Doctors/Insurance Companies

[Kori Ellis]

Back in April, I had to have some tests run and the total at the doctor that day was $370. They told me I hadn't met my deductible, so I needed to pay $230 on the spot - so I did.

I never pay much attention to the "Explanation of Benefits" that come in the mail from the insurance company (yeah, I know - not smart). So I was looking at it today and the doctors office billed my insurance for that $230 I pay them .. and they got paid on it -- $180. :flipoff Of course they never contacted me to say they owed me the money. So I call right now .. and they got flustered and then told me they'd call me back.

When the billing manager called back she was like .. uh .. yeah, sorry it was posted in the wrong column. :lol

So anyway, they are mailing me a check.

[SpursWoman]

Nice catch! :elephant


I'll definitely need to pay more attention to things like that....and now that I think about it, I reallly want to go back and check my dental statements.... :lol

[SWC Bonfire]

I am convinced that insurance companies are more crooked than a dog's hind leg. You don't make any money by paying out benefits.

[Summers]

I make it a habit to always call and ask questions about medical bills. I used to work in a hospital and they make so many mistakes--it's just human error because every insurance company is different, etc. Anyway, good job finding the mistake... treat yourself to something nice! :)

Edited to add that I once got a nice surprise like that, too! When I was pregnant, I was making monthly payments to my gyno. After I had my baby, the receptionist said the insurance covered almost everything and I got over $400 back. That buys a lot of diapers! :lol

[Kori Ellis]

I am convinced that insurance companies are more crooked than a dog's hind leg. You don't make any money by paying out benefits.

Yeah most insurance companies are crooked, but in this case .. my doctor was stealing from me, not my insurance company :lol

[MannyIsGod]

Also keep in mind when your deductible starts. Does it start Jan 1 of each year or on your enrollment date? They could try to screw you on shit like that.

[T Park]

I am convinced that insurance companies are more crooked than a dog's hind leg. You don't make any money by paying out benefits

They lose thousands everyday cause of frivelous lawsuits.

So think that might be part of the reason they dont pay out all the time.

[Johnny_Blaze_47]

I need to actually get some health insurance.

Anybody have any good companies a 24-year-old (25 in two weeks), non-smoking, single w/ no kids male should look at?

[Kori Ellis]

I need to actually get some health insurance.

Anybody have any good companies a 24-year-old (25 in two weeks), non-smoking, single w/ no kids male should look at?

We have Unicare and it's actually good insurance. They have a variety of different types of plans depending on what you need.

[Johnny_Blaze_47]

We have Unicare and it's actually good insurance. They have a variety of different types of plans depending on what you need.

Thanks.

I'm just waiting for my loan check to come in late next month (or Sept) so that I can start. The school offers one, too, but I don't know how good it is.

[T Park]

Mutual of Omaha aint too shabby.

[Clandestino]

that's why i just hit the VA... anytime, something is wrong, i get a bill in the mail later for $15!

[MannyIsGod]

Unicare, Humana, and BCBS are going to be your best bets.

[SequSpur]

Unicare, Humana, and BCBS are going to be your best bets.


Anything outside of a regular doctor visit, Unicare blows. Humana just got their asses handed to them in a lawsuit last month.

BCBS is probably the best bet. Also, Pacificare. United is good as well, however their in network group is terrible. So be prepared to have to pay out of network rates for great service.

[MannyIsGod]

Dude, for a single person unless Joe is willing to shell out 150 bucks or more every month, he's protecting himself against big hospital stuff. All of those companies are fine. Personally, I'd go with hospitalization insurance only and skip out on anything with any PPOs.

[SequSpur]

You aren't hearing this from me, but Humana is definitely under the microscope right about now. Especially in this region.

Humana gets part of blame in death
Web Posted: 07/02/2005 12:00 AM CDT

Tom Bower
Express-News Staff Writer

In a verdict that could have widespread implications for HMOs across the nation and the millions of Americans they serve, a local jury Friday awarded $7.4 million in damages in a wrongful death lawsuit against Humana Health Plan of Texas Inc. and a physicians group under contract to provide health care services.
Jurors were to consider punitive damages in the second phase of the trial set to begin Friday afternoon, but attorneys for Humana and the plaintiffs reached an out-of-court agreement that would cap those damages at $1.6 million, bringing the total amount of damages to $9 million.

