No More Emergencies
ฝัง
- เผยแพร่เมื่อ 12 ก.ย. 2024
- Like all of my health insurance content, this is completely true. This is one of the more egregious examples from Anthem of blatant criminal activity, and it’s been going on for years. Remember, they don’t care about you. They just want to extract money from you any way they can. You can read more here👇
www.acep.org/g...
Insurance companies will usually just pay less money on a claim they disagree with. Anthem takes it further and flat out refuses to pay anything. No appeal, nothing. This is illegal but when you have the most money on planet earth, laws don’t matter.
there is a thought where we make them pay money worth about 10% of the company in stocks, that should make them think twice and net the government more money, the consumer wins, the government wins, and the insurance company thinks twice
@@theodoreeliaseronsten5468
Just do a thorough check on all illegally denied claims, make them pay the claim with an added zero on top... then fine them for the same amount.
See how long it keeps happening.
Surprisingly, this suggests that reputable but smaller insurance companies won't do you dirty because they can't afford to break the law
@@Diviance This, unfortunately, would require a government that isn't 100% and entirely fine with the status quo.
Why the hell are doctors billing thousands of dollars for an ultrasound of the chest?
If a crime is only punishable with a fine, then it is a punishment for the poor only
Sadly well said...
Agree for some crimes and the way we do fine people needs to change (I know some countries do them as a percent of income), but they are a good middle ground between inprisonment and things being ilegal. Would you rather Jaywalking is a misdemeanor makes you go to prison (AMERICAN prison) and be put on your record for future jobs or that you get a fine/wages garnished without a record similarly to a traffic fine?
"Punishable by fine" = "Legal for a price."
Only way around that is to pin fine amounts to a percentage of income, like a few non-lobbied-into-irrelivance national governments over in Europe have started doing.
@@roganf4013 That's a big ask for many governments and there are things governments may want to discourage without giving prison time for them, which is worse especially in the US (although with the kind of insurance stuff in this video the CEO or someone should probably get some).
@@RRW359 I'm not sure I understand. Are you disagreeing with Rogan? They're suggesting that what currently are basically flat fines, should be a percentage of income. That way, the multi-millionaire will be pissed when he has to pay 3M$ for running a red light at 75mph and the big ass corpo that makes 100B$ a year will think twice before doing something that'd cost them 20B$. Fines are there to dissuade people from taking a certain course of action. For corpos, it's simply numbers. If the gain/loss ration is bigger by breaking the law than by following it, why would they follow it? If the cost of a fine is insufficient to dissuade people from doing it, then it fails in its purpose.
The issue with the US is that those big ass corpos and those multi-millionaires and billionaires gave money to the government in place in order for that not to happen. If the government were to still try and get it to go through, another government would take its place and undo any progress.
I know johnathans get a lot of attention and are considered the heroes, but for me, Jimothy, questioning the absolute insanity of our healthcare system, is my hero.
Yes!
Let’s not forget Jimothy!
He too, is essential.
Jimothy is our inside man.
Yes! I need a Jimothy prayer candle!
@@kristinamcdonald3316 I second this!!
True, but a good Jonathan knows how to use language in charts to make it very difficult for insurance agencies to deny basically anything legally or in their current policies
Remember, if fines are not EXISTENTIALLY THREATENING to a company, they are merely the cost of doing business. Also probably jail some CEOs or something.
You'd think that after a certain point, people would become criminally liable...
@@TN-rf7nt The point that criminal liability comes in is when a lack of justice threatens the entire status quo. But that's up to people to have expectations of the government doing things that are helpful.
I saw a story on reddit I think once, a person had a rich friend and the friend thought of every illegal thing that came with a ticket as it "costing that much", not being bad to do.
Fining, when meant to be punitive, should be proportional?? Because otherwise you are literally punishing poor people more than rich people for the exact same offense.
@@nyandoesthings They do proportional traffic fines in Finland. Some big millionaire got a 100K ticket.
@@nyandoesthings yeup. Non-scaling fines effectively just become defacto legal for the rich. Now it might just be my political bias but I think that's a bad thing, something we should fix.
"People need stop having emergencies!"
"Good idea, we could make primary health more accessible and affordable!"
"No, I don't think we'll be doing that."
Exactly! Invest in preventative medicine and maybe people's health won't collapse.
In my area it's almost impossible to find a PC doc that's taking new patients and if you find one they're so busy its w tom3 months to get an appointment
@@jimw7723 Same in my area except you can't even find that. My insurance assigned me a PCP, I contacted them to find out that they don't accept patients on public insurance, "assigned" or not. I contacted my insurance, they "assigned a new PCP and same thing. Did this 3 times before I started looking myself. I must've called a hundred doctor's offices, all the same thing, they don't accept patients on public insurance. Guess I'll die.
Exactly! If I could finally find a PCP that accepts my insurance and is taking new patients I wouldn't have to go to the ER everytime I need my asthma meds refilled
And create a comprehensive public health service across the US, working on health promotion and heathcare public health as well as health protection, focussing on reducing inequality as a fundamental driver of ill health
As an ER doc who just finished a work meeting regarding the new CMS changes for billing reimbursement this feels 100% factual. I truly believe there will be a special place in hell for people like this corporate guy. Until there's a law passed that prevents financial profit from healthcare none of this will change.
I struggle to sleep at night because of how sickening and immoral it is, but the execs sleep like sociopathic or willfully ignorant babies.
Are you an American ER doctor? Question! I'm a Mexican doctor caters to American doctors in the US as an interpreter and I've heard patients had a CT scan because "they had abdominal pain". Like... They weren't even sure what they were looking for and AFTER the CT scan they did an US... I almost burst into laughter from the irony of the situation. Seriously, who makes the guidelines over there? And they're complaining about insurance not paying? I mean...maybe 🤔 diagnose first and then order a CT scan? Also, I've heard many doctors say "im not sure why you have the pain but we've ruled put anything threatening because all your tests results are normal so just go to your PCP".
True.
This kind of garbage is exactly WHY i quit healthcare.
For-profit healthcare KILLS people. I didn't train to work for insurance, pharmaceutical and medical supply companies. And that's who we are actually working for.
When healthcare is actually interested in helping people and no longer a for-profit business, I'll go back. Not until then.
@@chinchillamdgamer I was thinking that US Dr's might be over testing their patience in order to avoid legal action against them, because sueing Dr is more common in the US because they are not a well integrated with and protected by the Government. Does it sound likely to you?
The truth in this actually hurt my heart. Lost my sister thanks to insurance companies playing the delay-and-deny game. These people are absolute trash and nothing stops them
😡Health insurance companies should be charged with the murder of people like your sister, and I’m not exaggerating.
they need to be stopped
A general strike would make them sit up and listen. All of us workers (not healthcare providers) striking even one day/month until we got universal health care. What solidarity that would be. What a difference we could make.
