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Want to mention in my semi-rant above that it is actually not directed at doctors (especially GP's) It's with the crazy convoluted guessing game our health care/insurance has become. "Terms and Conditions May Apply" - per the insurance companies (sometimes doctors). Seems like we need a law degree in contract law now a days before we can go see a doctor with peace of mind.
Then complain about how the law was written. Instead of a vague "preventative services covered or free physical " it should have said 0 copayments to primary care doctor or x number of no copayments to primary care doc. Or you could have made it easier by having everything subject to the deductible, but have a lower deductible.
First dollar premium paying for a service was a political move to try to buy approval. Now its biting people in the butt with higher deductibles, crazy rules that no one can understand, and limitations in HSAs.
Vague, poorly written laws have consequences.
Last edited by NSHL10; 08-12-2014 at 07:53 PM..
Reason: added
Lets get real here. What does the doctor do at a yearly physical? The nurse or assistant takes your blood pressure, your weight and sometimes your height. The doctor comes in introduces himself/herself and asks how your doing. ( I presume to see if you know of anything wrong ) He may ask you a few questions, listens to your heart and tells you to cough, and then writes up a script for any lab tests he thinks you may need based on your age and how you answered his questions. It isn't until he gets the lab work back and you come back in for your follow up visit, do you find out from the doctor, how your blood work/urine tests came out and if he thinks there is any concern that warrants further investigation.
So where are you drawing the line. If he looks at you while examining you in your initial visit, and says you look tired are you getting enough sleep, and you answer no, not really and then he asks you how many cups of coffee a day do you drink, or are you getting enough exercise. Is that now, not a physical any more because he's uncovered that your tired. Is it a diagnostic/therapeutic service if he tells you to drink less coffee?
So what's the correct answer here? Do you answer the doctor's questions truthfully, or do you sit there like a log with your mouth shut? If one of your answers triggers suspicion in the doctors mind, does the suspicion based on your answers translate into a diagnoses or does the diagnoses actually have to be established by further testing or exams?
Call me stupid, but isn't the purpose of going to the doctor for annual exam to rule out any underlying health issues you may have and the only way he is going to achieve this is by examining you and asking you questions? Where lies the difference when he listens to your heart and hears it skipping a beat and tells you it would be advisable to see a cardiac specialist about that funny sounding heart, then if he listened and didn't hear anything. Is that diagnostic/therapeutic service? He's not doing the further testing.
What are we paying the doctor for? His time, or his good hearing? You get my point. This is getting kind of silly.
I agree with everything you have said. These distinctions are created and defined by the insurance companies, not the doctors. Doctors would rather not be involved and would like to focus on "doctoring" instead of this insurance BS. These are all concepts defined by the insurance companies. A similar concept is "medical necessity". I have patients tell me their insurance will only cover something that is "medically necessary" so they ask me if it's medically necessary, as if I am the one who makes that determination. I explain that this is an insurance company decision, not mine. I learned this after writing a few letters explaining certain treatments were "medically necessary" only to have the insurance company disagree. So I no longer write those letters because there is no point. It's actually pretty insulting when an insurance company essentially says I am doing a bunch of "unnecessary" work, although patients beg me for it and often just pay cash instead. Go figure.
Then complain about how the law was written. Instead of a vague "preventative services covered or free physical " it should have said 0 copayments to primary care doctor or x number of no copayments to primary care doc. Or you could have made it easier by having everything subject to the deductible, but have a lower deductible.
First dollar premium paying for a service was a political move to try to buy approval. Now its biting people in the butt with higher deductibles, crazy rules that no one can understand, and limitations in HSAs.
Vague, poorly written laws have consequences.
No, sorry NSHL1 I'm afraid these insurance shenanigans have been going on for quite some time. The new ACA law has just initiated a new set of "go arounds" aimed at their dodging paying claims or passing on any costs they can get away with to the patient through silly vague languagethey come up with for their policies. The ACA has only given them new laws to skirt.
