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What Are They Up To and why? any ideas?
sin
Remember way back in the 1980's when it was up to the patient to send in the medical forms with the bill from the Doctor to your Insurance Company assuming you were insured back then. Then the traditional Insurance coverage came out with PPO, CHN and the Doctors flipped out, panicked then raised their fees. I remember one doctor who used to charge $50.00 for an office visit raised it to $90.00 for one office visit because he thought the Insurance would pay much less than what he charged. I can't believe it was that low back then when I see how much more they charge now. Anyway that was when the Insurance Co's. decided to curb the over chargeing the Doctors were doing. What the greedy fuckers didn't realise was that they still would have gotten the full amount had they not raised their fees out of retaliation towards the Ins. Companies from the patient. See the Insurance Co. was going to hold the patient responsible for the remaining balance regardless of if it was approved or not by the Ins. Company. But when the Insurance Companies got umpteen phone calls with customers complaining that the Doctors are holding them [patients] responsible for the amount the Ins. Company claimed to be an over charge that would only serve the Ins. Company not the patient they quickly acted on it and made sure the patient was held no longer held reaponsible for the over charge amount. That meant the Doctors had to accept what the Insurance Company considered the right amout of charging for the services provided, depending on what service they provided, office visits and mostly if a diagnosis was given.

Well time goes by and before we know the Doctors are all too willing to send in the Insurance forms for the patients and we get whats called "in network" "out of network". If In Network hooray hooray you pay nothing out of pocket unless you have an arrangement to pay a co-pay. If Out of Network you must pay the remaining 20%, 30% and whatever else the Insurance Company won't cover because it's out of network.

Well out of network is better than nothing if you're lucky enough to have insurance but what gets me is how the Doctors wanted nothing to do with going "In Network" with Insurance Companies because that meant accepting what the Insurance pays and no more from the Insurance Co or from the patient. It's an arrangement between the doctors, facilities for diagnostics, etc that benefits the patient if In Network. So they can't charge what they want, extra or over charge and they agree to accept what the Insurance Company agrees to pay. Ok they then go into the Insurance Companies book [list] of Doctors, facilities, etc. that are In Network.

My question "what are they up to" or should it be why? has to do with what are the Doctors and these diagnostic facilities, etc up to? you see I have noticed the and facilities and Doctors are making deals with patients ....that don't include the Insurance Company. They make deals with places that perform certain proceedures and with the patients saying they will accept what ever the Insurance pays "In Network" agreement but they don't include the Insurance Company on this verbal agreement then they extend it to the patient who calls up asking if they are "In Network".

This is a puzzle to me especially since I am told they do this to pass a break to the patient or for the patients benefit. Another words they give up what they can when they can and accept the "In Network" dollar amount and nothing else is supposedly charged to the patient. Thing is if they are willing to do this then why not just get on board and join in the "In Network" with the Insurance Company and get their name and the facility name in the Insurance book? So the patient will know ahead of time if they already are "In Network". What the hell is the point of agreeing with this on the side with the patient when they don't agree to it...well..I'll say legally with the Insurance Company?

Anyone who has this arrangement with their Doctors and/or facility should make sure they get this in writing from the Doctor and or facility where the procedure is being done so later on down the road the patient won't be be charged the any claimed remaining balance due that the Doctor claimed the bill was for. See saying its paid in full by the Insurance Company doesn't mean there's isn't a 20% or whatever % remaing the patient must pay out of pocket because they weren't on the list of "In Network" with the Insurance Company.

That happened to me a about 2 years ago. I had surgery like 8 yrs. ago and the hospital sold out. The new name for the hospital decided to charge me for the remaining balance the Hospital wanted. I went right to my old Insurance Company and got a copy of the statement saying "paid in full" as the Doctor and Hospital were both "In Network" at the time. Had I chosen a hospital or facility and Doctor that wasn't "In Network" I would have been screwed and responsible for payment of what they charge not what the Insurance says they could charge.

So What Are They Up To? why not just join In Network? rather than make deals with the patients, etc. ? What do they benefit by not being on the list or in the book of "In Network" with the Insurance companies. Are passing on breaks to whoever they can? whoever doesn't have insurance? and charging regular fees to whoever they think can afford it?