@@janinawaz4596 i’m down. We need a general strike in healthcare probably more than any other field.
I am SO very sorry you lost your sister. That should not happen. My heart hurts for your loss
I worked medical billing for a few years in an ophthalmology office, I also assisted with a few other basic things. There were way to many claim denials. One that still sticks out to me though, was a simple visual field test I did for a patient. After it was finished I noticed something that looked very concerning. I immediately grabbed one of the techs, showed it to her and she took it to the Doctor while having me call a Neurologist who was in the hospital and tell them we were bringing someone over now. I later found out the visual field had detected what turned out to be a brain tumor. The tumor was caught early and the patient survived without much damage. The insurance declined to pay for the visual field, claiming that because it was an unnecessary test and they only would cover one every other year. Calling the test which found an early brain tumor unnecessary completely blew my mind. Sadly that was only the second most frustrated I ever got at an insurance company while working there.
jfc, can only imagine what the first one was....
@@linedpaper5374 The first was when Cigna Opticare dissolved and just got rolled back into Cigna. 2 months worth of patient visits didn't get paid for. All attempts to talk to Cigna about this were met with either claims that they never received the HICFA or claims that they had prepaid for the services, of course they could never provide a check number or even a contract with us showing we were setup to take prepayments. Over 50 ophthalmology offices banded together to sue Cigna. It went on for over 6 months. Cigna was telling their clients not to pay us because they already had (remember if your insurance doesn't pay, the client is responsible). Cigna's legal team was so good at talking in circles that the lawyer we had hired quit and sent us a fairly nasty letter stating that Cigna had paid us and that we were just wasting his time.
About 2 days after we received that letter from our lawyer, Cigna finally paid, but refused to pay any late fees. I like to think I had something to do in getting it resolved as I "leaked" a senior VPs direct phone number to every one of our patients and the other offices and the letter Cigna sent where they acknowledged that they owed the money had a large P.S. about how we need to be careful not to provide that information to any of the clients and only have them call Cigna through the normal client number.
Edit: The funniest part of that whole mess was the lawyer who had quit on us, got wind that Cigna was finally paying and sent us a letter demanding his percentage. Our office manager basically told him to pound sand and he never tried again.
@@matthewpoff2077 you a SAVAGE! Leaking the VP's number, total savage. 😅
@@matthewpoff2077 The word is doxxing.
@@xinfuxia3809 Giving out someones business number is not doxing. I didn't give out their personal cell or anything.
Ugh people not realizing that yes it is law that has no real teeth and they pay their fines and NADA. It keeps on happening.
Here's an idea, we fine them the amount equal to the claims they illegally denied, plus more to cover the costs. Too bad wealthy politicians who benefit from healthcare for profit would never allow this.
As the old saying goes, "If the punishment is a fine, that just means it's legal as long as you're rich."
@@Radiodragonofdoom
We may need to enhance their consequences a bit 🙃
Here is another idea : Set the amount of the fine as a percentage of the revenue of the company.
Fines are just the fees for doing whatever you want in America.
Back in high school I worked at a call center that Anthem contracted with to provide follow-up questionnaires and feedback. I had worked at the call centre for about 2 years prior to that contract, and quit after the first week. That was the saddest and most depressing week of I have ever experienced in my entire life. Listening to family members crying and yelling because Anthem denied care and their loved one had passed away. It broke me.
Only apathetic /evil people can do those jobs. I hope you take good care and have a Merry Christmas. ♡
I worked for a health insurance company once. For 3 days. Then I walked out. I couldn't be evil.
Good for you
heck, I worked as a *broker* for a few weeks and my conscience hurt trying to sell products I knew were flat-out evil. I couldn't do it
I worked in two different jobs for approx 3 weeks each merely handling insurance for clients. I became so angry I had to quit. Absolutely infuriating injustice.
If everyone had such scruples, the insurance companies wouldn't exist. (Just the thought of it makes my heart sing 💞)
There was a health insurance company I worked for for maybe a few days - I quit, mostly because I didn’t want to be the one telling someone, “you have to get prior authorization first,” “we want you to try two or three other medications first before we’ll cover the one that your doctor says you should,” or, “looks like the meds your kid needs is going to cost around a hundred dollars or the one you need is going to cost you about a thousand dollars this month.”
I am not a violent man, but sometimes when I see these situations, and I see the people whose lives have been RUINED by the greed of these mfs... I cannot say that I do not have less than calm thoughts.
Thank you for your service, Dr. Keep bringing the heat, so that maybe more people open their eyes.
Sorry, vision wasn't covered by the insurance either so, eyes have to be optional organs
You can take comfort in the fact that people who have power and authority and commit injustices go to hell when they die.
@@privacyvalued4134 hell isn't real, they ought to burn now
Mood af. Viva la revolucion…maybe someday…
they only have about 20 sites, im sure with a few visits we can make them see how important the er is.
Years and years of getting a life-changing operation and a procedure once a month so I can function like a human being and then all of a sudden they send a letter saying that we do not think it's medically necessary the second letter said our doctors do not believe it's medically necessary I love how their doctors can tell me what's necessary for my health but they're not my doctors
Contact the place you got the procedure at, mainly the claims department. Sometimes they can help. Also, contact your in insurance companies claims department, and look into what their "doctors" specialized in. You'd be surprised how many times auths get denied because their Ortho doctor denied a test to that had nothing to do with orthopedics whatsoever. Like denying a test needed to diagnose cancer when the doctor only knows foot medicine and nothing else.
Lol, their doctors definitely have no doctor-patient relationship. They only have a doctor-money relationship.
Good luck, it's a hard fight trying to get them to pay up
Like
How workman’s comp works
Ur unable to shower alone but ur “only 50%” disabled so…
Ppl just suffer with no pain meds n no income - along with their kids
@@riorio982 Also contact the Insurance Commission in your state, the Attorney General for your state, and all of your state and federal senators and congressional representatives. Call your local and state newspapers and news broadcasters. Use the ombudsman at the hospital where you have your procedures performed. Encourage others with problems to do the same. Make noise! That may help get some pressure on the insurance companies to do better.
If my insurance no longer pays emergency bills, there is literally no more reason to have them.
Exactly.
Exactly! I only have insurance for my kids for emergency room visits. Because everything else I always end up having to pay out of pocket anyways. So take away emergency room visits and it becomes completely useless
Just wait a few months and it will be illegal to not have health insurance. Who's it protecting? America of course.
@@hotmodelinbikini it already sorta is
I'm so thankful for the healthcare here in Australia. 3 weeks ago I had to have surgery for a ruptured bicep tendon and my only expense was the TV hire fee for my room as I had to stay overnight. Even my physiotherapy is covered.
