Excellent point, Karl, and nice to hear for someone in the “business”. We have had a couple of things that have been done out of network The wife works in the health care industry on the infrastructure (IT) side, and as a result knows the back end of the business as far as claims processing, provider agreements, etc., etc.
For whatever reason, we’ve never been able to get her reconstructive surgeon accepted by our carrier. They simply make it as difficult as possible for some disciplines to get on board, most likely because they don’t want to deal with the costs, I’m guessing. So we negotiate. Since our out of network copay is like $3k, we negotiate that with the provider. In nearly every case we are able to get at least 50% knocked off of that amount, if not more. And we pay cash at the time of service, which also gives us leverage when negotiating, as the provider knows they’ve got money in the bank when they’re going home that day. Something else for everyone who uses private insurance to be aware of: If you’ve got a provider who is out of network, but the carrier’s providers are substandard or inadequate, you can ask for a waiver and challenge the carrier’s choices. We did this with the reconstructive surgeon. Her carrier’s in network providers weren’t board certified nor did they specialize in the type of reconstruction work she desired. When the carrier denied the approval of the (out of network) provider she chose she challenged them. A week later there was a conference call between her, her cancer surgeon, a nurse advocate from her employer, and a couple of people from the insurer. The insurer couldn’t make a case for not approving the surgeon she chose, so they green lighted the work and treated it as being in network. On a related note, this same thing comes up with the stupid claim that some forms of treatment are “experimental” when they’re being used in the mainstream. I believe Aetna has gotten nailed on this a couple of times and backed down. You can challenge the insurance company’s decisions. There is a process for it and it does work. Unless whatever has to be done involves a life threatening condition if you don’t like what they tell you, challenge them. Just be sure to do your research and be calm and reasonable. When I worked in the schools a peer of mine’s husband had some sort of muscular issue where the muscles in his neck forced his head to be turned to one side. Not only was it painful, it affected his ability to eat and he had to retire early, as he certainly couldn’t teach. Whatever standard treatments were used to address his condition didn’t work for him. He was like this for a couple of years. One day I was talking to his wife, who was telling me about a hospital in Jacksonville that had a procedure that could likely cure his condition, but it was fairly new (not “experimental”). Our insurer had refused to pay for it. When she told me this I asked her if she challenged the insurance company on the denial. She didn’t know that was an option. She went back to the practice that was doing the procedure and told them what happened and asked if they could help her challenge the denial. She collected a great deal of information where it had been done and paid for by other carriers. The practice provided one of their people for the conference call with the insurer. A couple of weeks later she got the approval. Her husband’s condition was cured and he’s leading a pretty normal life now. You gotta advocate for yourself. No one is going to do it for you. These corporate behemoths certainly aren’t going to help you out, either, especially if it’s going to affect their bottom line. -D > On Aug 28, 2019, at 4:13 PM, Karl Wittnebel via Mercedes > <mercedes@okiebenz.com> wrote: > > Just about anyone should be able to negotiate a 75% cash discount on a > hospital bill. Big insurers typically receive over 80% off. Many > people/individuals simply fail to negotiate. Hospitals keep the posted > rates high because some (few) insurers actually pay the full rate. > Hospitals will happily take 25% over nothing. But even 25% can be a lot of > money for many people to pay. > > One thing no one mentions here is being able to choose who you see when you > get sick. Cheaper plans tend to be more restrictive. You may not want the > team or the facility they give you. It is almost impossible to be an > educated consumer in the health insurance business because you dont know > what dread disease you are going to get, and the coverage provisions are > almost impossibly arcane and disease-specific typically. > > Like Dan and others said, the answer all depends on how sick you plan to > get. My counsel for any middle aged person would be to go for the PPO and > sleep well at night. It does depend a (tiny) bit on how big a bite that > extra 400 takes out of your monthly budget, but penny wise, pound foolish > as they say. Your employer is paying more than you are typically, if it is > any consolation. > > On Tue, Aug 27, 2019, 2:39 PM Dan Penoff via Mercedes <mercedes@okiebenz.com> > wrote: > >> DING!! DING!! DING!! >> >> We have a winner, folks! >> >> That’s