2 hour survey - $225.00!!

[Taribor]

I hear you and certainly agree with most of your opinion, but one reason for all of this red tape is to try (usually unsuccessfully)and make it harder to commit fraud.

I investigate a lot of doctors who bill for services not rendered and/or procedures not required. Some are gutsy enough to literally walk into medical facilities and add fake charts to patient files, just so they can bill Medicare. It is far more common (and easy) than many would believe and the response, unfortunately, results in yet more holes in the system. Combine that with the billions of dollars a year lost to bad medical labs, fraudulant durable medical epuipment companies, etc. and it is easy to see how/why we have gotten to the point that insurance companies, sick of getting ripped off, are a pain in the arse to deal with.

As far as drug seeking beneficiaries talked about in another post, I doubt the DEA is going to raid a Dr's office over being a little lenient on his prescribing practices, but leniency is a far cry from being a flat our supplier, and those are getting easier to identify; though I guess I can see his hesitation. In any case, once suspected, is not hard to identify the bad apples.

Our healthcare system, administratively (not quality of care), is broken all the way around and you would be stunned to see just how much fraud is really going on.

I usually just lurk here but I saw this and had to jump in, sorry!

The sad part is that all of the rules and regulations and prior authorizations and pre-certifications don't really save the insurer any money. In fact, they often increase costs, increase emergency room utilization, increase prescription expenses and increase the insurancy company's overhead.

[St. Theresa]

Actually, even a positive MRI doesn't protect the doctor. This is absolutely not directed at you personally, but many drug-seeking patients take advantage of their positive MRI findings to obtain narcotics inappropriately. They will doctor hop, meaning go from doctor to doctor, bringing along their MRI report showing that they have legitimate disease and need pain meds. Since this country has yet to establish a computer database linking pharmacies (a disgrace, in my opinon), it is quite simple for a patient to see multiple doctors, get multiple prescriptions and fill them at multiple pharmacies without anyone finding out.

Like Rush Limbaugh?

I don't get how people can get away with this with insurance. You'd figure they would catch on. Without insurance, I don't see how it's worth it. To stay under the radar, you'd have to pay the doc and the pharmacy out of pocket, and that's mighty expensive. But I suppose if you're a junkie and you have the cash, like Rush, it's no problem.

When I went to the ER the first time, I was really hoping for an MRI. Because it wasn't emergent (no numbness or incontinence), they didn't do one. They gave me a script for 20 pain pills. My co-pay is $100. I could probably have bought 20 pain pills from a street dealer for that much in a lot less time. The one good thing that came out of that visit was that it got my doctor to finally approve the MRI.

And you're right. Pharmacies should be linked, not only to prevent the kind of abuse you brought up, but to help patients get meds that some pharmacies may not have on hand.

My doc has been my doc for a long time, so even if I were to be a drug-seeking doc-hopper, he'd probably be ok. The other docs, who I'd be seeing for the first time? Not so much.

It's funny, because I watched an episode of "House" just a few days prior, when he goes to a doctor to try to get some Vicodin and is told that "It's our policy not to give narcotics to first-time patients." I get sick to my stomach every time I watch House down several Vicodin pills at one time. That stuff makes me queasy. Plus, there's so much acetaminophen in them that I predict liver problems for Dr. House next season.

While I understand why this is becoming the norm, it's disturbing. What if your first visit to a doctor is because you've been injured and you're in real pain? They give you do-nothing stuff like Tramadol and you suffer. OR, as you said, you go to an ER, which is much more expensive.

As for HMO's, ugh, I am so pissed. I just got a bill for $860 for my portion of my MRI and I have to have another one on Saturday! I can't afford this! I have insurance through my ex, and he picks the cheapest plan his job offers. This is SO stupid because the premiums he pays are deducted from his child support, so it makes no sense to go cheap, especially when we have two kids.