Damn near impossible to get postnatal or paediatric support in Tasmania, too, let alone mental health. We literally don't have enough psychiatrists to cover essential services and our government is focussing on putting in a football stadium. Our elective surgery wait lists are 3+ years for some procedures and people regularly die on them but what do we get? Burnt out nurses, abused paramedics, ambulance ramping and a FOOTBALL STADIUM.
If there are any American doctors reading this, come to Tasmania. We need skilled workers, we take them readily and our state is incredibly beautiful. National parks, beaches, mountains and fewer species of dangerous animal than mainland Australia.
@@helenkettle2208 there's no universal med care in NZ?
@@snausagesmcqueef1604 why don't your people riot? I know that the same question could be asked of america, and I know the answer to it, but what's the answer in your case?
@@helenkettle2208 I thought you had a good social support system in NZ? Or do you mean that you don't qualify for Medicare if you aren't an Aussie citizen in an Australian healthcare setting? I think that's actually reasonable and lines up with what most migrants have to put up with, international insurance is pretty reasonable anyway. When I worked in public health admin I am sure that NZ citizens had all their oncology treatment free at the hospital I worked in as well. I think Kiwis get better treatment than a lot of other migrants in Australia overall
Read the room
If this executive ever ends up in an emergency room I hope they run ALL the tests they possibly can just to make him pay for it.
I hope they don't and just send him home with Motrin.
But, see, he can easily pay for it
Let him sit in the waiting room for hrs.
@@stephaniejensen4103 but see, being an exec, he probably is in good with hospital administration staff and so he'll get priority treatment for his stubbed toe
This is why Glen Beck stopped saying America has the best healthcare in the world. He got macular degeneration and had to spend the night in the ER. Now he doesn’t talk about American healthcare.
Poor Jimothy doesn't get paid enough for this. 😭😭
Yeah, I had an insurance company say today that a CT of the knee needed for pre-surgical planning was "experimental or investigational". We were able to figure something out to help the patient not get stuck with the bill ultimately, but it is ridiculous. I'd like to say it's a new low, but it's probably a new middle when it comes to them.
A CT scan...experimental?
Burning the midnight oil eh doc? Always appreciate your videos, cheers.
Thank you for not being afraid of these companies and speaking out against them!
I want someone to honestly explain to me why we need medical insurance in America. We pay a huge chunk of our income to have to argue with a heartless company to keep your life savings if we get sick. Imagine paying for private fire insurance to be denied coverage because they changed your plan at the start of the year to no longer cover electrical fires.
Yeah, and I don't think you need to go to school for business to realize that a middleman company, that makes a profit, between you and a hospital does nothing but increase prices overall.
Yeah. But that's not an issue with "Health Insurance" per se, that's an issue with " *_For Profit_* Health Insurance".
Every unnecessary person wedged between a client/ customer/ whatever and a product/ service they want/ need is one more mouth to feed on that client's/ customer's teat. And private/ for-profit... well... *_anything_* , really... is all about squeezing those teats as dry as they can get away with in the name of their owners/ shareholders.
We need them because their hearts pump blood. Fix that issue and we'll be free.
@@j0ndav1s you are dense
You are such a breath of fresh air. After a long day you bring us joy.
John's Hopkins straight up sent out a letter saying they couldn't accept BCBS anymore starting in December because they weren't paying the bills enough out of insurance claims to pay staff. They came to some sort of resolution, but I think health care facilities have more sway in this than they realize.
Your assuming tha fac1lities are owned by people who care. M3dicine is so corrupt lately.
You have a gift sir. You somehow made a video that was entertaining, informative, and devastating to people who don't know these things are happening. Please keep up the great work.
I would like to nominate this video to be played over and over 24/7 in both chambers of Congress, piped into the home and DC offices of every Senator and Rep, and blasted 24/7 in every office of every federal and state level department regulating health care, insurance, big corporations, and criminal prosecutions until all of these snakes--elected folks and government employees alike--either resign and flee the country or fix it.
So true. Now I understand that the health care companies own every aspect of their business I'm less frustrated for some reason. I guess I know I'm not nuts trying to get around in the system unnecessary, it's designed that way. So not only are you physically ill when you start dealing with them your mentally ill when you give up and they won't pay jack on that claim either.
We have Anthem BCBS. This scares me because my husband had an expensive and necessary surgery and they’ve been running us in circles over paying for it. The hospital, a large hospital, keeps calling us asking us to call them again because they’re not responding to the hospital. 😬
I know it's annoying, but keep on them about it. Escalate it. They just hope that you give up and wont have to pay.
Request a written explanation of the denial. Then use that to submit evidence describing medical necessity in an appeal. If they deny again, request an outside independent review - such as a state insurance regulator. Over half of those end up getting paid by insurance. Deep breaths.
so now insurance companies can practice medicine without a license....
I was in the same boat after my first kid. Eventually had to conference them both on the line myself to make sure the hospital sent the claim correctly and insurance received the update. Good luck, but I'm sorry you need it.
@@NoorAtaVFX i can absolutely attest to this. i cleared my surgery with my insurance before i had it performed - they agreed it would be zero cost to me as the patient. after the procedure, i received a 12k bill and a million excuses as to why they reneged. it took 8 months of calling, harassing, escalating, threatening but in the end, i won and paid zero. they are 100% waiting for you to give up but victory is possible if you have the determination.
As someone from a country with universal healthcare, from the outside the American system looks terrifying. Russian roulette every time you need to use the health service: will my insurer find a way not to pay and I lose my house? The health service where I am is far from perfect, but at least I don’t have to wonder if it’s worth going to the ED with chest pain just in case it is just heartburn and suddenly I’m staring down the barrel of a bill with many zeros on it.
It's usually not that bad. We also usually go to our primary care doctors for things like heartburn, but sometimes lately if primaries have absolutely no open appointments they tell you to go to urgent care or the ER/ED. Usually most of the unpaid cost falls on the hospital for outpatient visits, usually. I've looked at my EOB (explanation of benefits, a monthly or biweekly outline of what was billed by medical facilities, what insurance paid, and what the customer may be responsible for) sometimes and seen an injection that was billed for $1000 (which is way overpriced, but that's another story) and the insurance company only paid $5, and some of my migraine nerve injections in my head my insurance company pays far the local anesthesia, but the steroid that does the long-term work? They just deny payment. My doctor still gives it to me, I don't pay extra for it, but the doctor's office just eats the cost of the medication required for that treatment. It's so bizarre.
When I saw that it happened that way I actually apologized to my doctor that he wasn't getting paid for it, but he told me it was ok and not to worry about it because that's just how insurance companies work sometimes. Granted he is still paid very well and his family will not go hungry while he works, but I still feel bad when my providers aren't getting proper payment. Granted the loss probably doesn't fall on him but on employees lower down the food chain and cost cutting in supplies, tools, etc.