pretty much it, Kaleb. They’re doing nothing more than transferring >> the risk (cost) to you. If they’re going to take on more risk (PPO) they >> are going to charge more. If they take on less risk by shifting it to you >> (HDHP) they charge less. >> >> -D >> >> >>> On Aug 27, 2019, at 5:34 PM, Kaleb Striplin via Mercedes < >> mercedes@okiebenz.com> wrote: >>> >>> I really wish they offered 2 tiers of PPO that includes a mid range >> option. I may take a look at the more expensive hdhp which it’s deductible >> is not that much higher than my current ppo. It also has the same 20% >> coinsurance my current plan has. Premium is very close to the same >> also. So if I did that one it would come out to 420 per month. If I put the >> max into the hsa it would be more per month before taking into account >> coinsurance. I guess I would not have to max it out on that one because the >> plan would kick in sooner. I guess it really all comes done to betting you >> won’t have to use it and the money stays in the hsa. If you do have to use >> it the money goes away pretty quick I would guess. >>> >>> Sent from my iPhone >>> >>>> On Aug 27, 2019, at 4:09 PM, Dan Penoff via Mercedes < >> mercedes@okiebenz.com> wrote: >>>> >>>> And that’s the point my HR benefits buddy was saying - the costs are >> much the same, it’s just a matter of whether or not you want to pay up >> front (PPO) or pay as you go (HDHP). >>>> >>>> If you pay up front and don’t use the plan, you lose. If you pay as you >> go, you bear more of the risk if you do need it, and if you don’t, you come >> out ahead. However, next year you might not come out ahead, so it’s really >> a roll of the dice. >>>> >>>> -D >>>> >>>>> On Aug 27, 2019, at 5:03 PM, Kaleb Striplin via Mercedes < >> mercedes@okiebenz.com> wrote: >>>>> >>>>> If I do it I would just about half to max out the hsa. I really need >> to do some more math and figure out how much the out of pocket would be if >> the plan was used. I’m starting to think it maybe end up being a wash if >> you actually have to use it before the plan kicks in. >>>>> >>>>> If I’m reading it correctly with it being an unembedded deductible >> which is $6000 family on the cheapest plan. With company contribution that >> comes to $7k a year so that would leave $1k left for the coinsurance. >>>>> >>>>> Sent from my iPhone >>>>> >>>>>> On Aug 27, 2019, at 3:30 PM, Mitch Haley via Mercedes < >> mercedes@okiebenz.com> wrote: >>>>>> >>>>>> Kaleb intends to max out his HSA limit, which will eventually cover >> the deductibles, but not if a big payout happens in the first month. >>>>>> >>>>>> I wonder if "50% off" is more or less than the insurance negotiated >> rates? >>>>>> >>>>>> Mitch. >>>>>> >>>>>>> On August 27, 2019 at 9:12 AM Dan Penoff via Mercedes < >> mercedes@okiebenz.com> wrote: >>>>>>> >>>>>>> >>>>>>> I’ve mentioned this before, but I’ll say it again: >>>>>>> >>>>>>> When the wife was going in for one of her cancer surgeries, I was >> sitting at the desk in admitting and saw a sign on the desk. It said if you >> didn’t have insurance they would discount the bill 40% if you paid it >> within 30 days. If you paid it in 15 days or less, they would give you a >> 50% discount. >>>>>> >>>>>> _______________________________________ >>>>>> http://www.okiebenz.com >>>>>> >>>>>> To search list archives http://www.okiebenz.com/archive/ >>>>>> >>>>>> To Unsubscribe or change delivery options go to: >>>>>> http://mail.okiebenz.com/mailman/listinfo/mercedes_okiebenz.com >>>>>> >>>>> >>>>> >>>>> _______________________________________ >>>>> http://www.okiebenz.com >>>>> >>>>> To search list archives http://www.okiebenz.com/archive/ >>>>> >>>>> To Unsubscribe or change delivery options go to: >>>>> http://mail.okiebenz.com/mailman/listinfo/mercedes_okiebenz.com >>>>> >>>> >>>> >>>> _______________________________________ >>>> http://www.okiebenz.com >>>> >>>> To search list archives http://www.okiebenz.com/archive/ >>>> >>>> To Unsubscribe or change delivery options go to: >>>> http://mail.okiebenz.com/mailman/listinfo/mercedes_okiebenz.com >>>> >>> >>> >>> _______________________________________ >>> http://www.okiebenz.com >>> >>> To search list archives http://www.okiebenz.com/archive/ >>> >>> To Unsubscribe or change delivery options go to: >>> http://mail.okiebenz.com/mailman/listinfo/mercedes_okiebenz.com >>> >> >> >> _______________________________________ >> http://www.okiebenz.com >> >> To search list archives http://www.okiebenz.com/archive/ >> >> To Unsubscribe or change delivery options go to: >> http://mail.okiebenz.com/mailman/listinfo/mercedes_okiebenz.com >> >> > _______________________________________ > http://www.okiebenz.com > > To search list archives http://www.okiebenz.com/archive/ > > To Unsubscribe or change delivery options go to: > http://mail.okiebenz.com/mailman/listinfo/mercedes_okiebenz.com > _______________________________________ http://www.okiebenz.com To search list archives http://www.okiebenz.com/archive/ To Unsubscribe or change delivery options go to: http://mail.okiebenz.com/mailman/listinfo/mercedes_okiebenz.com
