Posted on 03/19/2016 5:16:45 AM PDT by Kaslin
Late last year, while playing tennis, I reached up to serve and felt a painful pop in my shoulder. The inflammation got worse over the next few months. Now anytime I try to put my arm above my head, pain shoots up my arm. I often wake up at night with an agonizing throb in my shoulder.
So I finally and reluctantly went to the orthopedic surgeon; he said that I had a rotator cuff tear and I would probably need surgery. Ugh! He scheduled me for an MRI, but the day I was set to go, the hospital called to tell me my insurance company declined to pay for the scans. The insurance company, Cigna, tersely sent me a note: "You will need to complete six weeks of conservative treatment, such as physical therapy and anti-inflammatory medication. Once that has been completed and you have been re-evaluated, we can try to have the MRI re-authorized." Gee, thanks. You guys are the best.
I've been doing therapy for many months already, with not much improvement. The doctor explained that the insurance companies want to make sure that physicians aren't padding bills with unnecessary procedures. Incidentally, I've paid for health insurance for 30 years and have almost never used the medical care system. I calculate the insurers have made well over $100,000 off of me.
But I am lost inside the bureaucratic maze. They don't want to pay for the MRI because they don't want to have to reimburse for rotator cuff surgery. So their hope is that I will just go away. Studies show these delay tactics and bureaucratic runarounds work to reduce insurance payouts.
Everyone has horror stories of insurance companies denying coverage for valid procedures. As an analysis in The Baltimore Sun recently put it: "Among insurance professionals, it is common knowledge that health insurers are denying claims for coverage with increasing frequency." This is what the health industry calls "cost control."
Look, I get it; the insurance companies are trying to root out fraud and abuse of excessive procedures, which drive up costs for everyone. But the insurance companies are becoming barriers to care even for legitimate and necessary procedures.
What's the root of the problem here?
First, the excess of health insurance actually drives up cost. The more insurance for a procedure, the more expensive it is. Health inflation and premiums has been rising by nearly double the consumer price index for at least the last decade. This is also why there are so many frivolous procedures performed. Patients have been removed from the decision-making process.
Second, Obamacare has increased demand for health care and is driving up costs, so insurers appear to be cutting their expenses by denying claims more often. By the way, the insurance lobby should take note that this sleazy practice only plays into the hands of Bernie Sanders and others who want a single-payer government system to take over health insurance.
That will make medical care worse -- and more expensive. Studies on Medicaid patients find little or no improvement in health outcomes compared to the uninsured population -- because the level of care is so lousy. Government health care will be Medicaid-type coverage for all. It will be "fair" because we will all get equally subpar medical care -- and I would never get my shoulder surgery under that system.
The health insurance scandal in America today argues not for a vast expansion of government-run health care; instead, it suggests the wisdom of the medical savings account approach, where people put money, tax-free, into an IRA account and draw it down to pay for their first few thousand dollars of coverage. That way it isn't an insurance company who makes the call as to whether I should get an MRI. I make the call with my own money. Is the pain in my shoulder so bad that I want to shell out $1,200 to have a scan? Right now, Cigna says I don't get to make that choice. So it's "free" but I can't get it. Wonderful.
The only people who know whether I need surgery are not the faceless, bean-counting claims adjusters living in Toledo, Ohio, but my doctor and me
How exactly can he repeal it? Wave a magic wand? How many presidents have repealed any federal program that involved all citizens?
I read it and what it tells me and you and everybody else is that TerrifiTrumpCare will replace 0blowmeCare. It'll be the same government crap, or worse, but the Trumpbots will think it's the greatest thing since sliced bread because it will have Trump's name on it.
TrumpAid, which comes in a rainbow of flavors, only lets in terrific Trump sound bites.
I posted earlier that the system is broken to the point that not even the terrific Mr. Trump will be able to fix it. I think Cruz has the most conservative approach to the federal government but unless the corrupt, spineless congress critters are willing to work with him then he will be ineffective in realizing his goals. Same goes for Terrific Trump, of course.
I am assuming that if everyone paid for their own care instead having someone else pay for it it will get vastly cheaper. The vast majority of people will never need the procedures you just mentioned. Just because it’s edema S doesn’t mean women’s else should pay. If financially ruinous bills are a concern then insurance should be purchased. But insurances is not health care and again everyone should contract and buy their own.
