D's Daily Drama (fablespinner) wrote,
D's Daily Drama

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Important Ranting ahead... If you have Medical Benefits, you should take time and READ THIS!

Equality in Marriage Act... Passed, House, Senate, Courts and gets VETOED by the UPTIGHT AUSTRIAN ASSHOLE in the Governor's Office.

Screw Californian Popular Opinion, We the People Wanted it, Asked for it, BEGGED FOR IT.
We got Human Rights and Equality Passed through every government office in the State only to have one man Stop it cold. Even when his office stated he would "GO with what the courts decided,"

Lying sack of Shit. I want you rogered with a lead pipe with spikes.

Zieg Heil Mein Furor-fuck, Hilter was Austrian too.

Jesus Man, you came from HOLLYWOOD! I lived there too, It's Gay Mecca down there... you didn't have at least ONE FRIEND this bill might have affected favorably?

Dude you'd better never try to go back to Hollywood, that right there was a nice burning of a former bridge Mister Governor.
Is it November Yet? Can I torch my sample ballet on his porch with dog poo in a bag?


------/End political Rant/------

Onto Medical Fronts...

The Red Cross alert came across my Desk yesterday. The High demand since Katrina has led to shortages....
They are desperatly short of Type O-, B-/+ and A+ (O- and A+ especially as they are the rarest Blood Types)

Thankfully I work in HealthCare, so as soon as the alert was recieved at work, our Site President schedulded the Mobile RC UNIT to come by the office today.

I am A+ so when the Blood-mobile pulled into work today, I gave again, I had JUST recieved my reminder letter in the mail last week, (They send me letters every 8 weeks like clockwork, I'm a regular donor,)

And... Yes, if you are Diabetic you *CAN* still donate. They can't use your whole blood, but they CAN use the plasma! Just as important.

They will always take ANY blood type you are, I urge you all to go donate please.

And since I'm on the subject of WORK....

Welcome to D's Insurance Definition Corner... Where I will attempt to explain some really basic concepts you ALL should know, but ya know I get so MANY MANY MANY people asking me these same things day after day... Common Sense Ain't what it used to be,

#1.) HMO = HealthCare Management Organization. HMO's have the lowest out of pocket expenses for members. You generally have very small and resonable copays to Physician's and Hospitals and your benefits are usually 90-100% limiting the dollars you have to fork out in medical bills. I recommend this to EVERYONE on lower incomes with lots of medical expenses. How does it work? An HMO means you have a PRIMARY CARE PHYSICIAN (PCP) whom you go see first and then he MANAGES your care, sends you to specialists, gets you authorizations for surgeries, tests, etc... you have ZERO LIABILITY. If somewhere along the line, a Doctor sends you to a specialist Out of your Network, or they forget to get your auth... you are NOT FINANCIALLY responsible. Period. HOWEVER, if you decide to step out of the process and self refer yourself to a specialist or scehdule your own tests etc... If you try to manage your OWN CARE because you saw 20/20 and think you are now medically trained and know better than your doctor... guess what... you ARE financially responsible. If you are unhappy with your PCP, you always have the freedom to choose another doctor from the network at anytime. However you MUST have referrals, without them you are screwed. You have no OUT OF NETWORK COVERAGE. You step out on your own, you pay it all.

#2) HMO/POS = HealthCare Management Organization & Point of Service Plan. THis is an HMO with Out of Network Coverage. In-Network Is just the same as an HMO... you get managed by your PCP and you have Lower copays, co-insurance, etc... HOWEVER you have the option to Opt-Out... you saw that 20/20 episode on colonoscopies and want one. Your PCP says, "You're not at risk, you don't need one." but you want one anyway... You can self-refer to a specliast... HOWEVER, the catch? YOu have Higher Copay's and Coinsurance and higher out of Pocket expenses. Know this going in folks, cause this is WHERE IT HURTS YOUR WALLET!!!

Let me give you an Example with simple figures:
Your In-Network Benefit reads: $5.00 Copay, paid at 100%
Your Out of Network Benefit reads: $250 calendar year deductible, 70% coinsurance.

Office Visit Base Price = $100.00
In Network Doctor Contracts with Insurace and agrees to a reduced rate. He'll accept $60.00 as payment in Full and Write off his Taxes that $40.00 discount.
You Pay the Doctor $5.00, Insurance Pays him $60.00 You're done.

Out of Network, Doctors do not contract... no discounts. If you have not met your yearly deductible that office charge of $100.00 gets applied to your deductible and YOU PAY the Doctor in full.
But let's say you've met that $250.00... So we pay him $70.00 which is 70%, you have to pay him $30.00 your percentage.

See how FAST that can add up out of pocket for you? No discounts apply and believe me, I look at medical claims ALL DAY!!! That office visit I'm giving an example of above is about average for a 15-minute, just a quick chat with the PCP visit.