As for further clarifying parts of the ACA law: Can you really sit there with a straight face and say the House would lift a finger to help modify and improve the law's language. Perhaps you should read up on some of the other huge bills we have passed like social security and medicare and see all the fixing that went into them after the law was passed. But excuse me, I lost my head for a minute. I forgot, that's when we had mature men from both sides of the isle trying to work together in Congress instead of spending their entire tenure dedicated solely to defeating the other party for the next coming election.
You can make this as political as you desire. Bottom line is this law was not thought out or implemented properly. Hence all the problems with the exchanges, delay of business mandates, all the waivers added in after the law was passed, etc.
BTW the law mandated the coverage of first dollar premium so the law is responsible for the confusion over what is covered during a physical. The language was poor and vague enough to create confusion. Laws are supposed to be created in a way to ensure compliance. Maybe the vagueness was in response to all the campaign contributions the creators of the law got from the insurance companies?
Regarding "obamacare" changes and waivers: 24 changes to law were done via executive order without any approval from Congress, but 16 have gotten Congress' approval to change the law. But I guess a good political rant doesn't look at any facts though. http://www.galen.org/newsletters/cha...macare-so-far/
You can make this as political as you desire. Bottom line is this law was not thought out or implemented properly. Hence all the problems with the exchanges, delay of business mandates, all the waivers added in after the law was passed, etc.
BTW the law mandated the coverage of first dollar premium so the law is responsible for the confusion over what is covered during a physical. The language was poor and vague enough to create confusion. Laws are supposed to be created in a way to ensure compliance. Maybe the vagueness was in response to all the campaign contributions the creators of the law got from the insurance companies?
Regarding "obamacare" changes and waivers: 24 changes to law were done via executive order without any approval from Congress, but 16 have gotten Congress' approval to change the law. But I guess a good political rant doesn't look at any facts though. 42 Changes to ObamaCare…So Far | Galen Institute
#1-#24 Administrative Action: dealt primarily with delays in implementing.
#25 - #40. Changes by Congress: With the exception of #27 and #39, congressional changes dealt mostly with slashing funding for things like Co-Ops (public option) , and making favorable changes for small business, and clarification on Military Tricare as it relates to ACA, modifying premium tax credits people would have to repay if they were over allotted, extending tax credits to businesses, defunding Prevention and Public Health fund. You know most of what the Republican's favor - giving tax credits and rejecting taxes levied and rejecting government over sight. Looking at what was passed, I'd say that was largely concessions made on the Left, wouldn't you?
As to Supreme Court ruling, that is not in question here.
Your quote: " Maybe the vagueness was in response to all the campaign contributions the creators of the law got from the insurance companies?"
This statement I will agree with. I think if the new ACA act were written solely for the purpose of protecting the consumer, there would have been a lot of changes. I am not so naive to think that anybody but big business rules Congress, and we got passed only that which we could negotiate to pass with concessions protecting the insurance companies and their profits.
However, my point originally being that insurance abuses and clever language and funny coding used to either avoid paying or shift more costs on the consumer has been a problem way before there was an ACA, which you refuse to acknowledge.
Last edited by modhatter; 08-13-2014 at 12:46 PM..
The entire problem is not the health care act, but the insurance billing systems in general. The health care act has only exaggerated an already existing problem.
About 10 years ago I had a corner of a molar break off near a large filling. There was decay beneath the filling and the dentist told me that I would need a crown in the near future. I did not have the money for that and asked if he could just put in a new filling for the time being and i would come back for a crown at a later date. he agreed that it was not so time sensitive that a fews months or even a year would be a problem.
The office manager came in to go over the costs before we proceeded and told me that the dentist was going to be doing a buildup on that tooth and my portion of the bill would be over $350. My insurance would pay 100% of a filling, but only 40% of crown related work which a buildup is considered.
I asked the dentist, when he came back in, what the difference was between a buildup and a filling and why we could not do the filling as discussed earlier. He responded that they were the same thing. The work involved was exactly the same and it was just the office billing procedure to code it as a buildup to make the crown work easier to track. i explained that his office convenience was going to cost me an extra $350+ and would prefer they code it as a filling. He agreed with my reasoning and told the office manager to change the billing code. She was not happy, but my wallet was.