@@Just1Nora It's very easy to say you can just go to primary care for heart burn, but the entire point is that you don't know if it's heat burn, and before you do it can feel exactly the same as the pain caused by an imminently life threatening heart attack that needs emergency treatment.
One fun thing is going to one location that I supposed to be in network but you get bills from 4 different departments. And if you you to the emergency department, it may be managed by an outside company and have a provider that is out of network so you get dinged for that.
@@rockbe02 Oh, the ER thing is called double billing or balance billing and it's illegal in most states and under most insurance plans. Unfortunately most people don't know this so they pay it thinking that they will be in deep sh!t if they don't. It's best to just call your insurance company and ask them what you owe and to whom. They'll usually tell you that the balance billing is charges that you don't owe, but the hospital is trying to make up the balance that they know your insurance company won't pay. One of the pretty easy ways to detect this fraud is that you get a bill from the hospital before you've even gotten an EOB from your insurance company, and they will be SUPER pushy about getting it settled, offering payment plans, etc.
Your EOB is like a credit card bill. It tells you who was paid what and who MIGHT ask you for additional payment and how much. If someone asks for money that isn't on your EOB you tell them to call your insurance company and work it out because you don't see that you're responsible for those charges.
Never rush paying medical bills! Trust me, you usually have at least 3-6 mos before they consider sending you to collections, often a year. Don't ignore it, but don't rush and pay it just because you're scared. They will try and intimidate you into paying, but don't budge!
I'm poor and chronically ill, so I do this crap all. The. Time. It's a dance. The gentle threats they slide in, then they say they worry about you so they offer payment plans, sometimes they mention how they don't want it to end up affecting your credit score! The horror! It's not much, seriously, it's very low impact on your score, like a private credit score check. And if you think the claim is balance billing and a debt collector calls, tell them that you dispute the debt and you need more time to talk to your insurance company and the company that filed the debt collection. It will get you another 6-8 wks.
@@Just1Nora what a nightmare. Glad I don't have to deal with that mess anymore.
Oh man, as a patient with multiple chronic illnesses, this hits close to home. I'm always amazed when the insurance company thinks it knows better than my doctors.🙄 Your videos are amazing! Thank you for the laughs as well as for spreading the word about more serious issues too (like in this video).
Same dude...
I love that Jimothy questions the nonsense that comes out of the health insurer’s mouth to his face. It just feels so refreshing 🥰
I've been doing the dance, trying to figure out why my insurance suddenly wasn't covering or adjusting the cost of a med check visit that we'd done half a dozen times. Insurance companies are a blight on civilization and should be eradicated. These are the same MF-ers who wouldn't cover my brother's treatments when he was having multiple seizures a day. It's long past time we built a better healthcare system in the US, one that doesn't profit off denying medical care to people who need it.
it does seem like the biggest part of the problem is the insurance companies themselves. this is not something that would be difficult to change... politicians are just not willing, and both the republicans and the democrats alike both have this problem on their hands. neither has done much of anything.
@@xisotopex The politicians who jare "just not willing" are in bed with/owned by the insurance industry. Wake up!
@@kathleencardincpm4435 no shit, sherlock
You need to call the billing department. There EPIC system always forgets to contractulize. Now if you are eating through your deductible, let them bill insurance then ask for self pay rate.
I've been waiting decades for someone to put into words this clear and creative how the greed and corruption which is the insurance industry harms the nation. Thank you for trying to bring to light what our politicians should be screaming from the rooftops.
They don't want to cross their lovers/bite the hand that feeds them
@@kathleencardincpm4435 Yes, I think that's a big part of it.
Can you say lobbyists? PAC contributions? 🤑
As someone who works in emergency medicine I just flat out cried
The trick is for billing is if you received a triage rate for an emergency room visit that was a higher value you need to verify doctor reimbursement. I always see professional billers(a different entity then the hospital) paid correct. If coders are messing up address that problem, rebill as a corrected claim. If the both codes. If you verified your codes are correct then grab 4 accounts like these call the insurance department. Anthem in the pass would reprocess a list of triaged accounts. I only left my last billing place because they would never promote me to analyst. Why pay a collector analyst money.
Tell us where these people sleep and we'll do the rest. Put the info out and change will come.
Every time you post something about insurance companies I'm more thankful for the NHS. I'm a severe asthmatic and had quite a few trips to resus and not had to put my hand in my pocket once.
I can't get my head around the US medical system. It's like a dystopian nightmare
to think that we spent nearly 100 years demonizing the soviet bloc, when they actually gave their people state-subsidized education and healthcare, all the while sending young kids to invade sovereign states overseas and die for our greed, when that same greed can't even afford us the fulfillment of basic human needs that the evil commies could readily provide.
You got that right
After a 12hr shift working triage in an ER, your videos are a breath of fresh air
This is absolutely correct, as a person who has suffered 2nd and 3rd degree burns on 23% of my body, the insurance company is denying me coverage for burn garments and laser treatments. Now, these laser treatments aren’t cosmetic, they are to lessen the unbearable itchiness. Gotta love insurance companies.
As someone who has had multiple episodes of being in the ER for emergency level symptoms that turned out to be undiagnosed POTS, this is my nightmare. Thank you for letting me know to avoid BCBS
I've been in and out of the hospital all year; MRIs, CT scans, overnight stays, allergic reactions to the meds that supposed to help my neurological disorder. I wonder if my health insurer feels like this! 😂 You are so spot on
Wonder? I'm surprised they didn't drop you. I'm not being sarcastic, btw.
Dr. Glauc videos that expose the evil and corruption of health insurance companies are the most entertaining and important ones! Love this, keep it up.
Jimothy has to work part time for several of these unethical businesses, so he ironically doesn't qualify for the employee health care plan of any these places he gloriously warns us about.
More of the UK public need to watch this to understand why we all need to fight for our NHS
As someone who works in medical billing I felt this on a spiritual level
The trick is for billing is if you received a triage rate for an emergency room visit that was a higher value you need to verify doctor reimbursement. I always see professional billers(a different entity then the hospital) paid correct. If coders are messing up address that problem, rebill as a corrected claim. If the both codes. If you verified your codes are correct then grab 4 accounts like these call the insurance department. Anthem in the pass would reprocess a list of triaged accounts. I only left my last billing place because they would never promote me to analyst. Why pay a collector analyst money.
My favorite part of being a patient in all this is that Anthem wouldn’t cover the meds that would have kept me out of the ER, which cost less than $100, and my clinic couldn’t send the prescription directly to the pharmacy so I could pay out of pocket. Had to just wait until it became an emergency.
Guys like Dr. G spreading information through the channels of the young people is the only way we're going to get this stuff changed.
Agreed, maybe this is what will finally be a catalyst for change: smart satire.