I talked to him about it tonight and he didn't have much to say. After the call, I looked at the bill again and realized IT'S IN HIS NAME!!! He's the subscriber! When he learns about this, maybe he'll do the right thing and get a plan that actually covers us. I'm going to let HIM call Tufts and find out why they paid so little for the MRI. It's not MY credit and it won't be me they haul into court if I can't pay.

As for health care in this country, it's ridiculous. We are the one and only industrialized nation without universal health care coverage - and we're the wealthiest! And now in Massachusetts, it's a law that every person MUST have health insurance! But it's still not affordable and it still doesn't cover people enough.

Taribor: I was shocked yesterday as my doc coached the woman who had to call for the pre-auth on my MRI. He basically exaggerated my symptoms, as they were putting up a lot of resistance. I kept my mouth shut. If he thinks I need to have another, then he's probably right. We have no idea what happened the day I sneezed three weeks ago and could barely walk afterwards. When he operated on me last time, I had another MRI the day before the surgery because my symptoms had changed/worsened.

A few years ago, my ex had us on an even worse plan. We only got x amount of coverage per year - I think it was $1500. The next $5000 came out of our pockets, and then full coverage would take effect after that. Well, didn't a storm door slam into my sandled foot and gash it open. I was at a client's house and they weren't home. I wrapped it up in paper towels so I wouldn't bleed all over their nice house, did my work, picked up my check and went home. My then-partner insisted I call my doc. It was after hours and I would get the on-call physician and I preferred to wait until the next day when I could be seen somewhere other than the ER. But the doc on call said I might need a tetanus shot so off I went...six stiches, $1200. That left the entire family $300 for the rest of the year before we went to out-of-pocket.

Please excuse the rambling.

[jasanderson]

If it's a law in MA that every person has health insurance how do they enforce that? If you don't have access to affordable care and can't afford it if you have to put food on the table do they have an optional state program anyone can get on for reduced fees? That's crazy!

[disneysteve]

I don't get how people can get away with this with insurance. You'd figure they would catch on. Without insurance, I don't see how it's worth it. To stay under the radar, you'd have to pay the doc and the pharmacy out of pocket, and that's mighty expensive.

Around here, from what I'm told, oxycodone (the active ingredient in Percocet and OxyContin) sells on the street for about $1/mg, so a Percocet 10/325 is worth $10/pill. Go to a doctor, pay $50 cash for the visit, walk out with a prescription for 50 Percocet 10mg pills. Those will cost you about $90 at the pharmacy. So you've spent a total of $140 but now have a bottle of pills with a street value of about $500. Not such a bad business financially. Do that 4 or 5 or 6 times/month with different doctors and you're making a profit of a couple thousand dollars/month.

[disneysteve]

I investigate a lot of doctors who bill for services not rendered and/or procedures not required.

I certainly understand that issue and it deserves to be investigated and punished. What I'm talking about though is when I want to order a test or procedure that I have absolutely no financial interest in. If I want to send a patient for a CT scan or an MRI, there's nothing in it for me. I don't get paid for ordering tests. Just the other day, we had a patient who we felt needed an emergent CT scan. We couldn't get it authorized by the insurance company for 48 hours, so we ended up having to send the patient to the ER. They got the CT right away, of course, along with the usual ER workup. So the insurer will end up paying a few thousand dollars for that episode rather than just the cost of an outpatient CT, which would have been far lower. So what exactly did they save?

[Cashguy]

Hopefully the patient got the correct care/dx and is on the path to being better. ER docs seem to overlook the subjective if there aren't any remarkable objective findings and usually send you back to your GP. I agree insurance drags its feet sometimes but remember how many certs they may have to do at one time. My insurance company called me to say I was inappropriately charged 1k for a MRI deductible and copay and to seek reimbursement back from the provider. How's that for service. I would have never known.

