For all of you that stopped here in hopes of a horror story about private insurance just keep looking this is not that story.
My condition (fibrous dysplasia FD) was first discovered by the Veterans Administration (VA) in 1993. Interestingly enough once I turned 21 my records were conveniently lost. The VA would forever be responsible for my care if the records existed. I did not see another doctor again until 2005 due to my dislike of the procedures the VA offered. These details can be found in other posts.
By the time I went back to a doctor I was insured on my wife's private insurance. In the past three years I have visited multiple specialists and have received many perscriptions and in all this time I have only had three refusals of payment from the insurance company. Two of these were for perscriptions and the insurance company recommended a different brand of the same drug that they would cover. The recommended drugs were the exact same as the one my doctor had ordered but they were not as expensive.
The only other time I had a refusal it was easily fixed. The issue occurred when I applied for Social Security benefits (which were denied because I spent too much time trying to work instead of just applying and not trying to make it on my own for years). The Social Security Administration denied my claims but generated paperwork that made it appear to my doctors and then the insurance company that I had another primary insurance. This meant that my insurance began to refuse claims because they were no longer listed as the primary insurer. This fix was as simple as cutting butter with a hot knife; I called the insurance company and described the problem. The customer service rep looked up my information and confirmed the issue. She then asked me to hold for about five minutes. When she returned to the line she informed me she had fixed the data in their system and resubmitted the claims. Problem FIXED.
When it has come to specialists I have never received a refusal. As long as I assure the specialist is in network my costs have remained low and I have always been able to find a highly qualified specialist.
A little over a year ago I had a major surgery and the insurance company approved the surgery and paid for everything. Now I know my wife did call the insurance company and do the pre-certification herself. She tells me this is because even though the doctor and the hospital are in network the anesthesiologist and other medical staff may not be participating in the plan. She always calls on the per-cert herself and does not leave it to the surgeon because when she calls the insurance company walks her through everything and then she knows what is covered and what is not covered. In our case the surgical assistant's full price would not be covered but he was willing to take the insurance negotiated amount so he could work with the surgeon. As noted in the past these little steps of directly working with the insurance company have always allowed us to get the services we need while keeping costs low.
On the other side of the issue I know multiple people that have struggled through care at the VA. I know consultants that have been hired to work with the VA to improve care. In one case I know of a VA project that has VA staff and the staff of two consulting firms working on outsourcing veterans care to private hospitals so that the veterans receive better care. I know of people that finally paid for their own surgeries because the VA refused to allow surgery even though their doctor recommended the surgery. I know of one man that had to fly from CA to CO to get a routine preventative test because the CA hospitals could not get him as soon as the VA insurance demanded he receive the test or lose benefits. I know of multiple people that have had to have scans and services done multiple times because their files have been lost.
My personal experiences make me unwilling to place my private insurer on the gallows so if you want to hear a story about private insurance abuses I am not the man to ask.
Showing posts with label private insurance. Show all posts
Showing posts with label private insurance. Show all posts
March 11, 2010
March 2, 2010
Update on Sean's Pain Management Fight
I just returned from the pain management clinic. What an experience! I had to take a drug test and learned that there is a database (PDMT) kept by the state that my name is on due to being on pain meds. I have to say I was horrified to find that the state is tracking my prescription use. While I understand there being a drug culture what gives them the right to track this with out my knowledge?
This doctors "office" was crazy. The office was dirty and in no way felt like a medical facility. It was located in a warehouse and felt like one. There was no lobby and chairs had to be fetched from other rooms for waiting patients. The exam room was actually an acupuncture room that had once been an x-ray room. There was a fight (yelling) between one patient and the doctor and people walked out of their appointments. The staff was unfamiliar with this "satellite" office and needed our assistance to give driving directions to other patients.
Moving on to the consultation. Once again I am faced with the choice of being a guinea pig for new drugs and therapies instead of being allowed to just continue the therapy that my general practitioner and I have found to work. The doctor seemed competent but actually stated she did not care about what I had tried in the past she was just looking to start over with the process. She was more than happy to prescribe opiates but wanted to take me through all the trial and error I have already done. However her willingness to send info to my GP is reassuring as I will continue to consult him through all therapies. The next steps for this clinic is for my drug test to come back from the lab and for the PDMT report to return clean. Then they will determine if I can be accepted into the program.
