Andrew Cuomo Takes On Insurers

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Oscifinna of AL 7:21AM August 12, 2009

Your acticle was accurate except for the last paragraph.
Providers are out-of-network because they can't provide quality service, office environment, and staff to do all the required certifications, authorizations, refilings, and appealls trying to get paid per their contract on the fictional "reasonable and customary"allowed amount dreamed up by the managed cost faction that manages the patient's insurance. Providers will not accept this because "that is what they normally get". A wallpaper hanger makes more per hour than I would if I accepted "reasonable and customary" of many insurers. Question: why are all the reasonable and customary rates for the same geographical area different between companies? Your statement is also misleading because by contract, providers must collect the full deductible amount on the patient's policy.
As a private practitioner in practice before managed cost (masked as managed care) replaced good patient care and professional business ethics, I have observed many good providers close their office due to these tactics. If the public realized how their health care has been and is now being controlled and compromised by this squeeze there should be an uprising. I, too, am scheduled to close my practice.

CS of TX 5:12PM March 17, 2008

This insert has nothing to do with Mr Cuomo's fight with the insurance companies regarding his charges that the insurer's are "systematically underpaying some physicians" and therefore leaving the patients with a larger out of pocket bill.
Furthermore, the insert "Find out what your insurer will pay, and ask the doctor to accept that as payment in full." This is 'GROSSLY' taken out of context because Mr. Laszewski suggest this when the patient CANNOT avoid going out of the network. (That is how I read your article.)
Doctor visits are what they for many reasons including the practice salaries (the physicians, secretaries, nurses, lab technicians, office assistants, transcriptionists, custodians, and service/repairman ) and "usual and customary" office overhead expenses including but not limited to the utilities, the phone bill, yellow page advertising, computers and software support, mortgage, and office supplies both medical and non-medical and medical equipment, and the list goes on and on.
And let us not forget all the insurances including fire, water, theft, general liability, workman's compensation, health and dental for employees, and malpractice.
Also, the time consuming billing of each patients' insurance and re-filing and multiple re-filings FOR the patients. Noting the practice CANNOT charge the insurance company any administrative fees for ALL of this work.
The insurance companies for decades have stated percentages instead of amounts that they pay or reimburse
They pit the patients against the doctor stating the doctors fees are higher than the "usual and customary" charges for the area but cannot and do not provide documentation of these fee schedules.
Why not just provide a fee schedule for all procedures? The insurance would not be marketable without these deceptive percentages.
Why different percentages for in and out of network services? This is another way to further decrease the insurance companies' liability and decrease how much they pay.
We all let the insurance companies get away with not paying. What happens when the patient does NOT pay, of course the insurance is terminated.
We (the patients - the insured) buy the insurance to have if we need it and then we expect it to pay.
Take your own example of $200 for the office visit, while the insurance company pays $77 under the disguise that $77 is the usual and customary fee for that service. This represents 37.5% for that basic service not the advertised and presumed 80% when the policy coverage was presented and sold to the insured. The visit would have needed to cost less than $97 for the 80% to equal the insurers' 'usual and customary' fee of $77. It is highly unlikely that this physician is charging more than twice as much as the other physicians in his area. DO the MATH!
Another cost to the doctor is the high cost of billing and collections and the losses from the uncollected debt.
Simply, do you want the doctor to be there when you are sick and wish to be seen THAT day, not the first available appointment perhaps in a week or two or even wait until the following day? Make the insurances pay what they promise and make them pay the first time they are billed. AND, those office vist would be LESS.
In closing would you take a 63.5% pay cut tomorrow if U.S. NEWS and WORLD REPORT were cutting cost simply to make more money for the company. I doudt it!
GO! Cuomo!

Buck Ray of NC 3:30PM March 16, 2008

Last fall my husband was referred to a Cancer Center for treatment. I asked prior to seeing the doctor whether the facility took our United Health Care insurance and was assured that they did. What I failed to ask was whether they were an in-network provider or out-of-network provider. It turned out they were an out -of-network provider with separate deductibles and copays. We ended up paying with a Home equity loan $24,000 in separate deductibles and copays last year. The kicker is the that the U of WI Paul Carbone Comprehensive Cancer Center is promoted by United Health Family as a NCCN Cancer center of Excellence so why they are not network alludes me. I have written a letter of inquiry(in January) but have yet to hear from them.

Marcia of WI 9:04AM March 12, 2008

My wife and I abide with HMO rules scrupulously, because we know how the fine print can be used by the insurers to deny coverage and push up their profits. Yet we had to file 6 appeals for denied coverage in 2007. In 2 cases we were denied coverage for failing to have a referral for a PCP office visit. Nonsense! Of the 6 appeals, we have won 2 so far, including one of the PCP cases. The rest, 2 of them over a year old, are still being processed! But to most politicians, we are in the category of people who are "covered", and therefore not worthy of further government concern. We should offer only standard HMO coverage to elected officials, and their identity should be legally hidden from claims personnel so they can get the same treatment other "covered" people are getting from the insurers!

Richard Small of FL 7:38PM March 01, 2008

Are they incompetent, or lying to us?
We contacted Aetna in April 2007 regarding a non-surgical procedure for TMJ, Temporomandibular Joint and Muscle Disorders (TMJDs) , and we went over each medical code with the Aetna representative. We had the work done in August 2007. The representative told us in April what the "reasonable and customary" charge would be for each code.
Since then, we have talked to over six Aetna representatives, we have mailed certified-mail the forms, etc. We have been told conflicting information. Anything from "you need to file and send THIS portion to Aetna Medical, and THIS form to Aetna Dental" to "your check should arrive in ten business days."
They are either incompetent or lying to us.
We have appealed, and been repeatedly denied. Each time we call Aetna, they put us on hold, "to pull up your records", and are put on hold 10 minutes or more. On average, each time we call, we are on the phone 20 to 30 minutes.
We have spend over six hours between being on the phone, filling out forms again, mailings and so forth. Friday, February 29th, they again denied our claim. This started in August 2007, and here it is March 2008.
We will continue to fight this. Let us and others know if we can be a part of a file, appeal or lawsuit against Aetna and other dishonest insurers. Thank you. Dale Luther, Orange County, California

Dale Luther of CA 3:03PM March 01, 2008

I tried to find out what my insurer would pay to an oral surgeon to remove my daughter's wisdom teeth. The insurance company told me I would just have to submit the claim and find out, they wouldn't tell me ahead of time!

Dee of FL 10:41PM February 29, 2008