Edited yep you bet I had to cut down some but not much since I really just go on and on LOL
Edited by sin on 06/28/2009 20:51
 
sin
Sheesh no one response. Must I do a new one? did I not make it clear? what? what?
 
derF
Sin,

Read my two posting on Single Pay Health Insurance and the Great American Bubble Machine. You might find your answers in there.
I'll drink to that. Or anything else for that matter.
 
sin
But Derf it still doesn't explain why they are willing to take less money from accepting only the inssurance payment without being in network. It's the same as if they were i in network. The only reason I can think of is that this way nothing changes and when things settle down or rather they hope it will keep people settled down and not fight/vote or reques a universal health care plan for eveyone. Everyone the same and all Doctors, etc must accept only what the Insurance Company pays. Another words comply with the patients request for now ...schmooze us over ....but later......Grinevilmorph:
 
derF
You will find that many doctors invest in testing laboratories and imaging centers and such. Then to support their investments they send their patients to these facilities often to perform superfluous medical procedures. Sin there has GOT to be a reason Americans pay so much and get so little. Some one (or many someones) is finding it very easy to get rich over our health care. In other words we are victims of blatant greed. Plain and simple.
I'll drink to that. Or anything else for that matter.
 
Bob of QF
derF wrote:
You will find that many doctors invest in testing laboratories and imaging centers and such. Then to support their investments they send their patients to these facilities often to perform superfluous medical procedures. Sin there has GOT to be a reason Americans pay so much and get so little. Some one (or many someones) is finding it very easy to get rich over our health care. In other words we are victims of blatant greed. Plain and simple.


There was a comparative study done recently.

It compared the highest-cost medical care locale with the best care (and it's cost).

The "business model" in the highest cost (a border town in Texas) locale had all of it's "hospitals" (and I use the term loosely) funded by doctor-invested funding.

That is? The doctors' own investments hinged on how much money the facilities made.....

...and you damn betcha it affected their attitudes!

Contrast this with one of the best care facilities: The Mayo Clinic. Not the most expensive, either. At the heart of the Mayo's business model was: "patients needs first, second and third. All else is below that" (more or less-- I paraphrased it).

In the former case, patents often saw a doctor for mere minutes, if at all. Contrast with the Mayo, where the doctor sat down, talked at length and took pains to ensure all questions had been addressed.

Greed model vs Patent Care model.

The greed model had the highest cost/patent, and the care was mediocre.

The patent-first model had moderate cost, and the care was one of the best in the world.

It really *is* that simple, it seems....

...doctoring for profit ought to be a capitol crime....
Quantum Junction: Use both lanes

Reality is that which is left, after you stop believing.
 
derF
Bob of QF wrote: There was a comparative study done recently.

It compared the highest-cost medical care locale with the best care (and it's cost).

The "business model" in the highest cost (a border town in Texas) locale had all of it's "hospitals" (and I use the term loosely) funded by doctor-invested funding.


I read that study which was Published in The New Yorker magazine. You might still be able to access it on the New Yorkers website. In fact that is where I was made aware that such practices (clever play on words) was fairly common.

You are absolutely correct Bob. Medicine for profit is obscene. You can thank Richard Nixon and Henry J Kaiser for presiding over the beginnings of the 'For Profit Health Care System" we are now enduring. They have the actual conversation on tape of Nixon and Kaiser discussing a profit motivated health care system and Nixon saying "Yes! That sounds good to me!" And hence Kaiser Permanente was born.
Edited by derF on 07/01/2009 00:57
I'll drink to that. Or anything else for that matter.
 
catman
There used to be a Kaiser Permanente down the street. Then it went away. I suppose it was a Kaisser Impermanente.

I used to not mind paying a doctor for health care, before greed got into it to such an extent. Now, I agree, it's obscene. It's nothing less than making as much money as possible off the suffering of sick people. How is that ethical?
Edited by catman on 07/01/2009 02:00
"If I owned both Hell and Texas, I'd live in Hell and rent out Texas." - General Sheridan
 
derF
It isn't ethical, Catman. And you and I and everyone else knows it. But those that profit from it have little to complain about. And those that don't, have little leverage to effect change in our current muddle.

