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Old 02-09-2018, 01:02 AM   #26 (permalink)
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My sister contacted the insurance company who said she could get the medication by mail for $15.00. I am confused by this. $294.00 at the drug store but $15.00 by mail? They are being shipped to her but she will believe it when she sees the bill. If there is a larger bill she will be sending them back she said.
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Old 02-09-2018, 04:53 AM   #27 (permalink)
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The problem with a bracelet, necklace, or other wearable, is that they can be easily misplaced or stolen. Probably a better idea to have it in an injectible microchip.
A fingernail with a USB connector ?
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Old 02-09-2018, 06:36 AM   #28 (permalink)
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CVS does auto-refill for me about every four weeks. A few extra bucks for them, and I build up a bit of a reserve supply. You need that reserve supply, because randomly "the doctor has to authorize the perscription" or some such, which holds things up.
Yeah, I prefer to have a reserve for things like that. Out of my epilepsy meds 2 of the 3 of them have auto-refills. Frustratingly, one does not and insists if I refill it in 90 days, no earlier and exactly how many are in the bottle, everything is fine.
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Old 02-09-2018, 06:39 AM   #29 (permalink)
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Originally Posted by DanielRavenNest View Post
Phone apps would be hackable because phones are connected to the Internet. It would be better to have a data bracelet or necklace that's normally unplugged, except when being updated by a doctor's office, or being read by paramedics in an emergency. Stupidly large amounts of data will fit on a chip the size of a fingernail, so such devices don't need to be large.
You have to draw the line at some point. It is just a REALLY bad idea to draw it with everything for everyone in the cloud. There are already electronic medical records and apps for them.
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Old 02-09-2018, 06:44 AM   #30 (permalink)
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Originally Posted by Kelley Wonder View Post
My sister contacted the insurance company who said she could get the medication by mail for $15.00. I am confused by this. $294.00 at the drug store but $15.00 by mail? They are being shipped to her but she will believe it when she sees the bill. If there is a larger bill she will be sending them back she said.
Actually, it is plausible. For plans I have been on getting a med delivered was typically a 90 day supply for what the plan would pay for two 30 day supplies at the local pharmacy.
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Old 02-10-2018, 05:31 PM   #31 (permalink)
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I am in Canada and this is not true. Yes there is some criteria for some procedures like knee, hip replacements but in general I have only heard once that a procedure is not covered and it was for wart removal. I had a minor procedure (that in the US I would probably still be waiting for it to be approved). I had a reaction and was re-admitted they did X-ray , and EKG, and a CT scan. Nothing showed up and I was release. I had an Ultra-sound later that week and a follow up appointment. Time spent consulting an insurance company none. Cost to me Parking at the hospital I think it was about $20.00.

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Your description sounds completely consistent with how it is in the US. It's the provider who works with the payer almost all the time. The horror stories you hear are the exception, not the norm. Complaints get a response bias. I've also never had to talk to my health insurance company myself in my life. Approvals normally are same day. If you were in the US, your provider would have worked with the payer on your behalf, just like they did in Canada. The really, REALLY big difference is that in the US, you don't automatically have insurance.

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Old 02-10-2018, 08:34 PM   #32 (permalink)
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Your description sounds completely consistent with how it is in the US. It's the provider who works with the payer almost all the time. The horror stories you hear are the exception, not the norm. Complaints get a response bias. I've also never had to talk to my health insurance company myself in my life. Approvals normally are same day. If you were in the US, your provider would have worked with the payer on your behalf, just like they did in Canada. The really, REALLY big difference is that in the US, you don't automatically have insurance.
This might be the case in some places and with some insurers; lady knows we did not have issues when in Atlanta and with KP. However, in the 5 years we've been in Florida, with BC/BS? We've had a LOT of issues where both ourselves and the medical folks have had to fight with the insurance; and it wasn't just Anthem, it was the same when we had Alabama BC/BS [and we're in a part of florida where that's NOT an uncommon insurance to have to deal with].

Maybe its just bad luck on our part too, but we've had to pay co-pays for surgeries we shouldn't have had to [and one time got a bill and another a refund], and our co-pays are just going up and up. We got a bill once for blood tests; the insurance wouldn't cover it, though that got sorted eventually...

