Social Question

JLeslie's avatar

Is anyone else fed up with this preventative care bulls**t?

Asked by JLeslie (47233 points ) September 3rd, 2009

My insurance company covers an annual mammogram 100%, but if I need a mammogram, because I found a lump or have a pain, it is not covered.

I just found out that the colonoscopy I need will not be covered 100%, because I am under 50, so it is determined to be diagnostic. If it was a regular old preventative care colonoscopy it’s covered, but if I am high risk it’s not? The reason I do the procedure is to prevent cancer since I am in a high risk group.

Isn’t it most important to diagnose people who are most likely to have a cancer to get them early or prevent a cancer altogether.

This just pisses me off. If we are going to argue that preventative care saves money in the long run, how can you not cover these things? Plus, if you are sick that is when you need your health insurance most.

And, it was explained to me that I will be responsible for 20% of the allowable amount, but they are not able to tell me the allowable amount until after the claim has been submitted. How is that right?

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22 Answers

hearkat's avatar

Insurance companies are the bane of the U.S. healthcare system. That’s all I have to say about that.

Judi's avatar

And people think that health care would be rationed with a public option? I tell them “IT ALREADY IS RATIONED” as your story so clearly illustrates.

robmandu's avatar

For kids, well visits to the doctor are covered at 100%, but sick visits are subject to deductible. Or going to the emergency room. Etc.

This is nothing new.

And why this is a Problem and a Bane and Rationing is something you folks will need to better explain.

It’s insurance, people. It’s an instrument to help minimize your financial risk.

Sheesh. Don’t like your coverage? Then change it.

Why you gotta come around here complaining about it I just don’t understand.

Judi's avatar

@robmandu ; I am sure everyone is going to go right to their boss and say, “This insurance is crap, Change it please.”
If they are buying it as an individual, no one would even consider insuring @JLeslie . She has stated she is in a high risk category, that’s why she needs the tests.
I tried buying insurance for my bipolar son. They laughed me out of the offices.

robmandu's avatar

Look, there’s supplemental insurance. So if you don’t think you’ve got enough coverage with your primary insurer, you do have options. And yes, you most certainly should complain to your employer if the health insurance options suck. It’s part of your fair compensation after all.

As for the cost of a particular person’s benefits, it’s a function of financial risk. Life ain’t fair. But the math generally works out.

Do you think anyone who owns a Lamborghini Gallardo actually buys automobile insurance for it? No, of course not. Not even liability coverage.

Why? Because the risk of insuring such an expensive, easy-to-crash-and-damage automobile is simply too high to justify the cost.

What they do instead is put x amount of dollars (per state minimums for liability) into some sort of trust that will act as insurance coverage if they’re ever in an accident. Should they get rid of the car, they can get all of their money back.

In a way, it’s analogous to retirement investing. We, each of us, could theoretically insure ourselves with sufficient planning and proper budgeting.

But that’s just too much to ask of people nowadays.

Zuma's avatar

Ahh, I see, its insurance its supposed to be riddled with exclusions and exceptions that ding you every time you access your health care. Its all about being profitable, and here you thought it had something to do with keeping you healthy.

There was a study done by the Rand Corporation that found that even a $5 co-pay discourages people from accessing their health care. It does not raise any meaningful amount of revenue, it is purely and simply a nuisance factor to keep people from getting services. And, in that respect, it is a form of rationing.

Just click your heels three times to change your insurance, its just that simple.

Why anyone would feel that simply paying their health insurance premium should be enough to get preventative health care is beyond me. But then I’ve had my empathy surgially removed.

The_Compassionate_Heretic's avatar

Yeah the insurance companies suck bad. They exploit the sick and the healthy alike.

Judi's avatar

@robmandu ; You just made my case for universal health care. Screw the insurance companies. health care should he a basic human right. People who make decisions about what is and isn’t covered should be answerable to the voters, not the share holders.

kevbo's avatar

It may be worth your while to explore your insurance company’s appeals and grievance process as well as that of your state’s department of insurance. Most states have a definition of “medically necessary” care that insurer’s have to provide coverage for. I would guess that recommended screenings for “high risk” individuals falls under medically necessary care.

You have a right to use the insurer’s appeals and grievance process and if that provides you no remedy to take it up with the state’s department of insurance as a mediator/arbitrator.