I love this!!! Can you do one about how we hospitalists have to keep patients for days once they are already well, waiting for insurance auth for rehab, while patients board in the ED waiting for medical beds? I always thought it was so nice that the insurance company staff in charge of auths don't have to work weekends. And that's totally fine because patients don't have emergencies on weekends, right? If you submit your auth request on a Thursday the patient goes to SAR on a Monday while patients stack up downstairs. It is such a screwed up and ridiculous system!
Here is the thing Rehab can take them Saturday, and fax the auth Saturday (if Medicare should not matter no auth just correct codes; hmo's need auth). The thing is rehab will not touch until correct auth. We cannot send a patient home without home health(Friday night Saturday, Sunday discharge is impossible ).
@@ashleybeasley5429 sure if Medicare it's easy. But almost half of seniors enrolled in medicare have medicare advantage. And then there are many patients who have private insurance too. They all will need prior auth and will get stuck over the weekend. It's even worse during holidays.
@@dannyash3805 no, just like a hospital admission you have up to Monday to fax in. Hospital refrains due to denials. If you meet criteria, you can appeal and if denied again report the insurance company. Make them eat crow. I did it Medicaid MCO insurance several times... never mess with baby or birthing accounts bad juju. The thing is the insurance company is banking on educated billers/auth getters. I agree I wish it was not like this. Here is the flip, I reported anthem on them denying me a miscarriage (woman birthed baby, already passed). After getting told I was wrong i emailed Medicaid. Never so fast did management (30 min) walk me in asked why was I not being nice. Patient Accounting. Needless, I told them I warned Anthem..
As a UK doctor this makes me so upset, our NHS may be crumbling but at least for now we can still do the investigations and treatments people need, no questions asked
This is why executives and boards of directors need to get jailtime for breaking the law for profit.
Itll never happen because rich people dont go to jail, but it should
I remember being a lil kid and watching a lot of Scrubs. I used to think, ah, well, the systems might fail us, but the good doctors will never fail. And then I grew older, and realized that the good doctors risk a solid chunk of their hide every single time they do right by a patient. And then I grew older still, and realized that the higher ups know this risk, and will actively exploit it. And then I grew older still, and realized that those higher ups are just as beholden to the "health insurance" companies as anyone else. And then I grew older still, and began to grow thirsty.
thirsty? diabetes? I am thirsty every single day beyond my ability to drink water.... but apparently my HA1C is normal...
@@xisotopex nah I was just drunk and felt like it was the most poetic thing at the time, but I hope you get the care you need my friend
As someone with type 1 diabetes who gets letters once a year about “cheaper therapies than insulin,” which my body does not produce, and who has to fight for months to get insulin pumps and continuous glucose monitors approved, and then still pay thousands out of pocket for each year, I am well familiar with these tactics.
They were fined 20ish million in my state. They keep sucking so they became the first insurance company I've ever depaneled from.
cigna?
Your healthcare system is draconian and you speak up about it.
You’re an activist! ❤
In draconian times there were very interesting solutions to problems like these. Did you know pirates would put a rat in a bucket over someone's abdomen and heat the bucket until the rat chewed clean through the person? Just some food for thought.
And I’m going to argue that financial punishments are not sufficient. They punish the corporation (a little) but not the executives making the decision. If you assume that most CEOs are sociopaths that only care about themselves (and there’s pretty good psychological research data to back this up) the best solution is to go after the executives themselves. Criminal charges will get their attention, I imagine. We don’t punish rich people here in America, but in some places in Europe they are actually quite fond of throwing executives in jail. We could learn something from them.
or just fine based on how much money they make.
the laws would have to change drastically for this to happen.... no politician on either side of the aisle would EVER advocate for that...
The problem with financial penalties is that they just raise our premiums to cover for their loss.
Bernie Sanders and Elizabeth Warren both would and have advocated for exactly that. Part of the reason I like them.
Poor Jimothy. He's trying so hard to hold back the evil.
Should do one on workers comp. Definitely belongs in this series
Oh God those bastards are worse than evil...
@@xionmemoria That depends entirely on how your body reacts to it. Flexeril has strong interactions with other pain meds. For me, it doesn't help at all. Instead, along with strong pain meds, it affects my coordination to the point that it's dangerous in day-to-day activities. I've had many doctors say it's the worst of all the muscle relaxants and I agree from personal experience.
Also, assuming things about someone and saying they have issues is insulting. I would suggest addressing how you speak to others regarding your opinion
As a nurse who does pre-certifications, this is spot on. What is sad is that while it is humorous, insurance companies authorize procedures based on their bottom line. Period. Doctors do not dictate patient care, insurers do. So.. how's socialized medicine looking now, America...
If only we could get it...
Edit: by that i mean if only we had socialized medicine
Thank you, thank you, thank you!!! As an EM doc working clinically and on advocacy, I sincerely you appreciate calling insurers out on this egregious behavior!
Years ago I had Blue Cross and you had to call and get permission to go to the ER. I once had serious second degree burns on both hands and they refused stating that not enough of my body was burned. I spent the night crying in pain with my hands in a bucket of ice water.
That’s ridiculous. If it’s an emergency you don’t have time to call and ask permission, you need medical treatment ASAP
I was desperately sick recently for 6 weeks with probable RSV. I ended up in the ER twice at 2 separate hospitals. I was tested for Influenza and for Covid, but neither tested me for RSV. I was told by one staff member that the most likely reason was the cost of the RSV test. 😥 Even though I'm an R.N., I felt too sick at the time to advocate for myself and to insist on the test, which I normally would have done.
If it's 6 weeks and you're an adult, it's highly unlikely to be rsv. Maybe CAP or HAP since you're a nurse
A friend who like me is RN took gpa to ER in respiratory distress,was RSV, which prompted her HCW mom with lingering illness to test RSV pos. So necessary for nurses to be patient advocate. So hard to be both
When we are very ill it is so hard to advocate for one’s self. I have spent much time attending and advocating for family and friends and I feel that it is very important, no, it’s critical to have an independent person that can communicate with the medical team and help the patient understand what is happening so that they can make informed decisions about their health care.
I hope that someone will be able and willing to be there for me when I need it.
@@Wait4me2 you are right,it is critical. 39 yrs of nursing was teaching moms to advocate, standing the line so often. Got myasthenia gravis and found the era of advocate is passed. When the dog is most care you get.... that's my world
@@cherylcarlson3315 Lifting you in prayer for your myasthenia gravis! 🙏❤️ My heart truly goes out to you. ❤️🫂
Okay, new idea: anything that one of these companies refuses to pay for, no senior executive (or their families) are allowed to have any of that type of health care, no matter what happens. So all they have to do is show us how not to have emergencies.
This has a good amount of vengefulness, but perhaps it’s a bit too sadistic
I got sent to the Emergency Room I work at. The insurance I got through the hospital, refused to pay for the trip to the department that I worked in! Insurance Companies are the Devil
Jimothy reminds me of a quote from "Yes, Minister":
"You must always try to do good,
but you can never let anyone catch you doing it."