Anyway, I think saying the whole US works the same as Canada, at least for filling, is a bit of a broad stroke, since it doesn't even seem to work the same across even what is sort of the same insurance type [BC/BS]. I know, after all this and speaking at length with billing folks, the ones I know would -love- single payer and loathe the current system because it is a mess.
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Old 02-11-2018, 05:55 AM   #33 (permalink)
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A fingernail with a USB connector ?
oooo and you can upload the information to the chip in your brain by picking your nose with that finger
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Old 02-11-2018, 09:28 AM   #34 (permalink)
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Old 02-11-2018, 10:20 AM   #35 (permalink)
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Old 02-11-2018, 12:16 PM   #36 (permalink)
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This might be the case in some places and with some insurers; lady knows we did not have issues when in Atlanta and with KP. However, in the 5 years we've been in Florida, with BC/BS? We've had a LOT of issues where both ourselves and the medical folks have had to fight with the insurance; and it wasn't just Anthem, it was the same when we had Alabama BC/BS [and we're in a part of florida where that's NOT an uncommon insurance to have to deal with].

Maybe its just bad luck on our part too, but we've had to pay co-pays for surgeries we shouldn't have had to [and one time got a bill and another a refund], and our co-pays are just going up and up. We got a bill once for blood tests; the insurance wouldn't cover it, though that got sorted eventually...

Anyway, I think saying the whole US works the same as Canada, at least for filling, is a bit of a broad stroke, since it doesn't even seem to work the same across even what is sort of the same insurance type [BC/BS]. I know, after all this and speaking at length with billing folks, the ones I know would -love- single payer and loathe the current system because it is a mess.
We don't disagree that sometimes US insurance companies are bastards. We disagree on how often this happens in other countries with universal healthcare. Seawitch agreed that there is criteria to be met in Canada for costly procedures. People who are initially told they don't meet it are going to be as pissed off as you. I personally know someone in Sweden that had a friend have to argue with their health service over cancer treatments. It absolutely does happen in other countries.

Also:

Issues with UK health service

I still support universal healthcare as a way to help the poor, but it will NOT get rid of a sometimes painful approval process.
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Old 02-11-2018, 12:47 PM   #37 (permalink)
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We don't disagree that sometimes US insurance companies are bastards. We disagree on how often this happens in other countries with universal healthcare. Seawitch agreed that there is criteria to be met in Canada for costly procedures. People who are initially told they don't meet it are going to be as pissed off as you. I personally know someone in Sweden that had a friend have to argue with their health service over cancer treatments. It absolutely does happen in other countries.

Also:

Issues with UK health service

I still support universal healthcare as a way to help the poor, but it will NOT get rid of a sometimes painful approval process.
I'm not saying there isn't an approval process, or even any issues. What I'm saying is, especially since we spend more tax money on health care %-wise than any other country in the world, we pay a lot, and even when we do have coverage, insurance companies find a way to screw us over.

And universal health care shouldn't just be for the poor, but for everyone. Because our current system can and has even destroyed wealthy families.

And again, we spend more taxes on healthcare than any other country. It -ought- to be better, and it ought to work for everyone.
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Old 02-11-2018, 12:57 PM   #38 (permalink)
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Originally Posted by TrollCampFollower View Post
We don't disagree that sometimes US insurance companies are bastards. We disagree on how often this happens in other countries with universal healthcare. Seawitch agreed that there is criteria to be met in Canada for costly procedures. People who are initially told they don't meet it are going to be as pissed off as you. I personally know someone in Sweden that had a friend have to argue with their health service over cancer treatments. It absolutely does happen in other countries.

Also:

Issues with UK health service

I still support universal healthcare as a way to help the poor, but it will NOT get rid of a sometimes painful approval process.
The US does things that I can guarantee would never happen in a country with single payer though. At the beginning of the year, every year, I need to call my insurance company and tell them I do not have secondary insurance or my claims will be denied until I do so.
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Old 02-11-2018, 02:33 PM   #39 (permalink)
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Your description sounds completely consistent with how it is in the US. It's the provider who works with the payer almost all the time. The horror stories you hear are the exception, not the norm. Complaints get a response bias. I've also never had to talk to my health insurance company myself in my life. Approvals normally are same day. If you were in the US, your provider would have worked with the payer on your behalf, just like they did in Canada. The really, REALLY big difference is that in the US, you don't automatically have insurance.
Actually it is not. We do not have providers who work with the payer to approve anything. My Doctor ordered tests, procedures, blood work etc and they were done the government health plan paying for them. There are no deductable, co-pay etc for health services.
I only indicated that the first procedure that was also ordered by my Dr. would probably have to be approved in the US. It will be repeated in 1 year as a pre-caution and I will not have to argue with an insurance company about it being repeated in 1 year instead of 5 because my Dr. has made that decision.
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Old 02-11-2018, 04:23 PM   #40 (permalink)
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Actually it is not. We do not have providers who work with the payer to approve anything. My Doctor ordered tests, procedures, blood work etc and they were done the government health plan paying for them. There are no deductable, co-pay etc for health services.
I only indicated that the first procedure that was also ordered by my Dr. would probably have to be approved in the US. It will be repeated in 1 year as a pre-caution and I will not have to argue with an insurance company about it being repeated in 1 year instead of 5 because my Dr. has made that decision.
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Exactly. Ideally the provider would be the patient advocate but that is not how it works. If you know your insurance will pay for, oh, 5 days in the hospital but not 6 you should make your Dr aware of that. After all, your insurance company knows medicine better than your doctor, right?