Overall I was very uncomfortable with this whole visit and on Friday I am going to another pain management clinic to discuss alternative medications.
February 27, 2010
How We Manage Health Care Costs & Quality of Care
This is the story of how we have worked with our doctor to manage the costs and quality of care for Sean's rare condition and our families medical care.
To control our costs we utilize a few simple but effective practices:
I realize at this time it is popular to hate private insurance companies but we can not engage in that activity. During the five years that we have had private insurance we have received much more than we have given. When we have worked with the insurance company we have always been able to find a common ground that allows us a great quality of care while allowing them to control costs. We view this as a civic duty to assure that our friends, neighbors, and fellow countrymen do not have to pick up costs we could avoid.
Our experience with private insurance stands in great contrast to Sean's previous experience with the military and our private insurance has provided many options and speed of care that we do not see with our family members that have VA, or Medicare.
Sincerely,
Yvette
To control our costs we utilize a few simple but effective practices:
- We make sure our general practitioner (GP) has records from all other doctors and that we never have a test or receive new medicine without our GP's knowledge. This not only controls costs but keeps us from endangering a life by having conflicting prescriptions.
- We take our insurance Rx formulary (a list of prescriptions covered by our insurance) with us to all appointments and check to make sure any perscriptions given are on the formulary. If they are not listed we find a comparable Rx that is on formulary. Note: we have always been able to find a comparable Rx that is on the formulary or have been able to work with the insurance company to get the Rx approved.
- We retain copies of all tests, x-rays, scans, and doctor files. We take these with us to any new doctor so that scans etc. do not need to be repeated.
- Two people attend every appointment. This assures we hear and understand everything and that the doctor receives the full picture of our sickness from our and our family's point of view.
- We ask questions and understand our conditions and the treatments available as well as the risks and benefits of every treatment.
I realize at this time it is popular to hate private insurance companies but we can not engage in that activity. During the five years that we have had private insurance we have received much more than we have given. When we have worked with the insurance company we have always been able to find a common ground that allows us a great quality of care while allowing them to control costs. We view this as a civic duty to assure that our friends, neighbors, and fellow countrymen do not have to pick up costs we could avoid.
Our experience with private insurance stands in great contrast to Sean's previous experience with the military and our private insurance has provided many options and speed of care that we do not see with our family members that have VA, or Medicare.
Sincerely,
Yvette
How Government Health Care Regulations/Practices are Ruining my Quality of Life
My name is Sean Cowlishaw and I have a rare condition (fibrous dysplasia of the skull). In short my skull has never quit growing and bone is surrounding my optic nerves, has filled my sinus cavities, and is putting pressure on my brain. My condition is extremely rare in that the bone growth did not end in puberty and the bone continues to grow to this day (I am in my thirties).
About three years ago I finally found a doctor that not only helped me find answers but that works closely with me and my family to assure us a high quality of life. I have also been blessed in that I have had good insurance (for the past five years) and a wife that understands the health care system. My wife and I have worked closely with our doctor to keep costs down for both us and the insurance company and to maintain a high quality of care (see my blog entry about cost containment).
As the Health Care Reform debate heated up in 2009 my quality of life was significantly lowered. The first blow was that my costs for specialists were raised due to the media and Congressional blitz about high quality insurance plans. At first this was not a huge issue for me as I have seen ever specialist possible and there is nothing they can do for my condition. The specialists had sent me back to my general practitioner for pain management and for almost a year my quality of life was the best it had been for a long time. I had one doctor managing my care and he took all aspects of my quality of life into consideration as well as doctoring my full person not just my fibrous dysplasia.