The only way to do good change is either uproot the whole thing from below with cataclysmic colleteral damage but effective results or try to sneak improvements in from the top, a much slower process with an even smaller rate if improvements and many casulties along the way but it keeps some form of order.
Came here for a relaxing video night cap. Now I'm staring at my bedroom ceiling awake in terror... (Thank you for these videos, though! Spreading the truth. )
Yup. There's two systems in America that you don't want to fall into. The medical system and the justice system. Both will suck you in and suck you dry.
That laugh when finding out it's against the law? I almost thought you were introducing a University of California admin character...
Agree completely with you, Dr G. But I can’t help but wonder if these companies won’t come after YOU someday? Be careful.....we all know how powerful these companies are!
Gotta love the American health care system. Money first, patient care later. I feel you Jimothy.
This isn't even American health care system
BCBS offers socialized healthcare as well
@@duckymomo7935 As far as I can tell BCBS is just a health insurer, that's not what universal healthcare/"socialised" healthcare is.
The problem is that socialized/universal healthcare does the same things, just in a different way. They'll put you on a two year wait list for a surgery you needed yesterday, or the healthcare that's afforded you that's free is so bad that you end up having to pay to go to a private hospital anyways. When I was dating an Aussie girl she complained of the horrors of socialized medicine hospitals, where the doctors straight up didn't care and/or weren't skilled, and the talented doctors would rather go work at the private hospitals where they make more money. She almost died from several health complications developed in the hospital due to negligence and poor treatment.
I'm not saying this from a misguided "America's Healthcare is the best!" But because universal healthcare isn't the best either. From what I've seen, every system has its own flaws and needs major reformation.
@HeirofCarnage Can't dispute what you say about Aus but in the UK most doctors in private also work in NHS. You jump the queue. Get a fancier room, but get the same doctors. You also get out of hours cover by an RMO with goodness knows what experience, no on site cardiology or critical care. So if there's any emergency it's off to NHS in an ambulance.
I disagree that socialised medicine results in doctors who don't care.
@@heirofcarnage1782 Australian healthcare prioritises rapid access, so surgery that you actually need urgently does get done urgently, plus because the private system has to compete against free the total cost of tax plus private cover still winds up being way cheaper than the US if you fancy the red carpet treatment. And yes, people sometimes have bad experiences here. Same with the US, doctors and nurses are human too and every system has its gaps, but the US has way larger gaps than pretty much any other well developed healthcare system.
Source, I am Australian, I have family who have spent tons of time in and out of the system, far more than "I spoke to an Australian once". Many of us don't even bother using private cover because the public system is so good in most cases, and basic clinics in private land are so cheap it's often easier to just pay out of pocket for them.
Yup, sad but totally true. I was a nurse who did the appeals to insurances for denials to the hospitals. It’s a losing battle.
The trick is for billing is if you received a triage rate for an emergency room visit that was a higher value you need to verify doctor reimbursement. I always see professional billers(a different entity then the hospital) paid correct. If coders are messing up address that problem, rebill as a corrected claim. If the both codes. If you verified your codes are correct then grab 4 accounts like these call the insurance department. Anthem in the pass would reprocess a list of triaged accounts. I only left my last billing place because they would never promote me to analyst. Why pay a collector analyst money.
The US health insurance system isn't broken, it's intentionality rigged.
I have a chronic health condition that causes my joints to dislocate very frequently. Usually I can fix it by myself, but sometimes they get stuck and I need medical assistance. Due to my job being at all hours, I find myself needing help at night, which means the only place available is the ER. Even in network, health insurance denies my claims and leaves me with at least half of the bill *constantly*.
It's legitimately gotten to the point where I just let the worst of it go to collections. I make just enough money that the bills can't be waived, but not enough to pay them. If they want anything from me at this point, they'll have to come get it--and even then, there's nothing.
I'll never forget being in a psychiatric hospital, only being able to do ECT outpatient because they would not cover it inpatient, and then being released while still actively suicidal because my insurance company said I "wasn't gonna do it" lmao
I just know someone is going to come in here and say something like “well they were right, you didn’t” and I just want to say that 1. That’s survivorship bias and 2. Mental health issues are real and people who suffer from them deserve to get treatment. Have sympathy
@@ckdraws410 I had outpatient ECT the next morning, so I was fine. But only because of outpatient treatment. Thanks for the comment.
We see this on the pharmacy end way too often and it's causing a lot of pharmacies to lose money and close!
Yup, that's how I ended up with $16,000 of ER bills. After my 7th concussion in 5 years (two of which I lost consciousness for longer than a minute and still have lingering physical and mental deficits from), my roommates took me to the ER because I was having trouble speaking, had practically zero balance, and my vision was fading in and out. The ED took one look at my history and immediately took me back for CT and other tests. Because of the pain I was in, I spent the night in the ER and got lots of fun meds. All my other concussions had been covered, so I wasn't particularly worried, I just wanted relief. Yeah, what a joyous surprise I had two weeks later, getting THAT bill.
My eighth concussion was just a few months ago, and it was very minor. I knew right away I had a concussion, but didn't want to be smacked with more bills. So I closely monitored my pain, my symptoms, and my heart rate for two weeks. I'm fine, but also scared that if I get another concussion and stay home to avoid bills, I'll miss something and end up in a worse state.
Hii there doc , how is your mother now?????
She’s doing ok, I’ll give periodic updates. Thanks for asking
the god bless america had me wheezing, thank you for always addressing such complex and important topics with your talent Dr. G
Love your content
For any company with on-staff lawyers, it should be a 3 strikes rule.
Strike 1 is the penalty decided by a judge,
Strike 2 is 10x the penalty decided by the judge
Strike 3 is the entire company's board of directors and beneficiaries removed, on the spot, the company is then split into 10 different insurance companies that are banned from hiring anyone related to the original company.
Long time viewer, Dr. Glac. And yes, I will say what more and more people have been saying for years.
We don't have a Healthcare system.
We have a Health Insurance system.
Pick one. Aetna. Cigna. United Healthcare. Anthem. Etc, etc. Someone screwed someone else out of a procedure/operation/test/medication/and so on that they needed, but nope, not paying. And then is there any wonder why doctors are getting people on their last legs? Because they could nor afford it and whatever insurance they had won't pay or is too expensive to maintain that insurance . It is like some sort of never ending downward spiral.
As an ICU nurse with 5 decades of experience, I have watched the anti dumping laws of the 80' s circumvented so many times. Cemeteries are full of Insurance denials.
I wanted to laugh, but then I remembered the gigantic bill from an ER visit that ended up being a stroke.
