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Posted on 6/7/18 at 9:12 pm to financetiger
quote:
No one is talking about running a charity! We are simply talking about quality care.
The issue is that the provider, the payor, and the governing body don’t agree on the definition of quality. So far the government and accreditation boards side with the payors. However, there are many avenues to contest denials if you truly feel they are unjust.
Posted on 6/7/18 at 9:13 pm to LSUfan4444
Agree with you for the most part.
It takes all parties to agree to a contract. Don't want to get into all of that here, as there has been a lot of recontracing with vendors in recent years.
Just saying, in my experience, the insurance companies I mentioned have a very tedious process of delays and denials despite being provided with all info THEY requested, including good narratives from experienced providers.
It takes all parties to agree to a contract. Don't want to get into all of that here, as there has been a lot of recontracing with vendors in recent years.
Just saying, in my experience, the insurance companies I mentioned have a very tedious process of delays and denials despite being provided with all info THEY requested, including good narratives from experienced providers.
Posted on 6/7/18 at 9:14 pm to Ric Flair
quote:
These PPO’s use gimmicks such as free gym memberships and whatnot to sell people their plan.
Exactly! And non-medical people don't know better so they think they are getting "perks". Next time, ask your doctor if his parents have a "managed care" plan (Humana, People's, etc) or if they have the "traditional" Medicare with a supplemental. You'll get your answer!
I've known too many people who have struggled to get the care they need bc their "advantage managed care" plans make it harder on them and their doctors to get tests, medications, referrals, medical supplies, etc. I've seen patients denied chemotherapy!
This post was edited on 6/7/18 at 9:23 pm
Posted on 6/7/18 at 9:20 pm to tigerjjs
quote:
They could only draw their blood at certain labs,
Not sure who told your dad that but that’s not true. I’m sure Peoples is contracted with certain labs but even if he went to a lab out of network he could have them drawn and just paid a higher cost..staying at those “certain labs” would have given him the lowest (or no) cost
quote:
their doctor got denied to try and get an MRI that my dad needed. The doctor said he could have gotten it covered very easily if they had a different kind of insurance. He had to go see a spine specialist to get the MRI covered
For the most part Medicare advantage companies follow similar criteria when approving tests like MRI’s. Like others have mentioned, original Medicare is different. They don’t have those prior auth requirements. They pretty much pay for everything and from time to time go back and due reviews afterwards to see if it was truly necessary and if not, then they recoup funds but it’s pretty rare. A HUGE reason medicare is broke is because of this very reason. They’ll pay for everything and providers know it.
Posted on 6/7/18 at 9:22 pm to financetiger
Yea. Those $0 outpatient copays are great until you get hit with the hospital bill for one of Humana’s 72 hour observation stays that would meet inpatient criteria for any other sane insurance company.
Posted on 6/7/18 at 9:25 pm to tigermed
Actually, he does know what he's talking about. Peoples' health doesn't allow their clients to draw blood from any OLOL labs. So basically, it's another "money" issue. Patients should be able to get their labs drawn any darn place they want to! There's no pleasure in getting labs drawn!
Posted on 6/7/18 at 9:25 pm to tigermed
quote:
Those $0 outpatient copays are great until you get hit with the hospital bill for one of Humana’s 72 hour observation stays that would meet inpatient criteria for any other sane insurance company.
What’s lower, 20% of a 3 day in patient stay with original Medicare or 3 days in obs while on Humana?
What’s humana old benefit for a 3 day observation stay?
Posted on 6/7/18 at 9:28 pm to LSUfan4444
You have been brainwashed sir. Everyone knows there's more baby boomers on it now, more than ever, and it's being stretched.
Keep believing Humana is "saving" you money. Bigger bonus coming your way at the end of they year!
Keep believing Humana is "saving" you money. Bigger bonus coming your way at the end of they year!
This post was edited on 6/7/18 at 9:30 pm
Posted on 6/7/18 at 9:28 pm to LSUfan4444
Not sure of the exact numbers but I do know people get hit with the full cost of medications when staying in obs. $20 acetaminophen adds up.
Edit: word
Edit: word
This post was edited on 6/7/18 at 9:30 pm
Posted on 6/7/18 at 9:29 pm to financetiger
quote:
he does know what he's talking about. Peoples' health doesn't allow their clients to draw blood from any OLOL labs.
They most certainly do..and the patient pays an out of network lab cost. If OLOL refuses to draw the labs that’s not on Peoples. Their members have out of network benefits for labs (at least for the plans in New Orleans and Baton Rouge they do)
This post was edited on 6/7/18 at 9:30 pm
Posted on 6/7/18 at 9:30 pm to LSUfan4444
quote:
What’s lower, 20% of a 3 day in patient stay with original Medicare or 3 days in obs while on Humana?
The member’s OOP cost would be less with any MA plan in LA than it would with Medicare.
Posted on 6/7/18 at 9:31 pm to tigermed
quote:
Not sure of the exact numbers but I do know people get hit with the full cost of medications when staying in obs. $20 acetaminophen adds up.
Id be willing to bet the patient responsibility is less with most advantage plans in Louisiana.
Posted on 6/7/18 at 9:32 pm to LSUfan4444
quote:
They most certainly do..and the patient pays an out of network lab cost. If OLOL refuses to draw the labs that’s not on Peoples. Their members have out of network benefits for labs (at least for the plans in New Orleans and Baton Rouge they do)
Go back and do some more research!
Posted on 6/7/18 at 9:38 pm to LSUfan4444
quote:
Id be willing to bet the patient responsibility is less with most advantage plans in Louisiana.
That’s fine and that may very well be the case. I don’t work in billing so I will concede this point. I do stand by my argument that these managed plans deny and delay transfer to appropriate rehab facilities when a patient is inpatient. This does lead to higher cost to both patient and hospital that the insurance company later denies to pay.
Posted on 6/7/18 at 9:40 pm to financetiger
quote:
Go back and do some more research!
See link below for Peoples Health.
Pg 76, 77
This post was edited on 6/7/18 at 9:42 pm
Posted on 6/7/18 at 9:43 pm to LSUfan4444
You are in St Tammany parish. This is EBR. Y'all don't even have OLOL over there! Try again.
This post was edited on 6/7/18 at 9:44 pm
Posted on 6/7/18 at 9:47 pm to financetiger
The more you try, the more you’re wrong.
OLOL most definitely is in St Tammany (Covington and Slidell)
For out of network lab policies in EBR, see link and pages 77/78
LINK
OLOL most definitely is in St Tammany (Covington and Slidell)
For out of network lab policies in EBR, see link and pages 77/78
LINK
This post was edited on 6/7/18 at 9:49 pm
Posted on 6/7/18 at 9:51 pm to LSUfan4444
I have family in EBR who uses an out of network lab on a Peoples plan multiple times a year out of Convenience. My uncle would rather get it done in the same building as his pcp so he just pays the difference..even with the out of network costs it’s only like $15 or $20
Posted on 6/7/18 at 9:55 pm to tigermed
quote:
I do stand by my argument that these managed plans deny and delay transfer to appropriate rehab facilities when a patient is inpatient.
I’m certainly no MD and in no position to argue what is and isnt appropriate on a patient I know nothing about but its not like Humana and Peoples just make up criteria to approve prior auth requests for admissions or procedures.
I do however acknowledge that those prior auth requirements make it harder to obtain services from time to time....but, that’s what they’re supposed to do. Theyre supposed to do what Medicare can’t, control costs and help limit over-utilization.
This post was edited on 6/7/18 at 9:59 pm
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