Of that amount, Humana could be liable for 35 percent after all appeals are exhausted.

The jury decision came after nearly three days of deliberation, capping a three-week trial presided over by 224th District Judge René Díaz.

In the lawsuit, John Smelik and his two adult children accused Humana and others of negligence in the June 1, 2001, death of Joan Smelik, John's wife of 47 years. She was 66 when she died and had a two-pack-a-day smoking habit for 42 years, testimony showed.

"I promised my wife I'd carry this through to the end. Thank goodness, the justice system works," Smelik said shortly after the jury returned its verdict.

The verdict wasn't unanimous, but 10 of the 12 jurors agreed that Humana was among three of the named defendants who bore responsibility for the fact that Joan Smelik "fell through the cracks" of her insurance coverage.

In broad terms, the plaintiffs alleged that she didn't receive the kind of health care promised by Humana's own written policies and standards.

Specifically, the plaintiffs testified Joan Smelik was suffering from emphysema, kidney disease and a circulatory condition and should have been more closely monitored in the months before her death.

Along with Humana, the lawsuit named as defendants two doctors, Dr. Michael W. Mann and Dr. Fred C. Campbell Jr., and the Alamo City Medical Group, PA, which was Mann's employer and the corporate health-care provider under contract to Humana. Campbell cared for Joan Smelik under another health insurance provider.

Prior to the trial, all the defendants had agreed to out-of-court settlements with the Smelik family, except for Humana. The earlier settlements totaled $620,000. Nonetheless, jurors were asked to attribute blame for the negligence among all the defendants.

Specifically, the jury found Humana was 35 percent responsible, Mann was 50 percent responsible and Alamo City Medical Group was 15 percent responsible. Campbell wasn't assessed any blame by the jury.

A 2004 U.S. Supreme Court decision in Aetna vs. Davila made it more difficult for disgruntled clients to sue health maintenance organizations (HMOs), such as Humana, in cases where plaintiffs claimed they were denied benefits.

The high court ruled those cases fall under the federal Employee Retirement Income Security Act (ERISA), which limits the amount of damages that can be recovered to actual losses.

Although the Smeliks didn't claim they were denied benefits, they alleged that the care delivered by Humana and its physicians to Joan Smelik was substandard.

"Given Aetna vs. Davila, this is a hell of a decision," said Dr. Brant Mittler, a practicing cardiologist and a lawyer who represented the Smeliks, along with Jon Powell and Renée McElhaney.

"The jury did something important for every HMO enrollee in the United States. This shows that individuals can fight against HMOs when the HMOs are focused more on saving dollars than on saving lives," Mittler said.

"This jury has saved lives," added Powell, the lead plaintiffs' attorney.

Humana said jurors didn't focus on the law, but instead allowed sympathy for the deceased woman and her family to influence their verdict.

"The evidence showed that Humana acted responsibly as a health benefits company, we approved every referral and paid every bill," said Ross McLerran spokesman for Humana. "We continue to express our sympathy to Mr. Smelik and his family, however, we intend to vigorously appeal today's verdict."

When informed of the verdict late Friday, one HMO watchdog group said the verdict demonstrates why Aetna vs. Davila doesn't make sense in the world of managed care.

"There is an irony in this verdict," said Ron Pollack, executive director of Families USA, a health care consumer's organization based in Washington.

"The irony is that denial of (health care) benefits has been shielded from regulation by state legislatures with the Supreme Court ruling, yet the issue of providing health care that's judged to be improper is not shielded from state legislation," Pollock said.

"It really underscores the folly of the Supreme Court decision in Aetna vs. Davila. Many times we see cases (involving HMOs) that are about denial of care, which tends to have even greater consequences for patients and their families and is sometimes done willfully and not only negligently.

"States routinely have jurisdiction over (medical) malpractice, why not over denial of benefits?" Pollock added.