IDK how they get justify denying that's an emergency or has coverage. I'm glad to know I can look into this being full ass illegal, instead of merely feeling like something that should be. I really appreciate your content and applaud your ability to do these skits without vomiting up concentrated void matter for 6 hours afterwards.
This video makes me think that American insurance companies don't actually care about healthcare... RIP in peace America
They probably never did. They just care about their profit.
@@JohnADoe-pg1qk
Insurance companies never cared about anything they insure. They will always do whatever they can to ensure the house wins.
That's just capitalism in action.
it's sad that I thought this was a joke because why would you ever think these maggots care about anything other than themselves?
You would be correct.
Thank you for your condolences.
I’m a nurse at a free standing ER and we are not getting paid by insurance. Hopefully they will start paying soon so we can get more staff
These sketches about the US healthcare system are like from another planet to me.
In Poland we do not have such a thing as health insurance. Because have completely free health care, also for the unemployed. It covers everything - the dentist, cancer treatments, surgeries (from wart removal to brain surgery), ambulances, rehabilitation, maternity care, tests... well, everything. We also have refunds for some medications. I can't imagine someone not calling an ambulance because they can't afford it. Or refuses cancer treatment (!) Or has debt because of the hospital visit, WTF???
In addition, when we are sick, we simply make an appointment with the doctor. The doctor gives sick leave as needed and we sit at home, not working (according to the law, we can't even work on sick leave) until we recover. According to the law, the employer cannot take any negative consequences on us for this reason. We are also entitled to sick leave if our child falls ill. We get 80% of our salary on sick leave. Of course, we can take sick leave every time we are sick, there is no limit.
We also have more than 20 days of leave and the employer MUST give it to us. In fact, employers even push employees on vacation, because if an employee does not use a minimum of 2 weeks of continuous leave during the year, employers face serious legal consequences. Working on annual leave is also prohibited. We turn off the work phone, leave the laptop at home and do whatever we want.
Pregnant women are extremely protected. A pregnant woman cannot be dismissed from work during the entire pregnancy and after giving birth. When she does not tolerate pregnancy well, she can take time off for the entire duration of the pregnancy, and after the birth of the child, she is entitled to 364 days off (yes, a whole year!), paid 80% of her salary. This leave can also be shared with the child's father. After that, you can also take childcare leave, which lasts 35 months. It is not paid, but the employer cannot dismiss you from work, so you maintain the continuity of the employment relationship.
As far as I know, in the US you can fire a pregnant woman overnight, and maternity leave lasts about 3 weeks? It's crazy. I would never want to live in the USA. Seriously.
The US has a family leave that is unpaid but protected through the federal government for up to 12 weeks. This leave does not cover pregnancy, as that falls under a special type of disability leave, but covers leaves for caring for your family members (including partners with pregnancy/birth compications or a sick baby.)
Pregnancy disability leave is determined individually by each state and allows the employee a set amount of time where they receive a percentage of their usual salary. The issue where employees are back in their seats after 2-3 weeks after birth usually has to do with the fact that they can't afford the reduction in pay (in California it's 65% of your normal earnings, paid in weekly amounts). The price for birthing a healthy baby in a hospital with little to no complications is easily over $10,000-$15,000 USD and only partially covered by insurance.
Also, if you're not the birthing partner, you rely on whether or not your employer provides leave (often unpaid, and you have to use your accrued sick and vacation time to get your hourly pay) for you to be present to help your non-hospitalized partner and bond with your own infant.
This is part of why people here are so upset over whether our kids are playing too rough or eating the wrong thing or developing poor mental coping strategies. Or why some individuals choose not to have kids at all. We frankly can't afford the medical charges (preventative care for kids is usually covered, but we're charged beyond that), but those with kids would still rather carry debt for 10+ years than watch them die from something preventable.
Yeah. 🙁
Only tangentially related but one hospital to which we transport recently changed their protocols regarding EMS pre-arrival reports. Basically you have to specifically call an alert and ask for a response team or you won't get one. You can say "We're bringing you a trauma patient" but unless you say the magic words "this is a trauma alert and I need a trauma team to respond" you're gonna get put in a double-digits room and wait for ten minutes to give report to a nurse.
here you are lucky if ems only has to wait 10 minutes to give report to a nurse.... we have a hallway where ems patients are stored, sometimes waiting a couple hours before ems can give hand over a patient... in those hours of course, those half dozen, or more, ems teams are unable to respond to any calls... and while that is going on, because the hallway is filled with 10 patients from one end of the hallway to another, there are another 8 patients, still in the ems gurneys, waiting to be transferred to the 'ems hallway'....
You would think that the argument of the company considerably losing money because of a collapse of the system would be enough to deter corporate dude from following through, but it didn't. These people are just pure, unadulterated evil.
That’s because while altruistic and long-term economic aims often coincide, short-term quarterly profits take priority even if they are unethical and unsustainable.
Take the response to climate change; doing the right thing could lead us into unimaginable prosperity/opportunity over the long run, but maintaining the status quo just a liiiiittle bit longer is preferable regardless of how many people have to die to maintain it!
@@acheybones588 ...but why? Like, feck altruism and lets concentrate on long-term stability. Why would short-term income take priority if it is clearly a short lived benefit? How on earth would it benefit me to lose my source of income in a "gamble" where I'm 100% losing? Unless these people benefit is straight up people's pain and suffering, "mantaining" an unsustainabe status quo is just stupid.
Hey Doc I appreciate the PSAs and see it first hand as well but I'm worried about you getting hit by a defamation lawsuit. Thank you for the hilarious videos but please be careful.
Stuff like this is why I am afraid to go to hospitals or doctor's offices. It just isn't worth it to do regular visits with a doctor that cost so much on top of insurance only to run tests to make sure I am not ill that will cost me so much regardless of if they find anything or not. There just doesn't seem much point in going into debt for them to screw me over whether I am sick or not. :/
Most insurance companies have instituted $0 copay yearly wellness visits with a primary care provider, and unless there is something that really flags the doctor you often don't need much if any blood work. You can check your policy to see how much lab work costs you beforehand. It's usually a small percentage of the cost of the tests. Most providers give you six months or more to pay off your debts and as long as you're making steady payments you can usually stretch it out longer if necessary.
I'm on SSDI with Medicare and a supplementary insurance. To me $300 is a big bill, but I can pay over a year sometimes. And debt collectors are not as scary as people make them out to be. I deal with them frequently. You work out a payment plan, or sometimes they'll accept a small lump sum that's a fraction of the cost just to close the account, but that's usually after it's been on your credit report for a bit. Medical collections don't heavily affect your credit score either. Carrying a high balance on your credit card makes a much bigger difference!
Your health is worth it.
I had an uncle who was afraid to go to doctors and hospitals. A year ago, like a few days ago, he went to bed and never got up. I miss him so much.
