Friggin health insurance

[shoooooots]

Oh, you can be sure, most of them know what insurance you have and what they pay.

you'd be surprised among hospital affiliated physicians. they don't care what insurance you have. they're "in the family" of the hospital system which pays them a salary & feeds them patients to care for, they joined the "family" either so they could keep from going bankrupt while the hospital ate up their customer base or to remove the worries of reimbursement, credentialing, staffing etc. (or more likely both)

Thats not how it works at all. You know just enough to be dangerous. Not enough to know what the hell you are talking about.

Really? Then pick something I've said & explain how it's inaccurate. All I'm saying is the patient being treated by roper can take that roper order to musc & get the same test, & it makes sense for the patient's wallet to shop around & not just blindly wander from appointment to appointment. if you can get the care from an independent provider, you are probably better off financially in doing so, what you have to watch out for is quality. not all MRI machines are created equal & not all doctors have a fellowship on their CV.

please elaborate. and explain to me why I get a call from INsurance Company A who asks me to be a part of their network. Surely I can say NO, but THEY are the ones recruiting.

as JJ explained, the insurance wants you to join because it expands their provider network. the provider chooses their in or out of network status based on whether they're willing to treat patients for the reimbursement amount the insurance is willing to pay. it's a contract negotiation between the insurance & the provider to decide on the "allowable" (the contracted rate for a given service) & the fact that a particular provider is out of network means that provider is not willing to work for what the insurance is willing to pay.

[marsh chicken]

nonsense, it's your choice. there are independent labs, x-ray places, etc. & your doctor can't force you to have the test at a particular facility. they're scheduling it at the one they own because it makes their bank account bigger or keeps them from getting bitched at by the folks signing the checks, all the while still providing you with the care you need. they care about your health, not your wallet typically.

False. the provider dictates their in or out of network status. i can elaborate if y'all don't understand how this works...

Correct. Why do you suppose the insurance prefers you to have the test some place your doctor has no vested financial interest? Could it be that some doctors would take advantage of the system & run unnecessary tests to afford a new Porsche?

The doctor can still "through bill" the patient for the lab tests. Medicare is exempt from this, but most insurance allows it. And the reference lab fees are often times higher than what the doctors office would charge of they ran the test in the office. So that argument doesn't hold water...

Quality of care and services? The reference labs, independent imaging groups, doctors offices, hospitals, surgery centers, etc all use the same or similar equipment for diagnostic testing. And they are held to the same standards by accrediting bodies that oversee them. So insurance shouldn't have a problem paying for services that are charged to the patient in a fair and customary manner, just like any other business.

What else you got?

[Bad Habit]

shoots- we must go to different Doctors- mine takes an active part in scheduling tests and prescribing medications based on the patients insurance coverage and ability to pay if un or under insured- that's one of the frustrating aspects about this entire thing- we( DR and patient) are doing everything possible to ensure the insurance covers the test and still get the shaft( billed out of network) somehow.

shoots- or should we call you shiiits- you sound like an insurance person trying to cover up the scams they run in order to never pay, it's not about intelligence, or knowledge, it's about a rigged against the patient system, and I'm sure plenty of Drs. get screwed by the Ins co. too

[shoooooots]

haha i do not work for an insurance company, but my employer does provide healthcare & consultative services in more than 1 state.

The doctor can still "through bill" the patient for the lab tests. Medicare is exempt from this

Medicare patients are not necessarily exempt, have you heard of ABN?

insurance shouldn't have a problem paying for services that are charged to the patient in a fair and customary manner

it's all about medical necessity & conservative treatment from an insurance perspective. this is not a patient care centered model & it sucks. The doctor is no longer given the benefit of doubt by the insurance company that their order means it is medically necessary nor is it assumed the less expensive conservative treatment options have been exhausted. This was a growing trend pre-ACA & post-ACA it exploded with even some of the best plans in SC like PEBA (Blue Cross for state employees like cops, firemen, teachers, etc.).

that's one of the frustrating aspects about this entire thing- we( DR and patient) are doing everything possible to ensure the insurance covers the test and still get the shaft( billed out of network) somehow.

so they sent you to a facility owned by their boss which uses a 3rd party radiologist who's not contracted with the only major payor in the state without telling you there's a place down the street which charges 3x less?

[marsh chicken]

An ABN is totally different than what I am talking about. It's a waiver for service not normally covered by Medicare. I Was explaining that Medicare will only allow the facility that performs a test to bill for the test. And why do you think the physician is responsible for knowing the costs of services that he refers out? I don't expect the local tire shop to be able to quote a transmission rebuild...even if they refer me to a local shop they normally use.


Insurance has no place in deciding what is best for a patient. That's between the doctor and patient. You can't use beaurocracy and data to dictate better medicine. All that does is add costs and frustration to an already fucked system.

[2thDoc]

it's all about medical necessity & conservative treatment from an insurance perspective.

said no insurance company...EVER