That's IT!

Be AWARE, BE CAREFUL, Don't cry to me when you get a bill that is $5000, you opted for that colonoscopy man, you should have known going in. Your benefits are in that nice big-booklet that says "YOUR BENEFITS AND HEALTH PLAN" you get from your employer... READ IT.

You'd be surprised how many, many people want me to pay the claim at 100% no patient/Mbr responsibilty at all... because.... and I quote. (drum roll please) "How was I supposed to know going Out of Network I'd have a deductible and co-insurance!?! No one ever reads those things!!! Who reads those? Can't you just pay it? (Cry, whine, cuss me out, scream etc...)"

Just because you didn't read it, does not magically change your benefits. It does not mean, because you FAILED to take responsibility for your own actions that we will turn around and say: "Oh gosh, I'm sorry. Here. let me give the hospital another payment just for you. *pet pet* There, there you poor person you. Here, let me hold your hand and while I'm at it and you're screaming at me. Let me also walk your dog, take out your trash, balance your check book, and pay your mortgage..."

Not gonna happen folks, no matter how many names in that book you call me or the company I work for... I didn't select your benefit plan, your employer did. I have to enforce the rules, which are pretty damn lenient 9 times out of 10...

Face it... You're adults, take responsibility for your own actions people. Just because you couldn't be bothered to read 20 pages of a booklet your employer put together for you to EXPLAIN your benefits they selected to GIVE TO YOU AS A BENEFIT OF EMPLOYMENT.... and you just tossed it in a drawer and never cracked the spine and wound up with a bill is not anyone's fault... BUT YOUR OWN. Expensive lesson, but true.

Okay... onto PPO

PPO = Preferred Provider Organization
That means, Providers contract with insurance to offer discounts to our members. Simple.

This means, you get a nice big book of providers, ranging from PCPs to Brain Surgeons... you manage your own health. You pick doctors from this list and go to them and save $$$$

If you toss this book into the drawer with your benefit breakdown booklet... and just pick up the yellow pages you could screw yourself. But here's the MAGIC QUESTION TO ASK IF YOU ARE THE TYPE OF PERSON WHO JUST TOSSED THAT INFO IN A DRAWER... ASK THIS WHEN YOU CALL THE DOCTOR TO SET UP AN APPOINTMENT:

"Are you CONTRACTED with my PPO?" or "Are you a Preferred Provider in my Network?"

Do NOT ask: "Do you take my Insurance?"


Because the answer to that question will always be YES. You have a ppo you can go to ANYONE, but you SAVE MONEY by going In-Network to a PREFERRED PROVIDER. A PREFFERED PROVIDER offers insurance members DISCOUNTS.

Here's another Example of what I mean that hopefully will open some eyeballs:

Your In-Network Benefits for Out-Patient Surgery Facility:
$100 Deductible, 90% coinsurance

Your Out of Network Benefits for Out Patient Surgery Facility:
$250 Dedcutible, 70% Coinsurance

Surgery Hopsital Bill: $10,000.00
Preffered Provider Hospital will accept $2100 as payment in full.
They will write off the top $7,900.00 off their taxes
YOU PAY: $100.00 Deductible... Which leaves a balance of $2000.00 We pay 90% of that $ 1800.00 your 10% coinsurance is $200.00 Your total financial responsibility: $300.00 (not bad for a 10K surgery!)

Same scenario out of network... NO DISCOUNTS!
Out of Network Hospital will bill the full amount $10,000.00
YOU PAY: $250.00 Deductible... Which leaves a balance of $9,750.00 We pay 70% of that $ 6,825.00 your 30% coinsurance is $2,925.00 Your total financial responsibility: $3,175.00


Please DO NOT CALL your insurance company Customer Service Representative and scream holy hell at them over this scenario. There is FUCK ALL we can do if you do not TAKE RESPONSIBILTY over your own health care. We told you, in that little booklet sitting in your drawer what your benefits are, when you OPT-OUT OF NETWORK because you "just HAD to go to the Beverly Hills Surgery Clinic for that MRI" rather than Cedar's Sinai because "LIEK OMG! IT'S BEVERLY HILLS THEY'VE JUST GOT TO BE BETTER BRITNEY SPEARS GOES THERE!"

This is what fucking happens.

Too Bad so sad, cry me a river you irresponsible, materialistic boob.

And Trust me, I deal with Beverly Hills Surgery Clinic, they don't contract with ANY insurance, and they charge a whole HELL of a lot more than every hospital in the NATION.

a one hour simple upper GI will cost you your mortgage! And guess what, no discounts man. Just because it's in beverly hills, does NOT make it any better than Porter Memorial Hospital in Valparasio Indiana.
Don't fall for hype people, research your doctors. WebMD is your best friend for Doctor ratings and information. Take the Doctor's out of your book, type in their names and read up on them. That little small town Doctor may just be the premiere specialist for *insert your condition here* and he does contract.

