Doctors determine medical care not insurance companies

Health
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@angelaoston
Insurance companies do not determine treatment. Insurance companies should pay in accordance with the plans purchased by the customer. If the companies are not allowing things supported by the plan or are not paying in accordance with said plan, that is an issue that is handled through a number of means, i.e. company procedure, civil preceding, etc.

I think what you might suggest is that there should be more government oversight and control.

We need to be clear about the issues involved and how we believe they should be handled.

  1. Do you believe that all healthcare should be covered, to the best extent possible, regardless of cost?
  2. If not, who or what determines the limit?
  3. Who or what determines the acceptable remedies, procedures, medications, etc?
  4. Should the customer be allowed to use any remedy they believe works, i.e. natural medicine vs pharmaceutical, regardless of scientific support? Again, who decides the standards and when they are met?

Just a few thoughts.

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I do believe the body does heal but under the current conditions we are overwhelmed by toxicity. Naturopathic medicine is what I prefer in most cases. Chinese medicine is thousands of years old, herbal medicine is what the Indians used. We may not have studies but thereā€™s a wry rich history that has been lost in our traditional western medicine.

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All excellent questions, Uziel and we need to find acceptable answers for these!

My head hurts just reading this whole thread :face_with_spiral_eyes:.

Just some background on where Iā€™m coming from, to give a different perspective:

I grew up in western Europe and had excellent health care. I could go to any doctor or hospital I wanted, none of that in and out of network garbage. In addition, there was no maximum health insurance benefit one could hit, no out of pocket co-payment, no yearly maximum out of pocket. No medical bills but rather statements of services rendered with the notice to contact your health insurance if there were any discrepancies. You did have to pay a few Euros per prescription but there was also a max of how much out of pocket you would have to pay and it was very reasonable (not hundreds or thousands of Euros).

What wasnā€™t covered was some alternative medicine, like Homeopathy or Naturopathy. But having that said, if youā€™d have back pain due to a non-physical issue, you would have the option to get prescribed massages to help you heal faster (or Acupuncture) and feel better in addition to medication.

After surgery and your hospital stay, you would have the option to either have outpatient rehab or inpatient rehab at Sanatorium (in between a hospital and resort, a wellness facility), be able to rehabilitate, gain strength, eat healthy food, physical therapy etc. Unheard of here, too. And this was regular insurance, not creme de la creme insurance.

Health insurance was something you didnā€™t even have to worry about, peace of mind. Now I realize that was a luxury unheard of in the USA.

If youā€™d lose your job, you still would have health insurance (no Cobra or anything like that). Heck, I remember being little and the pediatrician making house calls when I was sick, all covered by the health insurance. In addition, the health insurance one paid couldnā€™t be more than a certain percentage of your income so health insurance was affordable. There were several health insurances on could choose from.

Overall, having lived in the US for a while, what it boils down to, in some Western European countries health care means taking care of people and helping them heal. In the US, health care is almost like a drive through, get your surgery, go home, you are on your own. Well maybe not that drastic but you get my drift.

I donā€™t have the solution on how to fix the Affordable Care Act or Health Insurance in general but itā€™s disheartening seeing people becoming bankrupt, people who are ill having to battle health insurances and being denied care, itā€™s really sickening, living in the, dare I say, richest country in the world. Something needs to change and for the better, thatā€™s for sure!

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Ditto me on that! I had some acupuncture treatment for something that modern medicine could not fix. The great Chinese MD who had her own acupuncture practice healed me, not kidding!

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There are countless real life examples of alternative methods that heal people when the traditional western medicine tells them thereā€™s nothing that can be done. If we are truly to make America healthy again, we must incorporate a better system of healthcare that doesnā€™t rely solely on pharmaceuticals, cutting our body parts through surgery and regular misdiagnosis.

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This is so far from the truth.

They absolutely make money from denying claims. The longer they hold on to money the more they can invest. That means more profit. It is absolutely a tactic to deny claims, to delay claims, to go after claims they already paid and try take money back for services already provided and benefited from, and so many other tactics. Many years ago I had a claim rep tell me ā€œthings go by the wasteside hereā€. Meaning they get thrown out in the waste basket. This was paper era. The entire reason it came up was because they paid dates from a HCFA 1500 form but failed to pay all of them. A call went in to the insurance company who claimed they never received the dates. They insisted this was true. When they were called out for lying because all dates were on one HCFA 1500 form and some of them had been paid and others had not that was the response whispered over the phone. ā€œthings go by the wasteside hereā€

These are common things that occur and many more occur. It is completely malarky to say that they are protecting policy holders and the majority of people know it.

What is medically necessary is taught to healthcare providers. Thatā€™s why they go to school so long, take many exams then take Board exams and get licensed. There is no need for better understanding of medically necessary. There is more need for letting the healthcare providers use their skills without obstruction which is harful to patients.

