little? Just a little?

Cort - if you have your Sears insurance, which you said ends mid-July, but the new company's insurance doesn't kick in for about a month or so, and during that month or so, you have COBRA, you will have "seamless" coverage and no pre-existing issues will be a problem. The idea is the "seamless" coverage. Always keep coverage! That's where people run into pre-existing issues - because of a layoff, firing, self-employed, etc., etc., etc. It's really sad that the system works this way, but unfortunately it does.

I understand this....no problem here.

Course, if you're relocating, it sounds as if companies can get around HIPPA anyway .

And an insurance company cannot, by law, withhold any information THAT YOU, as the insured, request. If you request a certificate of coverage, they can't put any restrictions on when you receive it, especially with COBRA. I would call and raise holy hell with them. If it's CobraServ, it's a big corporation, but you can usually get someone that's reasonably helpful. I would talk to the Cobra servicer, tell them that you will be taking the Cobra coverage from X to X and then your new insurance will kick in and ask that, as soon as the second X date comes due, that they automatically send you a certificate of coverage, or if possible, do it beforehand.

I think I understand what you're saying...lol. Unfortunately, you have to pay for, iirc, 3 months of COBRA to get covered. Which irks me ... because I won't need it that long. Aye.

Cort - the other thing...start the Cobra paperwork NOW!!!! Don't wait until the Sears coverage is over - talk to the benefits people at Sears and make sure that you have all of the paperwork and get it into the Cobra servicer or whoever it needs to go to (each plan works a little differently) before your Sears coverage ends. The Cobra app specifically will ask when the coverage will start - make sure the paperwork is in and ready to go by that date!!!!

Alrighty. I'll get started on the paperwork early Monday morning. The # we have to call is the main Sears 800# which was always a pain to get anywhere on ... so, I'm not at all looking forward to making that darn call...lol.

*sighs*

I don't know how much longer I can deal with all of this crap.

 

[geebee]

Patti,

Just try and consider that maybe the second choice hospital will be the one with the best care for your husband. Somehow I would think that a hospital that is so cold as to do this to you might be just as cold with their care. You want a hospital that cares more for their patients than they do for money.

Although I realize hospitals must make money in the world we live in, this is just unacceptable practice. I would not want to subsidize such places.

Best wishes to you and your husband.

 

[baldstuart]

Patti,

Just try and consider that maybe the second choice hospital will be the one with the best care for your husband. Somehow I would think that a hospital that is so cold as to do this to you might be just as cold with their care. You want a hospital that cares more for their patients than they do for money.

Although I realize hospitals must make money in the world we live in, this is just unacceptable practice. I would not want to subsidize such places.

Best wishes to you and your husband.

Thank You. I would like to feel we were guided to this new hospital for reasons we don't yet understand, but haven't received any warm fuzzy's yet. Patti

 

[windsurfer]

must relocate first

must relocate first

My insurance said I must relocate first before they will let me know if my recently discovered aortic stenosis will prevent me from being underwritten. I had been living in Hawaii because of the great windsurfing but felt I would have better surgery options if I relocated to the mainland. If I had stayed on the islands, I would have been underwritten and fully covered at reasonable premiums. By making me move first before telling me that I cannot be covered they got rid of an "unprofitable" customer. They argued that such information about who is insurable is only available for applicants and that qualified applicants must live in that region before they can apply. That is how the large multi-state insurance companies can clean out their higher risk customers even if they have been paying premiums their entire adult life. I subsequently found out that aortic stenosis automatically excludes one from underwriting.

Bobco

 

[Jingbing]

My insurance said I must relocate first before they will let me know if my recently discovered aortic stenosis will prevent me from being underwritten. I had been living in Hawaii because of the great windsurfing but felt I would have better surgery options if I relocated to the mainland. If I had stayed on the islands, I would have been underwritten and fully covered at reasonable premiums. By making me move first before telling me that I cannot be covered they got rid of an "unprofitable" customer. They argued that such information about who is insurable is only available for applicants and that qualified applicants must live in that region before they can apply. That is how the large multi-state insurance companies can clean out their higher risk customers even if they have been paying premiums their entire adult life. I subsequently found out that aortic stenosis automatically excludes one from underwriting.

Bobco

Thanks for starting this thread. I have a question on the medical bill and appreciate any inputs. As you know, the hospital and the physicians bill seperately and you will not know who (in-network and out-net work) will visit you during the hospital stays. I recentlt received a check from my insurance company and tell me that the previder is a out-network and I should be pay more co-pay (30%) of the approved cost. This is not a problem since there is a stop-loss ceiling for the co-insurance. However, the approved cost is much less than the total charge and the statement of the insurance company reads that I may need to pay the difference between the charged and the approved. So, I need to pay for the total charge minus the 70% of approved amount --- which is the check that insurance sendt to me. For example, a clinic charge $4000 for a CT test and insurance company pays about $700 and the $3300 is claimed as 'charge greater than the service'. But if the clinic is not in-network, the paitient should pay the $3300 +30%*$700?

This does not seem to be 'insurancd'. Any advice?

Jingbing

 

[baldstuart]

You are only responsible for the allowed amount, so if your service is $4,000 and the allowed amount is $1,000, the insurance will pay $700 (70%) and you are responsible for $300 (30%) and the difference of $3,000 should be written off, Sometimes if they are out of network you will have to contact the billing dept and work it out.

 

[Jingbing]

You are only responsible for the allowed amount, so if your service is $4,000 and the allowed amount is $1,000, the insurance will pay $700 (70%) and you are responsible for $300 (30%) and the difference of $3,000 should be written off, Sometimes if they are out of network you will have to contact the billing dept and work it out.

Thank you for your inputs. Sometimes, I am wondering if this is the reason for a doctor not to contract to the in-network. You have to talk to wirte it off otherwise, he/she would chage more?