Many of the activities by doctors can be categorized by different billing codes, depending on how they got to that point in treatment. I always tell my doctor that I am there for a preventative checkup and proceed to fill them in on my past and present issues. I want them to be aware of my condition when they perform their checkup, but make it clear that this is a routine preventative visit and NOT a illness prompted visit. Most of my personel issues are chronic care type issues and as such my prescriptions fall into a different category, but the office visit coding is critical to keep my costs down.
I have had visits where the staff want to code the visit as a chronic care maintenance visit and I insist that it is a wellness check because the insurance company treats a maintenance visit as a illness based visit and it costs much more even if the diagnostic and treatment results are the same.
I acknowledge it. My point being before there was little oversight on insurance companies on a federal level as the feds were not involved in its regulation.. Now, due to ACA and its mandate, it is even more crucial that the law be very explicit in how things are billed etc. If you are forcing people to buy something from a private company, you better damn make sure you have proper controls in place. With the billions the govt will give to the insurance companies, it better regulate these companies more effectively than shown to date. The law is too vague as it stands. The old "this is the best we could do" is such BS to cover the politicians'butts while their base laps it up like the suckers they are.
Where and when did this so called negotiation occur? Are you so naive that you truly believe 1 party cares about people and the other is the big bad party? You need to research campaign contributions to BOTH parties, because they both bend over for their contributors, and they both share the SAME contributors. Obama has threatened changes to immigration rules without approval from Congress. Why csn't he fix the problems associated with ACA without approval?
The entire problem is not the health care act, but the insurance billing systems in general. The health care act has only exaggerated an already existing problem.
About 10 years ago I had a corner of a molar break off near a large filling. There was decay beneath the filling and the dentist told me that I would need a crown in the near future. I did not have the money for that and asked if he could just put in a new filling for the time being and i would come back for a crown at a later date. he agreed that it was not so time sensitive that a fews months or even a year would be a problem.
The office manager came in to go over the costs before we proceeded and told me that the dentist was going to be doing a buildup on that tooth and my portion of the bill would be over $350. My insurance would pay 100% of a filling, but only 40% of crown related work which a buildup is considered.
I asked the dentist, when he came back in, what the difference was between a buildup and a filling and why we could not do the filling as discussed earlier. He responded that they were the same thing. The work involved was exactly the same and it was just the office billing procedure to code it as a buildup to make the crown work easier to track. i explained that his office convenience was going to cost me an extra $350+ and would prefer they code it as a filling. He agreed with my reasoning and told the office manager to change the billing code. She was not happy, but my wallet was.
Many of the activities by doctors can be categorized by different billing codes, depending on how they got to that point in treatment. I always tell my doctor that I am there for a preventative checkup and proceed to fill them in on my past and present issues. I want them to be aware of my condition when they perform their checkup, but make it clear that this is a routine preventative visit and NOT a illness prompted visit. Most of my personel issues are chronic care type issues and as such my prescriptions fall into a different category, but the office visit coding is critical to keep my costs down.
I have had visits where the staff want to code the visit as a chronic care maintenance visit and I insist that it is a wellness check because the insurance company treats a maintenance visit as a illness based visit and it costs much more even if the diagnostic and treatment results are the same.
Interesting. What are the reimbursement differences to the doctor?
Oh, crap. Now I have to learn about billing codes, too? (not directed at anyone here! that's directed at the health care system)
It's already enough that I have to be my own doctor because I deal with bozos at the low cost clinics but I really didn't think I'd have to become an insurance expert now, too.
Sigh.
Just whining. If that's what I have to do, I'll learn to do it.
I miss the old days when I afford to see a doctor, the doctor could accurately diagnose the problem the first time, and I would leave with a scrip or a notion of what to do or not to do to heal the problem.
Today . . . forget it.
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