Jury foreman David Caraway, a social studies teacher, said the deliberations were difficult and the verdict turned partly on the issue of case management. Case management is when an HMO more closely monitors a patient who is chronically ill.

Testimony showed Mrs. Smelik had been under case management when Humana had outsourced that service to another health care provider. But when that contract ended and Humana began doing case management on its own, Mrs. Smelik's case wasn't given that extra oversight.

"The deliberations were even more difficult than we expected," Caraway said.

But another juror, Peggie Shook, disagreed with the majority. In a civil case, it only takes 10 of 12 jurors to agree on a verdict.

"I don't believe Humana was the cause of Mrs. Smelik's death," said Shook, one of the two jurors who did not support the verdict.

"By the evidence given in the court, I believe Humana was innocent of all the charges, and the doctors, too," added Shook, who owns a local manufacturing business with her husband.

[MannyIsGod]

Man, back in the day when I was selling policies, these guys were all in trouble. Every single one of these companies. Some things don't change however. Now, the wholesaler I work for deals mainly with Principal and Assurant although we're brining BCBS aboard.

[Shelly]

I have Blue Shield of CA PPO. No problems at all.

[SequSpur]

The problem is now case management. The doctor refers the patient and the insurance nurse or clerk delays it. Standard of practice violations all day long. I see it every day....

cough... cough..... Humana.......... cough..... cough..... United...... cough....

[AlamoSpursFan]

I need to actually get some health insurance.

Anybody have any good companies a 24-year-old (25 in two weeks), non-smoking, single w/ no kids male should look at?

Well, hell...since nobody else is gonna do it...


















AFLAC!!!!!!!

http://www.strangezoo.com/images/content/11735.jpg

[SpursWoman]

I've got Humana and it's great...you can go to the Texas MedClinics! :lol


When my kids get sick...it always seems to be on the weekend, which makes that a huge deal for me. :)

[Shelly]

I have Humana for dental. My dentist just happened to be on my plan. I haven't paid for anything in years.

[AlamoSpursFan]

I remember hearing something on the radio about a lot of people dropping their health coverage and going with medical savings accounts. Apparently they get catastrophic event coverage and then pay cash for the normal stuff. Doctors seem to be willing to cut their prices considerably if they know they're getting paid up front and don't have to mess with insurance companies.

Anybody know anything about this?

[SequSpur]

I remember hearing something on the radio about a lot of people dropping their health coverage and going with medical savings accounts. Apparently they get catastrophic event coverage and then pay cash for the normal stuff. Doctors seem to be willing to cut their prices considerably if they know they're getting paid up front and don't have to mess with insurance companies.

Anybody know anything about this?


Some will cut fees by at least 50%....

[MannyIsGod]

I remember hearing something on the radio about a lot of people dropping their health coverage and going with medical savings accounts. Apparently they get catastrophic event coverage and then pay cash for the normal stuff. Doctors seem to be willing to cut their prices considerably if they know they're getting paid up front and don't have to mess with insurance companies.

Anybody know anything about this?
This is exactly why I think HSAs or Hospitalization coverage is the way to go. Major Medicals are just not worth it if you have to pay for your entire policy yourself. It is no where near cost effective.

Doctors, Hospitals, and nearly everyone in the medical industry has inflated prices that get negotiated down. And because insurance companies delay payments and in many cases don't make payments doctors raise prices even more to in order to not miss out on money.

This is why I get pissed off to hear about the insurance "emergency" in this country. It doesn't exsist, people could get very affordable coverage to make sure they have insurance if something major happens. I don't know what the rates are now, but when I sold it most of the time it was less than half of what most people play for their major medical plans.

Anyhow, Sequ is right, a lot of doctors cut those prices by at least 50 percent.

[sa_butta]

My medical insurance is so expensive. This past year they raised the premiums, co-pays and emergency room charges. It really is through the roof. Before I got my daughter on Medicaid I was paying like $400 a month for the premium alone not to mention $15 every office visit for her.

[Shelly]

Doctors, Hospitals, and nearly everyone in the medical industry has inflated prices that get negotiated down. And because insurance companies delay payments and in many cases don't make payments doctors raise prices even more to in order to not miss out on money.