edit: It has since changed in some plans but transsexualism used to be a do-not-pass-go. Which means patients were constantly reminding doctors to use any other diagnosis code for things like hormones.
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Old 02-11-2018, 05:46 PM   #41 (permalink)
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State of California investigating Aetna over a shocking admission, in what may turn out to be a huge case

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California Insurance Commissioner Dave Jones expressed outrage after CNN showed him a transcript of the testimony and said his office is looking into how widespread the practice is within Aetna.

"If the health insurer is making decisions to deny coverage without a physician actually ever reviewing medical records, that's of significant concern to me as insurance commissioner in California -- and potentially a violation of law," he said.

Aetna, the nation's third-largest insurance provider with 23.1 million customers, told CNN it looked forward to "explaining our clinical review process" to the commissioner.

The California probe centers on a deposition by Dr. Jay Ken Iinuma, who served as medical director for Aetna for Southern California from March 2012 to February 2015, according to the insurer.

During the deposition, the doctor said he was following Aetna's training, in which nurses reviewed records and made recommendations to him.

Jones said his expectation would be "that physicians would be reviewing treatment authorization requests," and that it's troubling that "during the entire course of time he was employed at Aetna, he never once looked at patients' medical records himself."

"It's hard to imagine that in that entire course in time, there weren't any cases in which a decision about the denial of coverage ought to have been made by someone trained as a physician, as opposed to some other licensed professional," Jones told CNN.

"That's why we've contacted Aetna and asked that they provide us information about how they are making these claims decisions and why we've opened this investigation."

The insurance commissioner said Californians who believe they may have been adversely affected by Aetna's decisions should contact his office.

Members of the medical community expressed similar shock, saying Iinuma's deposition leads to questions about Aetna's practices across the country.

"Oh my God. Are you serious? That is incredible," said Dr. Anne-Marie Irani when told of the medical director's testimony. Irani is a professor of pediatrics and internal medicine at the Children's Hospital of Richmond at VCU and a former member of the American Board of Allergy and Immunology's board of directors.

"This is potentially a huge, huge story and quite frankly may reshape how insurance functions," said Dr. Andrew Murphy, who, like Irani, is a renowned fellow of the American Academy of Allergy, Asthma and Immunology. He recently served on the academy's board of directors...

Jones, the California insurance commissioner, said he couldn't comment specifically on Washington's case, but what drew his interest was the medical director's admission of not looking at patients' medical records.

He said his investigation will review every individual denial of coverage or pre-authorization during the medical director's tenure to determine "whether it was appropriate or not for that decision to be made by someone other than a physician."

If the probe determines that violations occurred, he said, California insurance code sets monetary penalties for each individual violation.

CNN has made numerous phone calls to Iinuma's office for comment but has not heard back. Heather Richardson, an attorney representing Aetna, declined to answer any questions.
Moar background at the link, definitely worth reading.
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Old 02-12-2018, 08:45 AM   #42 (permalink)
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Yeah, I prefer to have a reserve for things like that. Out of my epilepsy meds 2 of the 3 of them have auto-refills. Frustratingly, one does not and insists if I refill it in 90 days, no earlier and exactly how many are in the bottle, everything is fine.
Yeah, I have this same problem here in Florida. I really like to have at least 30 days in hand because if we have a hurricane or some other disaster where stores are not open etc.

The problem with epilepsy meds are that you can't just miss taking them for a day or two, that alone will bring on a seizure even for someone who's epilepsy is controlled.