[St. Theresa]

Around here, from what I'm told, oxycodone (the active ingredient in Percocet and OxyContin) sells on the street for about $1/mg, so a Percocet 10/325 is worth $10/pill. Go to a doctor, pay $50 cash for the visit, walk out with a prescription for 50 Percocet 10mg pills. Those will cost you about $90 at the pharmacy. So you've spent a total of $140 but now have a bottle of pills with a street value of about $500. Not such a bad business financially. Do that 4 or 5 or 6 times/month with different doctors and you're making a profit of a couple thousand dollars/month.

Any doc who gives 10 mg right off the bat has to be out of his or her mind. I've never seen a 10 mg Percocet, and I've had all sorts of painful things: wisdom teeth impaction, babies, broken foot, surgeries, herniated discs, etc. Wouldn't 10 mg be for someone who's taken oxycodone for some time already? It does seem to wear off its welcome, but I always start with one, if I take it at all, and only take 2 if it doesn't bring enough relief. Of course, there's more Tylenol that way, but a patient in real pain is liable to take too much OC meds if they can't get prescription pain relievers, anyway.

$50 for a visit? Wow, I want to go to THAT office My co-pay is $20! Not too far off. The last time I went to a doctor's office (and saw what the actual charges were) it was $178. That was just to be seen for about 10 minutes. No tests, no major examination - just a brief visit.

But yeah, you're right about the price. A former good friend of mine (we were buddies as teens) is now a "recovering" heroin addict, and I put that in quotes because a) I can't be sure she's not still shooting up and b) she gets a steady supply of methadone. Living in Arizona, she manages to get her hands on all kinds of pain meds, sends 'em to her sister and her sister sells the 5mg Percs for $5 each. Knowing this, I could have gone to her and spent my $100 (ER co-pay) there. It would have been cheaper and taken less time. Nuts.

[St. Theresa]

If it's a law in MA that every person has health insurance how do they enforce that? If you don't have access to affordable care and can't afford it if you have to put food on the table do they have an optional state program anyone can get on for reduced fees? That's crazy!

MassHealth. It's there for low-income people. In Mass, you're better off being low-income than lower middle class. The latter don't make quite enough to survive but make too much to qualify for programs like MassHealth.

I don't know how they enforce that. Interesting question. I think you pay fines, which are supposed to fund MassHealth, but that's just what I think I remember.

[St. Theresa]

Minor fines now, expected to go up:

"The law says that, actually as of the first of July in this state, that you haven't been exempted, you have to have health insurance. But there was a grace period that was built into the law," health connector spokesman Richard Powers said.

But the grace period is almost over. Consumers have until Dec. 31 to sign up for health insurance. The punishment for not complying is a tax penalty of about $200 for a single person or $400 per family.

"Well, basically, what happens is that you lose your personal exemption for the 2007 tax year," said Robert Bliss of the state Department of Revenue.

The state and health insurance companies have worked to make health insurance more affordable. For a single person, that means some Massachusetts plans cost less than $200 a month.

The Massachusetts health connector's Web site has an easy tool for finding out whether a consumer can afford insurance and the details of the various plans.

Massachusetts health connector officials estimate that since the new law went into effect, 300,000 of Massachusetts' uninsured have signed up for health insurance. They estimate anywhere from 100,000 to 300,000 residents still don't have health insurance.

"It's just like car insurance. If you don't have car insurance and you cause accidents, then those costs get transferred to someone else," Bliss said.

Consumers who really can't afford health insurance will most likely qualify for an exemption based on income. They can also apply for a hardship exemption.

"The principal of the individual mandate, which is sort of the bedrock of this program, is that if you have the means to purchase health insurance, you have a responsibility to do it. And it's DOR's job to enforce that responsibility," Bliss said.

The tax penalties are expected to increase significantly in 2008. But before you panic, check into whether you qualify for help from the state.

You qualify for free care if you're very low income. The state will help you pay for health insurance if you're a single person making $30,630 or a family of four making less than $61,950.

Deadline Approaches For Health Insurance Law - News - Turnto10

I'm reading about employers who prefer to pay fines rather than provide health insurance to their employees. It's cheaper! Obviously, the fines for them will have to increase if the law is going to accomplish what it's supposed to.