Medicaid and Medicare are one of the slowest payers out there. And if your bill is not coded correctly, they'll kick it back and you have to start all over again.

[sa_butta]

Medicaid and Medicare are one of the slowest payers out there. And if your bill is not coded correctly, they'll kick it back and you have to start all over again.
I have already had problems with medicaid and billing. But in all I have not had to pay for any of my daughters medical expenses. When I got medicaid they were suppose to cancel her off of Aenta which is what I had before. Even after I cancelled her off and was not paying her premium they still had her as active. So the Doctor was suppose to send the bill to Aetna because they were showing up as the primary insurance but luckily they sent it to medicaid and it was paid but big mess to fix.

[Clandestino]

I remember hearing something on the radio about a lot of people dropping their health coverage and going with medical savings accounts. Apparently they get catastrophic event coverage and then pay cash for the normal stuff. Doctors seem to be willing to cut their prices considerably if they know they're getting paid up front and don't have to mess with insurance companies.

Anybody know anything about this?

Money Magazine did a several page breakdown on this like 6 months ago.. You should check it out...

[Shelly]

I have already had problems with medicaid and billing. But in all I have not had to pay for any of my daughters medical expenses. When I got medicaid they were suppose to cancel her off of Aenta which is what I had before. Even after I cancelled her off and was not paying her premium they still had her as active. So the Doctor was suppose to send the bill to Aetna because they were showing up as the primary insurance but luckily they sent it to medicaid and it was paid but big mess to fix.


Yikes!

I was talking about them paying docs, though. :lol My husband said it can take 60-90 days for him to get paid by them.

[sa_butta]

Yikes!

I was talking about them paying docs, though. :lol My husband said it can take 60-90 days for him to get paid by them.Your husband is a Dr.?

[MannyIsGod]

Yikes!

I was talking about them paying docs, though. :lol My husband said it can take 60-90 days for him to get paid by them.
Yeah, I'd imagine they were the worst. It is the government after all. Insurance companies aren't much better, though. I am constantly reading about them being fined for late payments etc etc.

[hunter-thereckoning]

my dads a doc and hes always complaining about insurance

[Shelly]

Yeah, I'd imagine they were the worst. It is the government after all. Insurance companies aren't much better, though. I am constantly reading about them being fined for late payments etc etc.

It took forever for him to get his Medicaid/care # to begin with. He had to get his own number (is working for a corp until 9/1, then will be private) and it took 2 months!

We have government contracts for my dad's business. Our terms are 15 days. It's not uncommon for them to pay 6 months later. Meanwhile, you've got material vendors hounding you for payment. Fun.

[Shelly]

Your husband is a Dr.?


yes.

[Clandestino]

that is why some doctors are no longer taking any insurance or goverment help at all.. cash only! i read that in money magazine too. costs are lower, patients are seen quickly and everyone is happier. at least those with the money to pay cash for their treatment.

[Clandestino]

...

[MannyIsGod]

The insurance companies all fucked themselves with HMOs and the like. They basically offered too much product and it came back to bite them in the ass.

[Shelly]

The insurance companies all fucked themselves with HMOs and the like. They basically offered too much product and it came back to bite them in the ass.

Yep...he's got 3 people scheduled for surgery. But they need to get a referral for their PCP. How is that cost effective?

[hunter-thereckoning]

yes.


does he have to deal with mal-practice?

[MannyIsGod]

Its the equivlant of auto insurance companies giving you a copay for everytime you change your oil. You go to jiffy lube and only pay 5 bucks to have your oil chaged and your insurance company provides the rest. Too much product for what they charge, which is why you have constant rate increases.

Then they institute things like the referals which are designed to make it harder for people to get service and that in turn incrases costs as well!

They are getting better, but only because they HAD too or most would have gone out of business.

[hunter-thereckoning]

because thats what bites alot of docs in the ass...or thats what my dad always says

[SequSpur]

Medicaid pays us every Thursday. Takes less than 7 days after submission. Medicare pays in 14 days, however we can only bill once a month. The first of every month.

The commercial payers blow ass.