Likr Nora said insurance bills (and uninsured bills) are usually substantially cheaper and many primary care clinics are used to working with lower income patients and can connect them to resources to help reduce their costs further. It’s a lot cheaper to go to a primary care clinic and find out you have high blood pressure or diabetes and treat it with relatively cheap maintenance medications, than it is when it becomes an emergency (stroke, heart attack, severe and infected diabetic foot ulcer, etc.).
Of course the hard part is actually finding a primary care practice that’s still taking new patients. As one of the lowest paid specialties many new graduates don’t want to go into it because they’ll struggle to pay of their student loans, as a result it’s the field with the most severe shortage of providers.
🙁
@@Sharkster_J yeah basically all of doctors in my area are out of hospitals except specialists. I am already paying a bunch for the specialist I currently see. I can't really do any more.
I will say it again: America needs a public healthcare system not only for those who don’t have insurance, but for those that do as well. Insurances would have to provide good service in order to survive when there is competition from the public sector
As someone outside the horrible USA .... it's so heartbreaking to see.
These videos need to be required viewing for congresspeople.
See this is why I believe that the financial penalty for violating a law in a way that increases profit should have a penalty _dependent on the amount of profit made from violating that law_ as determined by an impartial 3rd party audit. Once a company is convicted of having ignored a safety regulation, or illegally underpaid employees, or unlawfully refused payouts, or disregarded environmental regulations, etc, they are billed for an external audit *by a forensic accounting company they do not choose,* and at the conclusion of the audit they are fined an amount greater than or equal to the amount of money they illegally saved or made.
If this causes the company to go bankrupt it gets a one-time public bailout in the form of the government purchasing a controlling stake in the company. It then becomes a publicly owned corporation and is subject to certain new regulations including a maximum wage gap, and the discontinuation of the use of contracted labor (or other measures to prevent getting around the wage gap limit). Afterwards, dividends from the shares purchased by the government are split evenly among all individual U.S. taxpayers in the form of an annual rebate.
Its sad how accurate this is with every large company. Tiny fines are just a business expense
Jimothy is starting to feel like a character at the beginning of a superhero movie who’s about to get into a superpower-granting accident and dangle his boss off a bridge.
Unfortunately, this is a dystopian story not a superhero story.
The "death panels" people should have considered that they already existed in every corporate boardroom and every senior shareholders' meeting.
So great!
Also we need a medical assistant character to be a duo with the scribe, basically behind-the-scenes-Batman-and-Robin of the office hahaha
Getting my husband migraine medicine that both WORKS and is covered by insurance is a friggin nightmare. He was using Aimovig for several years, but the single injection eventually stopped being effective. Insurance refused to cover double dose. We later had to switch insurance, and it didn't cover Aimovig at all. His neurologist managed to find some pills - Qulipta (daily) and Ubrelvy (an "as needed" thing similar to rizatriptan, which he had been taking, but less bad on the body). So far they're okay with the Qulipta, but we just got denied the 16 pill refills of Ubrelvy. Community Health Choice apparently thinks that 60 pills (they cover 6 refills of 10 pills each) should be enough to last a whole year, which... if you have chronic migraines, you'd know is absolute fantasy. Big ugh.
What's the difference between an insurance company executive and SARS-CoV-2? At least SARS-CoV-2 has become less deadly as it evolves.
Okay… I see the point being made. I love Dr. G and insurance companies do suck! As a hospital auditor for E/M codes, level 5s represent the highest level of care. Often, they are rarely supported by documentation. The guide the code needs to meet is set by the AMA. While a blanket statement that “we, the insurance, won’t cover these” is not right at all, it is not correct to bill level 5s for every/most patient(s) who come in, which is often what occurs. For example, a heartburn/heart attack patient like above. We have an undiagnosed new problem with uncertain prognosis. Let’s say we have two categories of testing performed to figure out what is going on. The end result is the patient needs prescription antacid medication. To bill a level 5, 2/3 of those categories need to be at a high level of risk. The example I came up with is a level 4, as only one category meets that high level. Absolutely. Not. Saying all cases are like that, or even all heartburn/heart attack cases, but I see too many that are. It’s expensive for the patient because of our broken healthcare system. Not every ER visit is a level 5.
It's good to hear a bit from the other side. Both insurance companies profiting from medical care (or lack thereof) and hospitals profiting from medical care are at risk of losing focus on the CARE in favor of the profit.
Of course over billing is an issue but you should read the Medline article from September about this. BCBS isn't just downcoding, they are completely refusing payment entirely - but only for physician services. Meanwhile they paid the much larger hospital fee for the same supposedly unnecessary care. They are doing this mostly for small physician groups that they know can't fight back as much. The groups examined the denied bills and found most of them met the level 5 MDM requirements but were denied anyway. It is basically extortion. Insurance companies make money by denying care - they should be put out of business.
Some insurance companies are deliberately denying full payment of emergency services in the hopes that providers will balance bill their patients. This is illegal in many states (including CA) and has been illegal nationwide since 2022 with passage of the No Surprises Act. I got a bill for $800 which I politely refused to pay. This prompted a letter from my insurance company demanding an interview to talk about my injury to see if other insurance would cover the claim, which I politely declined. It's not my job to figure out billing. I consider this harassment of me and my provider. Unfortunately at the end of the day, this also adds stress and potentially lost revenue for the medical provider as well.
A laser targeted directly at the truth.
"no more emergencies"
Well then perhaps you should increase your payments on primary care so people with chronic conditions don't neglect care to the point of emergencies. Just an idea, just...a thought.
Funny and terrifyingly accurate all at once as usual, Dr. G.
These American insurance ones are so painfully depressing. Sending well wishes across the bigger pond that you'll get somebody in congress with the guts to get universal healthcare passed!
"I don't want socialised medicine because I don't want the government deciding what care I get/paying for other people's care" ....... yet people are happy with a non medically trained, for profit insurance executive deciding?
Oof, I know this is staged as comedy. But knowing this is pretty much how health insurance executives think makes me really glad I live in a single payer healthcare system
The worst part is that sometimes the only place that can help you based on your symptoms is the ER! My 40+ year old husband had terrible chest pains in the middle of the night. I called the 24-hour nurse line and she said, "ER!" I frantically drove my husband to the ER and they ran the tests and concluded... he had chest pain. We figured out later that his chest pain was a result of us being "so in love" in the months after our wedding that me lovingly resting against his chest night after night hurt him. Then I had kidney surgery and a few weeks later, developed back pain that made it impossible to bend over so I worried that it was related to my surgery (and I had an international wedding to go in a couple weeks later and I didn't want to have a medical emergency abroad in the middle of my cousin's wedding). Went to Express Care and I was told, "ER (because you need imaging)!". I waited for 8 hours to be seen and the conclusion was... I sit too much. I was basically diagnosed with having an office job.
I don't know that I've ever had my soul feel so hilariously crushed before