As far as the current system goes, we, the middle class, have sufficient numbers to sway any political outcome. But we do not have the communal will to join together to guarantee that our needs are met. We are our own worst enemy.
Edited by derF on 07/01/2009 02:50
I'll drink to that. Or anything else for that matter.
 
catman
"We have met the enemy, and he is us" - Pogo

I don't think I'm middle-class. Besides, our numbers are only sufficient to "sway any political outcome" if our representatives listen to us and act on what they hear. The medical establishment has many people on its side because they wrap it all up in a flag, talk about good ol' American innovation and 'stick-to-itiveness', and then bash the Europeans with their socialist proto-Communist medical care where the individual doesn't get a choice. Here, we have a choice: pay the asking price or do without. Suffer for the country, that's patriotic. I'm not sure that we pinkos are in the majority.
"If I owned both Hell and Texas, I'd live in Hell and rent out Texas." - General Sheridan
 
Theory_Execution
We have both over here in the UK, we have the National Health Service and businesses such as Bupa. The first is paid for through tax of the populus and the second by money earned (or inherited).

Does it work, works ok. However we have some crazy shit we have to pay for along the way. For instance homeopathy is a credited form of treatment you can seek on the NHS, the NHS spends some 34-60mil on priests, vicars, rabbis etc as part of a chaplaincy programme.

A huge burden, growing by the circumferential inch is obesity. Id drags away millions upon millions of pounds for a condition that is wholely self inflicted, while those dying of cancer, or rarer diseases lose out.

Smoking, although a massive cancer causing problem donates so much through tax (iv heard for ever 7 tax, 5 goes to the NHS) that theyll not ban it in my lifetime.

Yet, with all of this, it is the price we pay for healthcare for all. There are no doubt people in the UK who think rugby is a waste of time, and that any injury arrived at from sporting should not be their problem or financial burden, but without it, I would not be the person I am today and I think our nation would be worse off for it.

I can understand how personal injury claims in America have taken off, and inspired the lawsuit culture, because when you get hurt its your body and your wallet, and if your wallet is empty you could lose your house. That my good friends, is fucked up.

 
sin
That's another good point. The relation to the injury, what caused it. Obesity isn't always the patients fault though here in America it usually is. My family has a history or obesity in the genes. There's only certain cousins who have it. They reach a certain age and shit it's like over night. My cousin {S} was scared to death it would happen to her so she was real careful, watched her diet, exercise, the works but it happened to her anyway. We can't understand what it is in their line of genes that causes it in them. We so far can only figure it's on the Mother's side but then the Father always was big himself too. Yet the other siblings weren't too bad except for one other one, a cousin once removed then permanently.

I can understand filing for a Medical Malpractice suit when it's legit. Many times it is but there are times when it isn't. Some patients don't always do what the Dr. tells them to do, they don't follow directions, attempt to live right, take meds as directed and lie to the Dr. not thinking they are only hurting themselves. Who pays for it the patient and Doctor and yes the rest of the public because the Dr. has to make up for the Hugh premium increase. We all cheat a little here and there on our diets but lets' face it almost everything we eat is crap because the food industry is crap. I won't eat McDonalds or Burger King or any other fast food heart attack joints. I bag my lunch and make sure I try like hell not to eat a cookie at work. I'm staying away from chocolate since the only kind I can have is the sugar free which can and does cause the trots. I can have a little chocolate on very rare few occasions so I save that time for the real occasions when I go out. So us Americans can make changes in our diets to help but we can't change our family history/genes. Still it isn't just Americans who are to blame and law suits and we all know it. I tried to explain to someone on a chat room once from another Country and he insisted I was on a rant with conspiracy theories when trying to get the knucklehead to understand how the Doctors are here and how they invest in the pharmaceuticals so that's why they determine what they will prescribe ....they choose the drug they have invested in. Asshat just wouldn't understand that and insisted on articles of proof. Shit that was all over the media years ago but I din't know where to find them now. I can't google it because I don't know what the articles were labeled. I just remember seeing it on one of those 20/20 programs and in the papers. If you went to 3 Doctors in one day for the same illness you'd get 3 different kinds of RX prescribed. why because it's all what the Doctor has his/her investment in.
 
Theory_Execution
Sorry Sin, but I will never buy this 'she was real careful, watched her diet, exercise, the works but it happened to her anyway...' mainly due to reliability of our understanding of physics. Energy can not be created nor destroyed, only transfered and transformed.