In February of 2010 the second and worst blow fell. I was called into my general practitioner's office and told he was no longer allowed to practice pain management. The clinic management has determined that because of the DEA practices of treating pain management doctors as drug dealers it was too big of a risk for their doctors to prescribe pain medicines. The clinic was only able to give us the names of two practices that are still willing to prescribe pain meds. One option will cost us and our insurance three time as much as our general practitioner. The other option costs over $1000 more a visit and is not covered by insurance. We have our first visit with the new doctor on Tuesday and will update this blog continuously.
About three years ago I finally found a doctor that not only helped me find answers but that works closely with me and my family to assure us a high quality of life. I have also been blessed in that I have had good insurance (for the past five years) and a wife that understands the health care system. My wife and I have worked closely with our doctor to keep costs down for both us and the insurance company and to maintain a high quality of care (see my blog entry about cost containment).
As the Health Care Reform debate heated up in 2009 my quality of life was significantly lowered. The first blow was that my costs for specialists were raised due to the media and Congressional blitz about high quality insurance plans. At first this was not a huge issue for me as I have seen ever specialist possible and there is nothing they can do for my condition. The specialists had sent me back to my general practitioner for pain management and for almost a year my quality of life was the best it had been for a long time. I had one doctor managing my care and he took all aspects of my quality of life into consideration as well as doctoring my full person not just my fibrous dysplasia.
In February of 2010 the second and worst blow fell. I was called into my general practitioner's office and told he was no longer allowed to practice pain management. The clinic management has determined that because of the DEA practices of treating pain management doctors as drug dealers it was too big of a risk for their doctors to prescribe pain medicines. The clinic was only able to give us the names of two practices that are still willing to prescribe pain meds. One option will cost us and our insurance three time as much as our general practitioner. The other option costs over $1000 more a visit and is not covered by insurance. We have our first visit with the new doctor on Tuesday and will update this blog continuously.
August 22, 2009
Health Care Administrative Costs
Earlier this year (2009) the Commonwelth Fund Commission issued multiple reports asserting a goverment-run health care plan could cut insurance premiums approximatly 20%. It asserts that private insurance spends 40% of claims costs on administrative expenses. The Sherlock Company was commissioned to do a study of private insurance costs in 2009 (the study most frequently quoted in the debate today dates from 1988).
The full report can be found at http://tinyurl.com/kjo9hq
I. Executive Summary
Health plan administrative expenses often are cited as consuming a significant share of health insurance premiums. Proponents of a public health insurance plan often state that Medicare is more efficient than private insurance companies. However, these statements are based on outdated data and misconceptions about private administrative expenses, especially in the small group and individual markets.
Recent reports claim that health plan administrative expenses in the individual and small employer markets can exceed 30%. However, these estimates are based on data from Hay-Huggins that is more than 20 years old (1988) — a time when most claims were paper-based and many electronic processes were in their infancy — and based on estimated, rather than actual, administrative costs for companies that no longer provide health insurance.
An independent analysis by Sherlock Company of health plan administrative costs finds that prior estimates do not reflect the actual administrative costs for Blue Cross and Blue Shield Plans and other major health plans. Based on our review of actual health plan administrative expenses, we find that:
• Private health plan administrative expenses are grossly overstated in previous reports.
Based on combined data from 36 health plans participating in our performance benchmarking studies in 2008 (2007 data) and other data, administrative expenses for all commercial products represented 9.18% of premiums. Administrative costs are 11.12% of premiums for the small group market and 16.35% of the individual market, amounts that are nearly one-half and in some cases nearly one-third of other estimates.
• Traditional Medicare performs only a fraction of the administrative functions of private health plans because it retains its original fee-for-service design and is, therefore, not comparable.
Private plans use their administrative costs to promote care coordination and wellness, reduce unnecessary utilization and aggressively combat fraud and abuse. No precise, generally accepted measure of Medicare administrative expenses exists that is comparable to private plans. Moreover, Medicare does not need to market its coverage, develop provider networks, negotiate provider rates or maintain capital. If the government were to create a public health option to compete with private plans in a health insurance exchange, it would have to take on many additional functions that are not part of Medicare’s administrative costs today, resulting in increased administrative costs.
• Private plans perform those administrative functions that Medicare performs at lower costs.
