Whistleblower Speaks Out On What Really Happens in US Healthcare

by sammielee24 107 Replies latest jw friends

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  Justitia Themis

  I simply must share what I am experiencing with my secondary insurance. I have my own insurance, and I am insured on my husband's plan. I went to the doctor for two medical conditions. Bot are accepted on my insurance, but only one is an accepted condition on my husband's insurance plan.

  My plan paid for everything but a $15.00 co-pay, and about $20.00 on a diagnostic test related to the condition that is accepted on BOTH insurances. My husband's insurance is refusing to pay the $35.00, because...drum roll...are you ready for this...the doctor listed the condition they cover as a SECONDARY diagnosis, not the primary.

  For those who don't know what I'm talking about, pretend you go see your doctor for a sprained ankle (primary diagnosis), and while your there, they discover you have strep throat (secondary diagnosis) and run a test to confirm it; that would create two diagnosis codes. If they didn't cover sprained ankles, but did cover strep throat, they should pay for the office visit and strep throat test.

  I appealed; they rejected my appeal. I asked for a Level II appeal. They tried to pretend they didn't receive it, and let it sit till almost the deadline when I contacted them for a status update. However, I had emailed it, so they couldn't pull that game. They said they couldn't accept an emailed request. I quoted them their own plan book that says I can write a letter, email or telephone it it. :) They forwarded my file to a medical doctor for review, which will cost them about $250.00.

  All to avoid paying $35.00 on a co-pay and diagnostic test for a condition that they do cover. BTW, my husband has LEOFF (Law Enforcement Officer, Firefighter) insurance for which is department pays $500.00 monthly for each of us; it is not a cheapo policy.

  Insurance companies have earned every bit of hostility directed towards them.

  I want a government plan to create more competition in the market.
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  Justitia Themis

  sadly, the USA is going to implode on itself because they can't seem to get it together.

  I agree Sammielee. The US is THE last first-world country not to have a national health care system, and if we keep the status quo, it will be our eventual economic undoing.
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  sammielee24

  It's sad that Americans are fighting for basic healthcare for everyone...a right for people everywhere in the world - while at the same time they allow their government to rip them off, socialize all the banks and wall street insitutions by handing over trillions of dollars and as that woman with breast cancer dies fighting her insurance company...you know, that woman who lives in the USA, worked all her life and had health insurance - that middle American who followed all the rules - as she died fighting for treatment in the USA, the CEO's sitting on Wall Street have put aside 6 billion of YOUR money to pay their top guns..I believe Citigroup is owned at least one third by the US Taxypayer but they set aside 100 million for their top man.

  What a shameful and embarassing way to live as a society when you devalue and undervalue ALL members of your society by not demanding universal type care and instead somehow believe that those who can easily afford any type of healthcare in any place in the world, are more deserving of your tax dollars. It boggles the mind. sammieswife.
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  sammielee24

  Whats so sadly ironic is that all those first responders who ran to protect Americans in 9/11 and who did so for the love of their people - more than half of all of them are sick and almost all either have no insurance or inadequate insurance. I think the last figure they used was 50,000 people now sick from the dust and asbestos that they were told was not toxic - and yet, the American society that called them all heroes has forgotten them and their service. When a responder dies who takes care of his family? His kids? Don't we feel any obligation for one another?

  There are people screaming for their right to keep and bear arms..a fundamental right according to their constitution but yet those same people don't support a healthcare system that would take the bullet out of an innocence person without bankrupting them.

  sammieswife.
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  beksbks

  Oohhhh Sammie. Teabaggers will show up and protest some tax increase that isn't even going to effect them, but heaven forbid we move a muscle over this issue.
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  FlyingHighNow

  Try having no insurance and little money and see how rationed your health care is. You're all in danger of this happening. I don't care who you are. The bigger you are, the harder you can fall.
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  FlyingHighNow

  I know I am not the only uninsured person on the board who considers just dying before running up thousands upon thousands of dollars of medical debt. I've been through one bankrupcty over medical debt. One too many.
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  beksbks

  Heyy here's some fun!

  http://www.youtube.com/watch?v=hea-4VJZXRE&eurl=http%3A%2F%2Fwww%2Ehuffingtonpost%2Ecom%2F2009%2F07%2F28%2Fvirginia%2Dfoxx%2Dwarns%2Dthat%5Fn%5F246434%2Ehtml&feature=player_embedded
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  purplesofa

  I worked at an MRI Imaging Center and MRI department at a hospitol.

  One of the major things we had to learn was using proper diagnosis codes for payment of insurance.

  The MD orders the scan with a diagnosis, if it does not have a diagnosis code that is payable, the diagnosis will be changed.

  Sometimes this takes a day of phone calls back and forth with doctor and/or clinic to get a proper diagnosis close enough to the real diagnosis.

  Some tests are ordered to R/O (rule out) another diagnosis which was not acceptable either. Rule Out is not a diagnosis. For many doctors a proper

  diagnosis cannot be given until the test results are in. Many people are diagnosed with something they don't have simply to get a needed test.

  Clinics were rewarded for having their codes entered correctly which meant they had payable codes. A person that knows

  medical coding is worth their weight in gold to a Hospitol or clinic. They know the loopholes. Insurance companies will do whatever they

  can to keep from paying, even when a code is submitted incorrectly by a minimun wage receptionist, is a typo, or paperwork is not correctly submitted.

  Also, if everything is correct but not pre-authorized, insurance companies won't pay.
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  purplesofa

  I know I am not the only uninsured person on the board who considers just dying before running up thousands upon thousands of dollars of medical debt.

  I have already told my kids to let me die rather than run up bills, I have lived a good life.

  edited:

  I don't expect our Healthcare system to be fixed completely while I am living......but I want this for my kids and grandkids so they don't have to go through and have the thoughts that I have.