If you’re not able to get it covered, then a) that should mean you can go to any provider you like and b) some of those providers may offer a “self pay” discount. Insurers get a break on the price for providing a network of health plan members (i.e. a “volume discount”), so if you’re paying out of pocket (a “self pay”) you may be able to get a similar discount for the service. This might be applicable only to non-profit providers (such as a hospital system), but I’m not 100% sure.

Try to talk to a claims specialist (either the GI provider’s or the insurer’s) to get an idea of what the mysterious “allowable amount” might be. Someone knows that number or at least a ballpark.

dpworkin's avatar

From what I can tell, we are going to have to deal with this bullshit a long, long time. Truman tried and failed to reform health care in the US in the 1940s, so has everyone else who tried, and it looks like Obama is about to fail as well. The insurance companies are 700% more profitable today than they were in 2002. 7 times the profit of 7 years ago. They will do, and have done, almost anything to hang on to that.

scamp's avatar

I would love to see the insurance company send me back some money if I don’t get sick! But we all know that will never happen, ha ha!

Here’s a real nightmare for you. My daughter is pregnant and she suffers from Hyperemesis gravidarum, which (quoting from the link here) If inadequately treated, HG can cause renal failure, central pontine myelinolysis, coagulopathy, atrophy, Mallory-Weiss syndrome, hypoglycemia, jaundice, malnutrition, Wernicke’s encephalopathy, pneumomediastinum, rhabdomyolysis, deconditioning, splenic avulsion and vasospasms of cerebral arteries. Depression is a common secondary complication of HG..

She has lost 15 pounds in 12 days because she cannot eat or even drink water due to severe nausea and vomitting.

The drug of choice for her condition is Zofran. It is used for cancer patients and treats severe nausea. Because it is expensive ($1000.00 per month) the insurance company says they won’t cover it because it’s not medically neccesary. Hmmph!! Staying alive and not starving both mother and child seems pretty neccesary to me, don’t you think?

Insurance companies are notorous for doing this thinking they will save money if the patient gets tired of fighting and lost in all the paprework and pays for medications and procedures themselves. That really stinks, and something needs to be done to make them stop doing things like this.

dpworkin's avatar

Frankly I blame the Blue Dog Democrats and nearly the entire Republican Caucus. Some because they are on the payroll of Big Insurance, some because they want to hand Obama a big fat loss and don’t care who gets hurt in the process.

JLeslie's avatar

With my original question my point was if both groups need the test, why are they charged differently for the SAME test. If they charged a 50 year old me $80 co-pay for a certain test, I would be fine, it is the unfairness of it. It;s the SAME test! Both are preventative.

@robmandu Let’s forget about the gov’t option for a minute and just talk like free marhet capitalists for minute. I HATE that insurance is seemingly attached to our jobs. I know we have the option to look outside, but realistically how the system is set up now it is cost prohibitive. I don’t want my company to offer me health insurance as a benefit…give me the money so I can choose and buy my own plan. The “group” arugument to negotiate better choices doesn’t work with me, because the best insurers would have the most individuals going to them, so there is a “group” all of the people using that insurance company and so the ones with good customer service and great plans would win. That would be real competition. How it is now your company chooses for you what company and what plan more or less with a few options maybe provided to you on deductables and things like that.

If the doctor had to tell me what he was going to charge me, I bet fees would be less in many instances, because it is easier to charge a company. The same with flights, hotels, etc. If you are flying last minute on a weekday look out, because you are competing with companies expense accounts.

I had one instance where I needed a drug to terminate an ectopic pregnancy. If I don’t get the drug I might wind up needing surgery or dying. The hospital could not get it approved…$450 drug more or less. I sat in front of the insurance girl while she talked to three different people at my insurance company. Finally, I said, “I will pay and fight later.” She called up to the pharmacy and mentioned I was a patient of Dr. Maxsom’s. Then she held the phone away from her face and said to me, “he says for Maxsom’s patients it is only $50.” Ripping of my insurance company! That is an outrage.

YARNLADY's avatar

We have discovered a little know option with our insurance company coverage, and that is the written appeal. Lucky for us, Sis is a paralegal in a large law firm, and she is authorized to help us with our written appeals. You’d be surprised how quickly an insurance company will respond favorably to a letter on a legal letterhead.