So people getting fat 'for no reason' is crap. Either the activity isnt there or theres too much food being eaten. My expanding gut was due to drinking like a fish, im slowly working it off.

I agree with you, that for many people low quality (high sat fat, high carb, high) food seems to be promoted more than a good balanced meal. And the sad factor in this low priced, easily accessed food is its aimed at our sugar/fat seeking nature.

As to the doctors promoting one drug company I can see how thats happened. In the UK medical students get a huge government loan and other benefits if they stick with the NHS, but if there is no state interest in healthcare, ie its all private sector you need a private company, with lots of money to fund the medical students, and who does that leave but drug companies.
 
sin
Theory_Execution wrote:
Sorry Sin, but I will never buy this 'she was real careful, watched her diet, exercise, the works but it happened to her anyway...' mainly due to reliability of our understanding of physics. Energy can not be created nor destroyed, only transferred and transformed.

So people getting fat 'for no reason' is crap. Either the activity isnt there or there's too much food being eaten. My expanding gut was due to drinking like a fish, im slowly working it off.

I agree with you, that for many people low quality (high sat fat, high carb, high) food seems to be promoted more than a good balanced meal. And the sad factor in this low priced, easily accessed food is its aimed at our sugar/fat seeking nature.

As to the doctors promoting one drug company I can see how that's happened. In the UK medical students get a huge government loan and other benefits if they stick with the NHS, but if there is no state interest in healthcare, ie its all private sector you need a private company, with lots of money to fund the medical students, and who does that leave but drug companies.


Then why does it happen to every single member in that family no matter what they do? It seems this energy in the body you talk about transfers into fat in them, I know they eat properly and don't over eat because I know them too well. There is only one person in their family that does over eat and his weight is his fault but that doesn't explain all the others and why it happens when they reach puberty. It's sad to see how hard they work exercising, dieting and stick to it lose a little then bam it's like their body fights against them. I think there are some obese people, not everyone, who are just born to be obese. Mind you I'm talking about the few exceptions not all obese people are that way. I notice some are obese and they are the only member in their family obese and some are because they were never taught to eat properly from childhood. But I swear my cousins on the one side just seem to have this problem. I'm not obese but I am over weight. I figure once I get over the smoking I will concentrate on my weight next and kick both habits for good. At least that's my goal and I sure going to keep trying until I beat it and get it right for life. You can't compare people to yourself TE everyone's different. It's like saying you can't quit smoking using the patch because I did it without the patch so you shouldn't need it either or shouldn't either. Everyone is different and has different medical conditions. Like with people who tell me I should be a vegetarian or could be one and give up meat. Well pasta isn't good for every night being diabetic and I have diverticulitis so salad, granola bars, etc. aren't so good either plus add Hiatal Hernia to that and I am really limited. Oh and as to your expanding gut....honey I knew that was coming long ago Grin

As to the doctors promoting one drug company I can see how that's happened. In the UK medical students get a huge government loan and other benefits if they stick with the NHS, but if there is no state interest in healthcare, ie its all private sector you need a private company, with lots of money to fund the medical students, and who does that leave but drug companies.


Not promoting one drug company they promote only the drugs they are invested in, they may have investments in more than one. Each Dr. will perscribe only what they are invested in. Hey it's expensive to start a new drug with all the testing, etc. so they take the chance if it looks good while in testing and invest in it. If it passes they get to promote and make money while helping to promote it. It's basically risk free, well almost, they don't get sued if it doesn't work out because they didn't do the testing but they would lose money they invested in it. It's like a loan to the scientists, labs. I think a lot of that has been curbed since it was exposed on that program and in the news way back whenever it was reported. Why only one in the UK? dumb question so they can promote that one and get rich. I did't think that happened in the UK.


