What is the limit on Insurance Companies' responsibility for payment?


As much as I dislike what has happened to me with individual policies in my life, I do not expect that every medical problems that I have should automatically be covered by insurance. All I have ever asked, then demanded nicely, was to know what they would cover and what would be denied prior to procedures. That information, particularly "reasonable and customary" allowed expenses was a closely guarded secret until recently.
I have noticed a definite trend toward more communication and transparency in the Insurance Industry in the last few years. As patients have become more aware of the abuses of some insurance companies to seemingly arbitrarily deny coverage , there have been those in the industry that have realized that unless they started treating people (customers) as if they had some sense of intelligence, they would be overcome with the public outcry of unfairness. The companies still seem to convey a sense of superiority, but not as much as 5 years ago. An amazing thing happened; a few major national companies decided to allow their customers access to what they considered "reasonable and customary" for most procedures. What a unique concept... telling people the benefits for which they are paying. I believe that when that happened, the cloak of "Newspeak" began to unravel. If you ask, many companies would still rather not tell you the R&C allowed or will give you a very low cost. But, even that is an improvement.

Although, the information that I receive is now more accurate, the demands upon doctors and hospitals are still staggering. If you have not read my earlier posts, I am amazed that anyone would want to become a doctor in the current environment of insurance companies demands of clarification on procedures and constant requests for additional office reports before payment. If "Health Care Reform" means cutting payments to doctors, then we need to rethink the meaning of reform. I do know that the time of obscene bonuses for substandard coverage for thousands of mid to upper level executives in health care is coming to an end. Many of the past bonuses were directly related to denial coverage or cancellation of high cost "customers."  I am a firm believer in free enterprise, but with transparency comes responsibility.

It is unreasonable for me to expect payments to be made that are outside of the contract with my insurance company. If I have a strange disease that requires $15,000 per month for the rest of my life, is that something that we are willing to add to all premiums? I may think so, but those who have to pay much more in premiums may not agree. I don't know the answer, but we will be forced to address those issues if we are to have a viable system. What is the Government's role, if any? This is why we need to have a civil discussion on our future system. Many would decide to have low premiums with minimal coverage until something bad happens; there is where the patient's responsibility lies.

What I want for now is simply some honesty on my coverage, simplicity of paperwork and allowing doctors to spend a little more time with patients and know that they will be paid a fair amount in a timely manner. That will be the first step toward prevention. We all have paid for a variety of products and services during our life and I know that there is not one other service that you have that is so shrouded in secrecy and obfuscation - that is why people are upset with insurance coverage. That is very slowly getting better, so now we need to decide what we, as a nation, are willing to pay,  and what level is acceptable minimum coverage.
TVP
                                            
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Posted by The Virtual Patient at 3/21/2009 9:48 PM
Categories: Patient Responsibility, Reasonable and Customary, Insurance, Private Policies, Universal Healthcare, Politics, Costs
Tags: Patient universal health reasonable and customary cost Private Policies Socialized Medicine deductible doctors coverage Insurance health care
 

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