Location and address of the building means absolutely NOTHING. It's the DOCTOR doing the work and the Facility Staff itself that make the difference.

Most Insurance carriers will have websites with Facility comparrison tools, Doctor information, etc... it takes you ten minutes to get pages of very useful info. Oh wait, I forgot, the most useful info is sitting in that desk drawer. How do I know this? People yelling at me day in and day out.

These are OLD SCHOOL insurance policies, there are no networks, there are no contracts. You go to anyone and you have a flat benefit:
$500 Calendar Year Deductible, 80% Coinisurance. (for Example)
THis means every year you have to meet your deductible and then after that's met, you pay 20% of every thing. Period.


Do NOT confuse these two things. They work together but are different.

Deductibles are the Dollars you pay out of pocket FIRST before your coinsurance coverage kicks in... These usually read like this:

$100 Individual Calendar Year
$300 Family Calendar Year

Family Deductible? What's that? This means You and your dependents (Spouse, Domestic Partner, Kids etc...) 3 members must reach their individual deductibles, if this happens, then say you have 4 other kids... they won't be charged individual deducibles because the FAMILY deductible was met. If it's just you and your spouse or just you, then you or both of you have to meet your $100.00 individual deductibles, there's not enough members of your brood to qualify for family limits, family won't apply to just 2 or less of you.

Out of Pocket maximums
These are really important for you to know. This is your saftey net. Your insurance company tracks all the dollars applied to your deductibles and coinsurance and when you reach a set limit.

Say for example: $5000.00 per calendar year, this means your insurance INCREASES to 100% coverage. In any one given year will will never pay more out of pocket than whatever your limit is.

They usually read like this:
OOP Max Individual: $5000.00
OOP Max Family: $10,000.00

So say you have a family of 4... YOU have to have emergency brain surgery. You easily meet your deducible and out of pocket max, Any bill that comes in for you for the rest of the year will be auto paid @ 100%

Then suddenly one of your kids the following Day has to have the same surgery and he/she easily meets the maxes....

This means... since FAMILY OOP has been met... EVERY MEMBER ON THE POLICY IS AUTO PAID at 100% for the rest of the year.

Yes, you have $10,000.00 in bills, but it COULD have been 2 million. That's why there are limits so you don't go into bankrupcy and shit. Believe it or not Insurance companies are not heartless! We also do not set these maximums. Your EMPLOYER DOES.

Okay... Moving onto more UBER IMPORTANT STUFF HERE....

EOB = Explanation of Benefits.

These are those letters you get that say "THIS IS NOT A BILL"
Do not ever, ever, EVER just throw these away!
This is CASH IN YOUR HAND FOLKS! Those are proof of payment records, You keep those like tax returns for at least 7 years.
Open these, read them. You'll see on these important details of your claim:
How much was billed
How much was discounted
How much your insurance paid
and How much you should expect to be billed from the hospital/doctor.

You get one of these and the billing provider's office gets a duplicate copy attached to their check for their records... So they know how much to bill you (if anything).

When your statement comes from said Doctor or Hospital ... COMPARE IT TO YOUR EOB... Does it match?

If NO, call the Provider who billed you immediately. Mistakes happen. Sometimes they forget to take off their contracted discount off your statement, sometimes they typo, sometimes the computer spits out a bill in error.

They will usually ask you for a photocopy of that EOB you have... then low and behold your bill is fixed.

Sometimes if the provider billing office is being a difficult (Which happens believe me) call your insurance company immediately... I will gladly call and rip a billing office a new asshole for over charging.

Now sometimes WE make the error, and things need to be reprocessed. People make mistakes, so please be aware of your benefits, that will give you a fairly decent idea of what's going to be on your EOB when you get it... you can catch errors better than anyone, it is your money after all.

Now... here's the scenario about EOB's I hate the most... 90% of people see THIS IS NOT A BILL and just toss it away.
5 years later, they are trying to buy HOUSE./CAR/ETC... and their TRW gets run... Guess what you have an outstanding medical claim messing with your credit score.
When it's that old? I no longer have it in my system, the hospital no longer has it since 3 years ago they sold it to a collections agency.
Which are all assholes to the 10th degree of Dante's Inferno.

I have to go pull microfilm (if I CAN and it's not purged for being ANCIENT HISTORY) and then TRY to determine just how this claim was paid 5 years ago, and then FIGHT with the pricks at the collections agency to get them to remove this issue.

Which should have never been on your credit report in the first place and, and this pisses me off most. I have to do all this horrible work, when the member readily admits they got bills all the time but ignored them because "They had insurance"

They never bothered saving their EOB, they never bothered calling the Hospital about the bill, never bothered to call US when they got the first, second, fifth, final notice bills....