In comparing only those administrative functions that Medicare performs, private administrative costs are actually lower — $12.51 per member per month, compared to a $13.19 per member per month in traditional Medicare. Many of Medicare’s administrative functions are, in fact, performed by private administrative contractors.
• Comparing administrative expenses between Medicare beneficiaries and people under age 65 should consider the unique healthcare needs of seniors.
Medicare beneficiaries have higher costs per claim compared to private plan enrollees. This means that the service requirements are less per dollar of health benefit, and administrative expenses are less for Medicare simply by virtue of the higher cost per claim.
• Comparing administrative costs as a percentage of claims overstates the difference
between plans for small groups or individuals and large groups.
Instead of calculating administrative expenses as a percentage of premiums, which is the most conventional metric used for comparing administrative costs, Hay-Huggins and subsequent reports have expressed the values as a percentage of claims, which is very misleading. Because health insurance premiums pay for both health claim costs and administrative expenses, the Hay-Huggins approach, repeated by Lewin, of dividing administrative expenses by claims costs unrealistically magnifies the differences between administrative expense ratios.
The full report can be found at http://tinyurl.com/kjo9hq
I. Executive Summary
Health plan administrative expenses often are cited as consuming a significant share of health insurance premiums. Proponents of a public health insurance plan often state that Medicare is more efficient than private insurance companies. However, these statements are based on outdated data and misconceptions about private administrative expenses, especially in the small group and individual markets.
Recent reports claim that health plan administrative expenses in the individual and small employer markets can exceed 30%. However, these estimates are based on data from Hay-Huggins that is more than 20 years old (1988) — a time when most claims were paper-based and many electronic processes were in their infancy — and based on estimated, rather than actual, administrative costs for companies that no longer provide health insurance.
An independent analysis by Sherlock Company of health plan administrative costs finds that prior estimates do not reflect the actual administrative costs for Blue Cross and Blue Shield Plans and other major health plans. Based on our review of actual health plan administrative expenses, we find that:
• Private health plan administrative expenses are grossly overstated in previous reports.
Based on combined data from 36 health plans participating in our performance benchmarking studies in 2008 (2007 data) and other data, administrative expenses for all commercial products represented 9.18% of premiums. Administrative costs are 11.12% of premiums for the small group market and 16.35% of the individual market, amounts that are nearly one-half and in some cases nearly one-third of other estimates.
• Traditional Medicare performs only a fraction of the administrative functions of private health plans because it retains its original fee-for-service design and is, therefore, not comparable.
Private plans use their administrative costs to promote care coordination and wellness, reduce unnecessary utilization and aggressively combat fraud and abuse. No precise, generally accepted measure of Medicare administrative expenses exists that is comparable to private plans. Moreover, Medicare does not need to market its coverage, develop provider networks, negotiate provider rates or maintain capital. If the government were to create a public health option to compete with private plans in a health insurance exchange, it would have to take on many additional functions that are not part of Medicare’s administrative costs today, resulting in increased administrative costs.
• Private plans perform those administrative functions that Medicare performs at lower costs.
In comparing only those administrative functions that Medicare performs, private administrative costs are actually lower — $12.51 per member per month, compared to a $13.19 per member per month in traditional Medicare. Many of Medicare’s administrative functions are, in fact, performed by private administrative contractors.
• Comparing administrative expenses between Medicare beneficiaries and people under age 65 should consider the unique healthcare needs of seniors.
Medicare beneficiaries have higher costs per claim compared to private plan enrollees. This means that the service requirements are less per dollar of health benefit, and administrative expenses are less for Medicare simply by virtue of the higher cost per claim.
• Comparing administrative costs as a percentage of claims overstates the difference
between plans for small groups or individuals and large groups.
Instead of calculating administrative expenses as a percentage of premiums, which is the most conventional metric used for comparing administrative costs, Hay-Huggins and subsequent reports have expressed the values as a percentage of claims, which is very misleading. Because health insurance premiums pay for both health claim costs and administrative expenses, the Hay-Huggins approach, repeated by Lewin, of dividing administrative expenses by claims costs unrealistically magnifies the differences between administrative expense ratios.
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