On How to Get Health Care While Uninsured

@Ron Santlofer@facebook Dear Ron, I just saw your post and you may not see this since it's been a while, but wanted you to know I've been on both sides of this issue but no where near where you've come from. I worked in hospitals, physician offices - coding and billing. I've worked for every type of health insurance (Aetna - BCBS - Medicare - Medicaid - Commercial - USHC - WorkComp. - Union Indemnities - HMO's - PPO's -,... you get the picture) I sat on a panel in Washington creating HCPCS (coding levels of care for billing), CPT codes w/alpha modifiers (billing for procedures)DME, pharmaceuticals, dental, etc.,- I've negotiated contracts with corporations, insurance companies, physicians and sat in on negotiations with hospitals - coordinated benefits [COB], applied Type of Coverages {TOC Codes applied to different contracts}, designed Explaination of Benefits [EOB's], and gone all over the Nation to see what physician's/hospitals use (expense off in a USUAL AND CUSTOMARY manner)for the care of these diagnosis. More often than not I ended up frustrated by 2nd rate insurance industry physician's, nurses, psych docs and executives watching out for their bonuses which were directly attached to what they saved companies I worked for/with and negotiated binding contracts for/with. {this practice now said to be - by Congress and the AMA - "non-supportive of the level of ethical and moral standards in an industry which should herald in and reach for the highest ideals of such Hippocratic care of humanity."} It came to the point that I was losing more and more cases like yours. Compassion was sucked out of the equations and "grandfathering" promises made to you by a company such as Empire began to tell on me and others. The law in NY changed - but the discretion of Empire and others was held to be outside this change to previously made contracts/agreements if both parties found common ground. I've represented as an expert for several cases analyzing the contracts and to the best of my ability found precedents to obtain coverage commensurate, equal or brought the insurance to at least maintain a 2ndary status. Working with others we were able in two cases to continue "Off Label or Experimental Treatments" being considered by the FDA having been denied for the reasons you state. The drive for profits and the assertiveness required to maintain pressure on these companies/providers/ suppliers/drug/institutions became too much. Looking at the compensation packages (even outside of bonuses) of a majority of Insurance Conglomerates makes Wall Street drool with envy and tempts ideas for career changes like no other time. I can only imagine that many physician's support the Patient Protection and Affordable Care Act since the reimbursements have plummeted even in the past 15 yrs to a miniscule portion of their practice. It's obvious why. One glaring item most American's haven't taken up ridicule and disgust with was the Obama proposal to mitigate the largest FRAUD being perpetrated on our system of pay and pursue on the "back-end" of Medicare and Medicaid. Obama wished to install prosecutorial ability on "providers" that obtain the master lists and submit claims all day everyday recieving checks Mon. Wed. Fri. of over $100,000.00. $300,000.00 per week. $15.6 MILLION a year. $60 BILLION total each year. Even those on the "front-end" getting a check(s) once a month couldn't match that. Republican Committees denied this as not "Revenue Neutral". Huh? Any time someone can spend $1billion to make $60 billion in a year,...isn't that a good thing? This outlay would also cover "combing out" the master list of dead people more often. {A woman recieved 12 wheelchairs in a year claimed by these fake "provders" - it was paid. Not only couldn't the Gov. "pursue" and prosecute because of policy - the woman, having a different wheelchair for every month of the year - she was deceased.) Someone dies - but disseminating this doesn't happen instantaneously of course, and it's paid so that if she were alive she wouldn't be tossed out on the street or having her credit ruined when all her claims were delayed in payment to investigate and prosecute the perpetrator. So Ron - with the debacle hitting you (no one can go back in time and recoup what they "might have done" with funds had they not been denied and cut off as you were). Doctor's getting about $.23 on the dollar and the cry and wail from American's about how their neighbor is sucking off the teat of the taxpayer - none of the real money will ever be captured. Europeans wish they could prevent on the "front-end" as we do (but they catch and prosecute Government Healthcare Fraud as we do NOT.) Having been in the middle of this Storm (I'm disabled now also) - it's time for a change in each portion of our system. I helped folks like yourself, but I was in a unique position and feared when I walked in with my hand cart of documentation. No program is perfect - Medicare and SSI weren't when made into law. PPACA won't be either - but it's a start - changes will be made to it - no doubt. It's got to begin somewhere - Congress said it's been being worked on for decades. It has been, but waiting for perfection has already let the buses go by this stop long enough. What's going on right now - today - in the Healthcare Insurance Industry would curl many people's toes - and they're fingers are crossed Obama will lose. Greed, however, is not called one of the Deadly Sins for nothing. Best of luck! Hope all's well - I'm sure you had other uses for all the money you were compelled to spend.

Posted on November 3, 2012 at 1:35 am 0