Yes the fast food market aims at our love for sugar/fat and salt. It's a shame and even in restaurants when you specifically order low fat, salt and sugar it's hard to get them to until recently only a hand full will comply with the public's request. We had a hard time for a long time when my Dad was alive and would go out to the diner. At their age cooking at home wasn't much for them. So they ate out at the diner almost every night like most Sr. Citizens do. They eat like little birds except my Dad LOL. He needed a low salt diet and couldn't get that in diner food. He finally got the owner to leave it up to the customer to decide how much salt they wanted when they got the food. That's the way it should be. At least cut down on the damn salt and pepper and let the customer put what they want or none at all if they choose none. *sigh* it's a bitch going out to eat and getting good healthy food or specific type of food for medical conditions in any establishment that's not ritsy titsy expensive.
Edited by sin on 07/01/2009 21:50
 
Hypatia
Ritsy titsy... hmmmm. Gotta remember that one.

Wink

 
derF
Theory-Execution wrote: I can understand how personal injury claims in America have taken off, and inspired the lawsuit culture, because when you get hurt its your body and your wallet, and if your wallet is empty you could lose your house. That my good friends, is fucked up.


T.E. I have been looking for feedback from my friends in other democratic societies about their own health care systems as compared to the U.S.'s system. I am going to quote your statement above in as many venues as will print it. Thank you.
I'll drink to that. Or anything else for that matter.
 
Theory_Execution
It seems this energy in the body you talk about transfers into fat in them, I know they eat properly and don't over eat...


Well Sin, we have RDA over here, recommended daily amount for sugars, protein, fats and other things, but they are just guidlines for the average person, the mean height, weight, age etc. So following these guidelines could leave you undernurished or over fed or both.

They may well eat three healthy meals a day, that supposedly cover all of their dietry requirements, but say if they eat a big meal before they go to bed, and a small one before they do exercise then the body will be more geared up to storing food. Maybe the solution is eating little but often, something akin to what our hunter gather ancestors would do. Eat as you go.

Speaking as a non-biologist-non-medic the only idea I can put forward about the puberty issue would be from a naturalist stand point, puberty is a time in which your body gears up for passing on genes, and not specifically saving the genes already present in this body. Thats just a guess mind.

Also, people lie, no matter how much they love someone they still lie. We all do it. I could lie to myself and say I eat healthily, but I dont.

Why only one in the UK?


It doesnt happen in the UK, the government funds trainee medics and nurses, and gives incentives. I think the drugs that do make their way to the hospitals are recommended by some governmental group in hand with an independent party of doctors. I would have to check that out though, may not be true.


How many years do you think it would take America to set up a state funded free healthcare system?
 
Hypatia
I know one food issue we here in the US have a continuous problem with is portion control - serving sizes.

We can look at a serving of something (everything, anything) we put on our plates and see it as a reasonable serving size. But if it were to be weighed or measured out, probably 8 out of 10 times it would be quite a bit over what a regular serving size should be. So we're eating almost two portions (or more) in one serving, and then going back for seconds.

Serving sizes in restaurants are really huge and a lot of people eat all, or nearly all, the food on their plates. In reality there are most likely two meals in one, and only some of us eat only half and take the rest home for another meal.

It's harder to eye an accurate portion size than we think, and this (I think) is one reason why it's so easy for people to over eat. We rarely actually look at what a serving size actually consists of - especially for snack foods - and then measure out and have just one serving.
 
catman
Well, when one is brought up to clean his/her plate, and a restaurant brings you huge servings of tasty food that you paid for, it's hard to resist. I know it's not much of an excuse, but it's my story and I'm sticking to it. It's so hot that I'm sticking to everything.Grin
"If I owned both Hell and Texas, I'd live in Hell and rent out Texas." - General Sheridan
 
Hypatia
catman wrote:
Well, when one is brought up to clean his/her plate, and a restaurant brings you huge servings of tasty food that you paid for, it's hard to resist. I know it's not much of an excuse, but it's my story and I'm sticking to it. It's so hot that I'm sticking to everything.Grin


That is so true Cat. When we're hungry our brains, and taste buds, get 'fooled' with the portion size thing, and like you, when I was a child I was always told I had to clean my plate - meaning I had to eat everything someone else served to me. My grandfather in particular laid on the 'starving children in (fill in the blank country)' guilt trip. I clearly remember many times being full, or just not wanting to eat certain things, and offering to let him (or whomever) send my food to one of those starving children. That always seemed to get me in trouble, but I thought it was a reasonable, and generous offer, especially considering the circumstances.

It's hot here too, and even though I try not to go outside much before 7:00 PM or so, everything either sticks to me too, or slides off. LOL.
 
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