There is no reason that paying fr your own health care should be any more complicated than procuring any other consumer good.
This I. The context f s there a better way to pay.
Just because te common doesn’t mean someone else should pay.
Geez I hate posting form a phone.
You are correct in this. The healthcare system before Obama was failing and now it is in a coma. Neither will be able to fix it and Medicare for everyone is just around the corner.
But Trump means so much more to our country's future that this one issue. We need a leader who can help Congress stay accountable and not another slimy congress critter like Cruz who has sold out his values as a senator at every chance and lies about his positions for the rubes. No president can be successful without forcing Congress to act. Trump is our best chance.
“I might have missed this, but why can’t he pay for his own MRI? He says Cigna won’t let him?
True he shouldn’t HAVE to. But are ins co’s actually telling people they can’t take care of themselves?”
I had a never ending bout with bronchitis last winter. It got to the point where I was bad enough that I couldn’t wait 4-6 weeks for an apt with my dr, but not bad enough for a same day or an ER visit. I just needed a chest x-ray and some antibiotics.
I called a walk-in clinic and found out that I could get a chest x-ray, exam and prescription for around $300. At my convenience. No waiting.
Sounds great, right?
Then they found out that I had insurance. They told me that they couldn’t see me without a referral from my physician. (A walk-in clinic?) I told them that I just wanted to pay cash. They said that they can’t see anyone who has insurance for cash. It was the law. They had to use my insurance if I had it.
So no. You can’t just give them money and get a service if you’re insured.
This guy’s situation is worse. If the insurance doesn’t accept that MRI (because it was out of system) they could deny the surgery because he didn’t go through the proper channels.
It’s a big mess right now.
Isn’t that exactly what the article is complaint about? Health care insurance companies. If you like the lower negotiated rates and you like the service your recieve in return (the author does not) then stay with it.
The article ask if there is a better way.
The biggest expense many doctors have is non-paying patients.
The author of this article completely ignores the millions of illegals and gimmedats who pay nothing for their care. Some physicians have to write off more than 50% of the care they provide. It is so bad that our locals hospitals require not just a picture ID but a palm scan.
The illegals even fly in their relatives if they get sick. They pick them up at the airport and take them directly to the ER. Their brain surgery or dialysis is then paid for by you and me.
Doctors I use routinely offer 40% discounts to patients who pay cash. Filing insurance claims is costly and time consuming. I just got a bill from a doctor, after the insurance payments were finally worked out, for services provided in June of 2015. Also, it’s far easier for insurance companies to raise premiums and lower benefit payouts, especially now, than it is to practice cost containment at the delivery end.
Actually, I was talking about the entire system, not just the healthcare system and one man ain't gonna make much difference.
Trump is our best chance.
Then we're done like dinner.
Go here: http://www.dpcare.org/
I generally agree, but one man leading millions can often accomplish much.
There are none so blind as those who will not see.
So, Einstein, tell us your plan. Better yet, tell us Cruz’s plan other than to declare by decree it is gone when it is not because it must be removed by Congress. Now that Romney is endorsing him, does that now mean the deal for that endorsement is to replace it with Romneycare for each separate state?
We can play this stupid game all day long.
My plan? See the Declaration of Independence. (Let me know if you need help finding it.)
You Trumpbots are so blinded by his terrific light that you can't see the reality of the situation.
Trump has campaigned on repealing 0bamacare and REPLACING IT WITH HIS OWN TERRIFIC PLAN. In other words, more Big Government.
With Trump as president it's gonna be meet the new boss, same as the old boss. (northeast liberal, NY values)
This type of thing; insurance companies not covering surgery for certain types of injuries like rotator cuff injuries without first having undergone PT and less invasive treatments, is nothing new and long pre-dates Obamacare. It even seems to be the first standard of care in most cases as described by American Academy of Orthopaedic Surgeons, although the insurance company IMO should have paid for a diagnostic MRI.
http://orthoinfo.aaos.org/topic.cfm?topic=a00378
Years ago (I think it was around 1999), I worked with a woman who started having severe pain in her shoulder and down her arm. She didn’t have a rotator cuff tear but severe rotator cuff tendonitis that ended up in what is called “Frozen Shoulder Syndrome – very painful) and was caused by repetitive and improper, non-ergonomic use of a computer mouse. Since it was work related, it ended up being a worker’s comp case and although both her personal and the WC ortho’s thought she may need surgery, she had to do PT, anti-inflammatory drugs and get cortisone shots for about two months, and only after that did not improve her condition, was surgery done.
Allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs should be tax-free and should be allowed to accumulate. These accounts would become part of the estate of the individual and could be passed on to heirs without fear of any death penalty. These plans should be particularly attractive to young people who are healthy and can afford high-deductible insurance plans. These funds can be used by any member of a family without penalty. The flexibility and security provided by HSAs will be of great benefit to all who participate.
I don’t see very much here that changes over what is currently in place and has been in place on HSA’s even before “Obamacare”.
https://www.irs.gov/publications/p969/ar02.html#en_US_2015_publink1000204020
http://www.hsacenter.com/faqs.html
As of right now anyone enrolled in a qualified High Deductible Health Plan (HDHP) is eligible to open a Health Savings Account (HSA). A HDHP can be offered through an employer and the HSA administered through the employer’s heath plan insurer or 3rd party administrator or it a can be a privately purchased HDHP insurance plan and the individual can open an individual HSA through most banks.
If through an employer sponsored plan, the employee contributions are deducted from payroll pre-tax (i.e. tax free – subtracted from Box 1 – federal taxable earnings) and employer contributions if any are also tax free, subject to the annual contribution limits. Individual contributions to an HSA paid for with post tax dollars whether to an employer sponsored HSA or a private HSA paired with a private HDHP are tax deductible, subject to the current annual limits ($3,350 for individual coverage and $6,650 for family coverage).
As long as enrolled in a qualified HDHP, tax free contributions up to the current annual limits can be made and the funds, whether contributed by the individual, employee or employer or a combination are 100% retained by the employee and is currently portable if the employee changes jobs or changes insurance plans. If no longer enrolled in an employer or individual HDHP, while one can no longer make tax free contributions they can still use, tax free the available funds for qualified medical expenses, including deductibles. At age 65, withdrawals from an HSA can be used for any purpose without penalties but such withdrawals are subject to ordinary income tax.
Unlike an employer sponsored FSA, HSA’s currently do accumulate and the funds roll over from year to year, and if one changes employers or changes plans, as long as they enroll in another qualified HDHP, the funds can be rolled over to a new HSA, or if not enrolled in a HDHP, they can still retain their existing HSA account, and currently once the funds reach a certain amount, the funds can be invested and earnings from those investments are also tax free if used for qualified medical expenses or tax deferred if withdrawn after the age of 65 for non-medical expenses. And as of right now, qualified medical expenses include unreimbursed medical expenses of the accountholder, his or her spouse, or dependents, even if they are not covered under the accountholder’s HDHP.
Currently when a person dies, the funds in their HSA are transferred to the beneficiary named for the account. If the beneficiary is a surviving spouse, the transfer is tax-free. If the beneficiary is not a spouse, the account stops being an HSA, and the fair market value of the HSA becomes taxable to the beneficiary in the year in which the HSA owner dies.
I like the concept of HSA’s but I would be a lot more impressed if Trump’s plan detailed things like opening up HSA’s to everyone whether enrolled in a HDHP or not, greatly increasing the annual contribution limits, open it up to persons currently enrolled in Medicare, allow people to use funds tax free from the HSA to pay for health insurance premiums other than COBRA or LTC premiums, allow HSA funds to pay for certain OTC medications without an Rx (like FSA’s once did), and allow non-spouse beneficiaries to inherit HSA funds tax free.
But I don’t see any of that outlined in Trump’s plan, so from my reading, what he proposes for HSA’s doesn’t change anything that isn’t currently in place.
Like they used to say at Burger King.
What is the Cruz Plan after Obamacare is repealed?
Like it or not Obamacare is an Entitlement since it pays part of the actual Healthcare Premium costs. There are not enough Politicians that want to be Reelected that would kill Obamacare without offering a replacememt Plan.
If anyone thinks they can just get rid of it without an alternative, they are smoking some good stuff. Try getting rid of Medicaid and Medicare and see what would happen.
BTW - Former Cruzer here. Just want all the facts presented.
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