Whenever I change I do so gradually also, so that means I'm trying to get the old med and the new one at the same time. Trying to explain that to those yahoos we use for mail order prescription though is insane.
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Old 02-12-2018, 08:53 AM   #43 (permalink)
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OMG they just got rid of our BCBS EPO which had a very low deductible and covered 100% if you did "in-network" doctors and gave us Aetna. The deductible was a sizable cut in my pay and on top of that they only pay 20% of anything. Aetna sucks.
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Old 02-12-2018, 09:03 AM   #44 (permalink)
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Yeah, I have this same problem here in Florida. I really like to have at least 30 days in hand because if we have a hurricane or some other disaster where stores are not open etc.

The problem with epilepsy meds are that you can't just miss taking them for a day or two, that alone will bring on a seizure even for someone who's epilepsy is controlled.

Whenever I change I do so gradually also, so that means I'm trying to get the old med and the new one at the same time. Trying to explain that to those yahoos we use for mail order prescription though is insane.
It is frustrating! They prescribe addictive painkillers like people are running out of them but try refilling a maintenance med and they start from the assumption that you are a criminal.
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Old 02-12-2018, 09:43 AM   #45 (permalink)
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It is frustrating! They prescribe addictive painkillers like people are running out of them but try refilling a maintenance med and they start from the assumption that you are a criminal.

Yeah, because I'm dealing out my insulin to druggies *eyeroll* Caremark is especially bad - went to get insulin [before we started getting the subsidy through the pharmaceutical company instead], and it was like way more than usual, and we couldn't afford to grab it; and it came down to 'maintenance meds have to be bought in three month supplies'
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Old 02-12-2018, 08:19 PM   #46 (permalink)
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I'm not saying there isn't an approval process, or even any issues. What I'm saying is, especially since we spend more tax money on health care %-wise than any other country in the world, we pay a lot, and even when we do have coverage, insurance companies find a way to screw us over.

And universal health care shouldn't just be for the poor, but for everyone. Because our current system can and has even destroyed wealthy families.

And again, we spend more taxes on healthcare than any other country. It -ought- to be better, and it ought to work for everyone.
I totally agree that our system is too expensive, but getting rid of insurance companies has nothing directly to do with that. Germany and Switzerland are good examples of multi-payer systems that function much better than the US system. US vs Canada aren't the only options. A large part of the problem is that in the US, we actually protect the rights of pharmaceutical and medical equipment manufacturers to charge anything they want. Other countries have price controls. We need to start doing that.

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Actually it is not. We do not have providers who work with the payer to approve anything. My Doctor ordered tests, procedures, blood work etc and they were done the government health plan paying for them. There are no deductable, co-pay etc for health services.
I only indicated that the first procedure that was also ordered by my Dr. would probably have to be approved in the US. It will be repeated in 1 year as a pre-caution and I will not have to argue with an insurance company about it being repeated in 1 year instead of 5 because my Dr. has made that decision.
Sea
I fully agree that the Canadian system is better in a lot of ways; but I insist that your doctors do have to work with the public health system in ways you don't see. You said yourself that they have approval criteria for certain procedures. How exactly is that criteria enforced? If they really don't have a prior approval process, they have to have a risk of the government not paying their claims.

I was able to find Canadian claim forms that looked very much like what we have in the US. They also have lists of things that are not covered, so I'm assuming someone has to decided whether or not the claim is payable.

Our discussion is getting side tracked from where it started. I never said I think the US healthcare system is all sunshine and rainbows. I only meant that other countries still collect data and don't automatically pay claims. What I found from Canadian healthcare websites seems to support this. ...even if we all agree that their system is better.

EDIT: I FINALLY found a Canadian source on the subject (I didn't want to post the ramblings of American Republicans on the subject): http://www.cbc.ca/news/canada/manito...-25m-1.2877135

So the system does sometimes demand that money back from doctors. I still haven't found how often that happens, since most sources are coming from American Republicans. Maybe they do a "Pay and chase" system as we call it in America.

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Old 02-12-2018, 08:59 PM   #47 (permalink)
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Because I can't be arsed to engage this thread fully, some reruns:

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American doctor offices need a team of people to argue with insurance adjusters for dozens of different companies.

