HOW HEALTH INSURANCES FOOL PATIENTS AND RESTRICT CARE! AND IN THE PROCESS RIP HUGE PROFITS! THESE ARE ALSO THE REASONS THAT SPARKED THE CREATION OF DIRECT PRIMARY CARE AND DIRECT SPECIALIST CARE !
When you buy a health insurance policy you need to be careful. The salesman will have you believe you are buying the best policy. If he makes the sale, he gets a commission or the recognition by the boss that he or she is a great salesperson and that’s all he/she cares about. What you get after you sign on the dotted line is your problem. Please be very careful.Health insurance companies will tell their sales staff what insurance products to push and usually those are the ones where they make the most money. Their priority is money, money, money.
Lots of the stuff insurance companies are allowed to do is because our legislators in DC sell themselves and get big political contribution from insurance companies! They get the laws passed that are convenient to the insurance companies because of their big donations. Hospital CEO also pay big money to Insurance companies to obtain beneficial regulations. Down bellow are examples of their huge "donations". Doesn’t it make you wonder how the health insurance policies of the politicians and health care executive compare to yours and ours? We both get shafted in the process with all this money floating around.
Keep in mind that insurance companies have tools that they use on you to keep their expenses down and restrict care and they also have tools that they use on physicians to keep insurance companies’ expenses down. These tools are geared to restrict care and keep their expenses down!
Here is what to watch out for and be aware of when you buy a policy:
1. Covered medical expenses: Know what is covered and not covered. You can rest assured that not everything is covered. Insurance companies have lots of restrictions as to what is and is not covered. Whatever is not covered comes out of your pocket, be it medical treatment or procedure or medications.
2. Monthly premium: What you pay for the policy every month. Usually, you get what you pay for. Nothing is free. Keep that in mind. Not unusual for a single person to pay $500 a month. In a year is $6000.00 to which you add:
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Copay: This is another weapon insurance companies use. A copay which can be from $30, $50 and even $75 is what you pay out of pocket for every doctor’s visit. So multiply this number by how ever many by office visits you have. This is on top of the deductible if you still have not met the deductible. What the copay does for the insurance company is keep you away from the doctor’s office because you want to avoid spending money. In this way the company does not have to pay their part and saves money.
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Coinsurance: This the percentage of covered medical expenses that an insured person pays for any covered service. It can be 20 to 30 %. Let’s say your insurance company has contracted with a particular doctor to be a participating provider with that insurance company and have agree to allow $130 for an epidural for back pain. Of this allowed amount, your insurance company will pay 70% and you will pay 30% ($39) of it. All this adds up.
In the example above here is your cost per year:
a) Primium/year ---------------------------------------------$6000.00
b) Deductible/year------------------------------------------ $5000.00
c) Copay for lets, say 10 office visits at $50.00-------$ 500.00
d) Coinsurance for the ten simple visits ---------------$ 290.34
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Your total expense/year = $ 11,790.34/year
Imagine spending that ammount for the rest of your working life. Scary! Do the numbers!
3. Total out of pocket for the year. This is an important number to find out when you buy a policy and keep in mind. This is the maximum you will pay out of pocket in addition to your monthly premium. This number tell you a lot about what you will be responsible for on top of your premium. Always read the fine print in the contract which is what counts and not what the insurance sales person tells you! Remember he/she want to sell you a policy!
4. Panel of doctors you can go to. Just like you choose what health insurance plan to buy, also doctors, physical therapist etc. choose what insurance company they want to contract with to provide services to their patient. So be careful. Your present doctor, who you may have gone to all your life, may not participate with the insurance they are trying to sell you. If that is the case you will have to pay him/her out of pocket or change doctor. Why do some doctors not participate with certain insurance products? Because sometimes you are working for pennies on the dollar or because the company has made it very difficult to follow their rules, etc. Your policy may have out of network benefits, but usually that means that your deductible and/or copay/coinsurance are going to be higher if you go to a doctor who is out of network.
5. The doctor’s side of the equation. When a doctor signs to participate with an insurance company he agrees to two things. Reduced payment and agrees to follow the insurance company rules if the doctor want to get paid. When these agreements are signed the company benefits from the doctor by having to pay him less but also since we agree to follow their rules, they also want to dictate what we can do to you if we want to get paid. And even when or if we can do this or that treatment to you. I will give you an example.
Let’s say you come to my office because I participate with your particular insurance company and you are complaining of severe lower back pain radiating down the right leg down to your toes with numbness and tingling for the last two weeks. You are really uncomfortable. I do a physical exam and I conclude that you most likely have a herniated lumbar disc. To confirm my diagnosis, I need to order an MRI of the lumbar spine. However, your insurance requires that I need to call the insurance company to get this test authorized (a waste of time for my staff and I). When we call, a nurse says that, before they approve that test you need to undergo six weeks of physical therapy and medication management. They don’t give a crap that you are in severe pain and they don’t care that the therapy is going to cost you money. The bottom line is they have saved money by not paying for the MRI and they have wasted my time and prevented me from making an accurate diagnosis and treating your pain. Who suffers with the pain? You do! The only way to bypass this is by you agreeing to pay for the MRI and any other treatment out of pocket.
What does the doctor get by signing up with any insurance to be a participating physician with them? What they get is that patient with that insurance can come to the doctor and he gets paid. BUT ONLY IF WE FOLLOW THEIR RULES. It takes a lot of manpower to deal with insurance companies and their payments are getting lower and lower. For that reason, some of us are cancelling our participating agreements with insurance companies. I just cancel my agreement with UHC. Every year we get cuts in payment from one or another insurance company while all our expenses keep going up and up. Here is what Medicare just announced!
The bottom line is, cut benefits for the insured and make it difficult to get the care, and cut payment for the care provided by the physician. And in the process line the pockets of the insurance company executives and hospital executives. Here is an example of what those parasites that don’t contribute anything to healthcare and the big bucks they extract from healthcare. There has to be a better way and that may be Direct Primary Care and Direct Specialist Care.
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