Yes, it’s a lot of trouble, yes, it takes a great deal of time, but what’s the worst that can happen – maybe your appeal will be denied. For a situation like @scamp or even @JLeslie I suggest the time and trouble would be worth it. Hire a lawyer.

alive's avatar

@JLeslie sing it sister.

galileogirl's avatar

Maybe I am misinterpreting the term “preventative care”. With my insurer it means more care pre-crisis in order to reduce the need for crisis treatment. Since I have had bad reactions to certain meds and a complicated history they automatically schedule me for visits and tests’ I had a quarterly blood test on a Friday and on Saturday morning when I got home from shopping there was a call from the emergency room to come in immediately. On another occasion I had been tested for glucose level & they called me to check into the hospital for further tests and shortly I had a colonoscopy and a cancer diagnosis. Although my brother was only 48 the same HMO scheduled him for a colonoscopy and found polyps.

I am automatically scheduled with a cardiologist, primary, GYN, diabetes educator and ophthamologist-the system has my preferred date and time choices. My primary has sent me to a cholestrol advisor, a nutritionist and a group that teaches people how to deal with chronic illness at no cost to me. Dr visits are $10. ER is $35. In-patient admission-free There are stress classes, diet groups, all kinds of exercise programs offered at a nominal fee, usually $10. They even subsidize joining the Y.

When I cancelled my GYN appointments and went past two years they sent me a registered letter to get my attention-it did.

This is the way insurance should work, keeping people healthy is more economical than waiting until they are sick enough to die-unless you are planning to deny them any care at all.

tedibear's avatar

@galileogirl – Are the calls, automatic appointments, etc. a function of your health care providers or of your insurance comany? I think it’s great, I just want to understand who is doing this for you. And if it’s your insurance, who are these wonderful people??

scamp's avatar

@YARNLADY Thanks for the suggestion of the written appeal. That is what we are doing at present. If you can get a doctor to take the time to get on the phone, appeals can also be done much quicker that way. You do not need a lawyer to do this. When I worked for a podiatrist, I did the insurance appeals and pre-certs for that office. Many insurance companies hire a third party company to do all of their authorizations and precertifications for them.

If a medication or service was denied, and it was something that was time-sensitive, I would call back and get the medical director on the phone with my doctor, and within 10 minutes we had a final decision, usually favorable.

In my daughter’s case, her doctor is too busy to spend the time it takes to get on the phone and wait for the medical director, so she faxed a letter to the company to appeal. I know she will be approved once they jump through all the hoops the insurance company puts in front of her. But it frosts my cookies, because they had to put her and her baby in a life threatening situation while making her do the paperwork. That is inexcusable.

alive's avatar

@galileogirl i think that maybe the phrase jleslie used was a bit misleading. no one is against preventative care, but WHEN there is a problem, for example, breast cancer cannot literally be “prevented” it can only be caught early, so if you feel a small lump you should not be punished by your insurance company. they should not deny a test just because of the timing. they really should not decide at all when or what test you receive. that should be up to your doctor. (i think we can all agree on that one)

Flo_Nightengale's avatar

Just what is the price of a human being?

galileogirl's avatar

The insurer is the provider/HMO, Thinking this over, I’ve figured it out. You mean managed care, insurance-speak for manage to spend as little as possible, not preventative care. It was on the news yesterday that the insurance companies here in California refuse, on average, to cover 20% of all claims. One company turns down 39%. Wouldn’t that qualify as rationed care?

JLeslie's avatar

Thanks for all of your replies, I was not able to get online for a few days. I think preventative care should include early colonscopies if you have had a polyp before and your grandfather had colon cancer (that is my history) I have never had cancer, and I am not symptomatic for that. If you get polyps early you PREVENT colon cancer the majority of the time. How am I different that a 50 year old getting a routine one? Isn’t the company going to save money catching my polyps now, then my cancer later?

With my mammogram I was due for a mammogram anyway, so they just recoded it and it was covered by teh insurance company. This seems like bullshit to me. All about the coding, and not doing anything illegal, not fraud, just a simple number changes things.

Of course they are rationing, I think someone should take a big fat book of an insurer and show what that looks like, how it reads, I bet it is just like the governments option more or less; although, I admit I have never seen a document like that I am just guessing.

I know you can challenge the decisions of insureres, but when you are SICK it is awful to have to do it. When you are already overwhelmed with medical decisions, pain, and stress, the last thing you need to is fight with your insurer.

Previously, my colonscopies and mammogram had been 100% covered. This policy with my husband’s new company it so illogical it makes me sick.

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