Canadian doctor offices have an office clerk (Two per three doctors would be my best guess) who handles all the phones, scheduling, and billing, and everyone goes home in time for dinner. Because everyone knows all the insurance policy rules. Because there's only one policy. And to be clear because I run into this again and again, family doctors in Canada generally own their own practices, need to maintain their clientele. People are free to shop around doctor offices. Referrals to specialists usually end up being a case of who your general practitioner knows. I had a Russian doctor for a long time in another city, and any specialist I was referred to... was Russian.
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Point of note: Basic Health Coverage is administrated on the provincial level, not federal. Most provinces will send you a bill monthly/quarterly/annually depending on how you want it. It's often a variable billed rate where the poorer you are, the less you pay, down to no cost. Middle earners on up pay the same rate. Albertans, who gargle freshly fracked crude oil every morning before coffee, don't get a bill like that.
And not to single Katheryne out (She's a peach.) I'll motor through it anyway.

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I'm curious: How will Universal Healthcare affect those of us who really like the current health insurance we have? I mean, I love the idea, and hope it happens; I'm just not sure how or where I'll fit in.
At its most basic, it's the difference between:
  • Weird, I should see my doctor.
and
  • Weird, would the benefit of seeing my doctor exceed the cost?
Those come from threads where the topic was touched on before, perhaps of interest to anyone interested.
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Old 02-13-2018, 08:18 PM   #48 (permalink)
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Originally Posted by TrollCampFollower View Post
I totally agree that our system is too expensive, but getting rid of insurance companies has nothing directly to do with that. Germany and Switzerland are good examples of multi-payer systems that function much better than the US system. US vs Canada aren't the only options. A large part of the problem is that in the US, we actually protect the rights of pharmaceutical and medical equipment manufacturers to charge anything they want. Other countries have price controls. We need to start doing that.

* Yes we have people buying Epi-pens to take back to the states and we are quite a ways from the US border.

I fully agree that the Canadian system is better in a lot of ways; but I insist that your doctors do have to work with the public health system in ways you don't see. You said yourself that they have approval criteria for certain procedures. How exactly is that criteria enforced? If they really don't have a prior approval process, they have to have a risk of the government not paying their claims.

There are far less procedures that are not covered so most Doctors office are aware of them. Also the Doctor can submit a claim outside of the criteria with an explanation and still be paid. Still not having to argue with an insurance company.

I was able to find Canadian claim forms that looked very much like what we have in the US. They also have lists of things that are not covered, so I'm assuming someone has to decided whether or not the claim is payable.

Prescription drug plans in Canada have various claim forms I would have to see the one you found to comment further on this.

Our discussion is getting side tracked from where it started. I never said I think the US healthcare system is all sunshine and rainbows. I only meant that other countries still collect data and don't automatically pay claims. What I found from Canadian healthcare websites seems to support this. ...even if we all agree that their system is better.

EDIT: I FINALLY found a Canadian source on the subject (I didn't want to post the ramblings of American Republicans on the subject): Canadian doctors' improper insurance billings near $25M - Manitoba - CBC News

So the system does sometimes demand that money back from doctors. I still haven't found how often that happens, since most sources are coming from American Republicans. Maybe they do a "Pay and chase" system as we call it in America.
This is talking about when the Government audits a Doctors Practice. We have occasionally gotten a letter asking if we saw our Physician on a particular day. There is Fraud / billing errors /etc in all business and a Doctor's practice is a business.
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Old 02-13-2018, 08:32 PM   #49 (permalink)
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Originally Posted by TrollCampFollower View Post
Your description sounds completely consistent with how it is in the US. It's the provider who works with the payer almost all the time. The horror stories you hear are the exception, not the norm.
Um.

Virtually every non-trivial encounter I have had with the US health system has involved unexpected large bills, frequently into the thousands, which I have had to pay. Yes, they "work with me" which means I often (but not always) get them paid off before the next unexpected large bill.

"The only cost to me was parking at the hospital"?

FUCK no that's not consistent with "how it is in the US".
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Old 02-13-2018, 09:02 PM   #50 (permalink)
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Quote:
Originally Posted by TrollCampFollower View Post
I fully agree that the Canadian system is better in a lot of ways; but I insist that your doctors do have to work with the public health system in ways you don't see. You said yourself that they have approval criteria for certain procedures. How exactly is that criteria enforced? If they really don't have a prior approval process, they have to have a risk of the government not paying their claims.
In the US if a doctor submits a charge and it is denied it is the patient responsibility. I think the fundamental missing assumption is that doctor's are our advocate here. Nope, they submit claims as a service to their patients and would rather not have to deal with the whole thing any more than possible (especially since the, oh, 20 insurance policies they accept will have maybe 50 different sets of criteria). How could them having 1 set of criteria be any worse?
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