The bills from the Hospital stopped coming, because DUH, you've been turned into collections and the Collections Company stalled for a while and then finally got around to billing YOU AGAIN 3 years later...

You ignored it until it inconvenienced you because you wanted to make a big dollar purchase so suddenly it's the insurance companies fault!

No one ever takes responsibilty. Stop passing the Buck people. Pay attention to your bills, your financies, we don't send you EOB's for nothing. Had you had that EOB? And got that FIRST bill from the hospital it could have been over 5 years ago... Had you had that EOB You could have given to the collections agency and immediately had your credit cleared and I wouldn't have had to spend 3 weeks ordering microfilm and fighting with evil collections reps who just want money and can care less about whether or not you actually OWE that money.

*IF* they'll even talk to me. They only EVER want to talk to the person they are billing and only you, so please save me mirgraines folks.

Okay more basics .... getting sleepy yet?

#1. most Stupid Question I get at the very minimum twice daily, sometimes More, when I quote benefits are that are based on the "Calendar Year"

"What's the Calendar Year on this Policy?"



Can you see that vein on my skull throbbing at your idiocy? Please think before you speak. Calendar years NEVER change and we are not in China and this is not the year of the monkey or something.... Mmmm'Kay?

Now onto Who is and Who is NOT covered on your plan. Basic terminology and basic standards and definitions of Each.

Primary Member/Employee: YOU Duh
Spouse and or Domestic Partner: Your sig-O

Dependant: Definition:  Child of the Employee who is unmarried and legally dependent upon the Employee for support until end age.
Dependent Start Age:  Birth
Dependent End Age:  19 Years (This is average, Check YOUR PLAN SPECIFICS ON AGE LIMITATIONS)

Dependant Step-Child: Definition:  Unmarried Stepchildren of Employee, Living with the Employee in a normal parent-child relationship.
Dependent Start Age:  N/A
Dependent End Age:  See Dependent or Student Definition

Dependent: FULL TIME STUDENT: Definition:  Employee's Children Provided such Children are:
1) unmarried
2) enrolled as full-time student in an accredited school, college, or university, and
3) primarily supported by Employee
Dependent Start Age:  N/A
Dependent End Age:  25 Years
AND YES, at 25-26 (This is average, Check YOUR PLAN SPECIFICS ON AGE LIMITATIONS) we consider you a GROWN UP NOW, get a job now you eternal student and stop sponging off mommy and daddy! You're almost 30 for goodness sakes!

New Born: Definition:  Any Dependent Child Born While the Employee is Insured will become Insured on his/her Date of Birth for a Period of 31 Days whether or not Dependent Medical Insurance is elected within 31 days of the Child's birth. If the Newborn Child is NOT Insured within such 31 days, coverage for that Child will end on the 31st day.
Dependent Start Age:  Birth
Dependent End Age:  31 Days

BIG NOTE HERE: The newborn covereage is limited to YOUR DEPENDENTS as in YOUR CHILDREN... if your 15 year old daughter drops a kid, unless you LEGALLY ADOPT IT, that baby is NOT COVERED. That is a dependent of a dependent... not yours, that's your GRANDCHILD...  and as you can see:

Grandchild: Definition:  The Offspring of a Dependent Child as Long as the Dependent Remains Eligible.
Dependent Start Age:  N/A
Dependent End Age:  N/A

See that N/A? Not Applicable, I don't know ANY INSURANCE that will cover dependents of dependent CHILDREN.
I'd make sure your teenage kids take advantage of the FAMILY PLANNING BENEFITS in your plan... Most Birth Control Oral Medications, IUDs, Depro Provera, Norplant, Counselling, etc... are covered at 100% USE THEM THAT'S WHAT THEY ARE THERE FOR... Do not yell at your insurance company when your 15 year old gets a bill from the hospital showing HER SERVICES were paid by the insurance but the BABY'S WERE DENIED AS NOT A COVERED DEPENDENT UNDER THE PLAN.

Too bad, so sad... the parents of that baby better get a job to pay for the bill then. Harsh reality of life. Old enough to screw, old enough to sleep in the bed they made.

Okay, I think I've force fed enough info to you all for one day... there is sooooooooo much more. Laws, pre-existing condition clauses, funding types, HRA savings, etc..
Please guys, if you have questions about YOUR plan, ASK ME, I'll be happy to try and explain ANYTHING about Medical Insurance to you if I can. It's really fairly simple and straightforward.
If I can't answer it, I can tell you at least who to call for clarification.

Don't get caught in the medical bill nightmare, be aware and you'll never have these very all too common problems.


---->End public Service Announcement<------

(EDIT) Feel Free to Post the link to this entry, the more people who understand their insurance the LESS I have to deal with idiots and Satan's Minions collection agencies!
Tags: insurance talk, political ranting

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