There are also many reasons premiums go up. Thatā€™s another conversation but it is not limited to claims alone. The way premiums are determined is based on multifactor contributors.

Most of the fraud being committed is really coming from private Insurance these days. They just donā€™t get charged. Nobody is looking. What really needs to happen is an Independent review of Insurance Industry behavior. A transparent look into the denials and how it has impacted patients and small businesses.

The insurance industry makes very large profits and their top employees are making millions.

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I agree that insurance companies need to get out of the business of making medical decisions, that should be between the patient and physician. That said there are doctors that their first go to is surgery.

Went to a doctor for a bone bone growth off my daughterā€™s knee. When the xray was taken they saw some damage to the meniscus. Dr said he would take care of both at the same time. I thought that was an option, but it wasnā€™t. Insurance said yes to the bone growth removal but no to the meniscus surgery, do PT first. Dr said will not remove the bone if he canā€™t do the meniscus as the same time, Dr did not want to do PT. ( RED FLAG)

We went to another Dr who removed the bone growth. Nothing done on the meniscus and her knee is no longer giving her trouble.

Surgery on her meniscus would have disabled her for several weeks and I have read up to a year to heal from. Really I should have said only the bone removal. When that Dr said either both or none, I would have found another Dr.

I donā€™t know the answer to health insurance. I think it may lie in taking responsibility for your own health.

Eat right, as healthy as you can. Moderate your diet and donā€™t eat junk. Most of our health issues can be resolved or avoided all together with a healthy diet.

What is a healthy diet? Research it. Everyone has a different body chemistry, so diet that works for me may not work for you.

Learn to cook to so you donā€™t have to buy the prepacked stuff that is loaded with junk. If you make the food you are eating, you control what goes into your body.
Exercise, sweat, get your heart pumping and not just once a week. Walk or do something that gets your heart rate up every day.

Those few things will put us on a path of wellness. They will not fix a broken bone, gun shot wound or any other traumatic injury.

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The government under the advisement of American Medical Association should set pricing for each kind of treatment. Then the doctors can discuss the best form of treatment with patients or insurance companies. Right now the cost of treatment is too high. It will take cooperation from medical professionals, hospitals and pharma to make treatments viable. But you are right the final decision on healthcare should come from the attending doctor.

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Iā€™m not sure if this is the case for everyone. My HSA/FSA is ran by my insurance company. This year they have been awfulā€¦denying what I use my funds for which have been strictly medical care like prescriptions or bills for an office visit. So I did not sign up for an FSA for next yearā€¦Iā€™m just putting money into a savings account for medical bills.

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not the doctor. the patient decides - or the patients family. the doctor advises and supports.

only in a very few and well defined cases, in emergencies, the doctor decides.

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Employment relationships may still be scrutinized: Although the Stark Law does not directly apply to physician assistants, their employment relationships with entities providing DHS may still be subject to scrutiny under other federal laws, such as the Anti-Kickback Statute (AKS) or the Civil Monetary Penalties Law (CMPL).

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Angela,
Please see the link below to my policies to improve healthcare. I address your issues.
Scott

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Debra,
Please see my policies and recommendations in the link below:

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I agree that it is absurd for a physician who is bound by ethical constraints to advocate for the best treatments to need to justify treatment to an insurance company. A treatment that is safe and effective should be available. Experimental treatments should be available on a research basis for free.

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Interesting. There is no difference between FP and NFP fundamentally. NFP are actually more likely to be profitable, NPā€™s receive huge tax break and free services in return for being mandated to service public patients. FPā€™s can accept Medicare/Medicaid at their disgression.

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Absolutely false. Claims are paid from the claims corridor. Denied claims stay in the pool to the benefit of other policy holders. Investment earnings, if any, accrue to the pool as well. Generally insurers lose money 3 yrs. out of 5. Any profits in the claims corridor from lower than expected claims are returned to policyholders. Some ACA members are receiving checks now. Profits come from the administrative corridor only. Average insurer profit is 3.3% making them the 77th most profitable industry. You can earn more at the bank.

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Itā€™s ridiculous to claim that insurance does not make a profit. CEOs would not be making millions of dollars in salary if there was no profit. There is a difference between no profit and greedy spending. There is not a lack of profit. There is a lack of proper spending. That also includes how they allocate for claims. They pick and choose which professions to discriminate against and who to reward. They dictate treatment by paying certain codes only and not others even though the Doctors may not set that treatment plan. Since the entire Country is so insurance dependent that results as the insurance knows in patients not getting treatment and opting for a different treatment protocol that will be covered on their plan. That produced unhealthy people because insurance should not dictate treatment plans. Insurance absolutley makes profit. The fact that their balance sheets show different is just another game they play. Letā€™s get DOGE into the insurance companies also. And how about maybe instead of 22 million per year for a CEO he could do 10 million. My gosh - if the CEOā€™s can make as much money as they do please spare us the they donā€™t make a profit narrative.

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