Conference 7.286::digital

RE: .0

Your case 2 (the hassle over physical therapy) certainly could happen with any
traditional insurance plan.  Not having to worry about such things is one of
the plusses of HMOs.

--PSW

My wife and I have both had significant medical expenses this year.  We used
top specialists in Boston.  We have Digital Medical Plan 2.  Every expense was
deemed to be "reasonable and customary," even though *BIG* bucks were involved.

As regards second opinions, they're required only for a small number of
operations (I think 11 types, but don't rely on this number).  Other surgery
doesn't require a second opinion.

        Re: .1

        Similar situations could happen with an HMO--you could get told
        by a physician `a chiropractor could help your problem, but this
        HMO doesn't cover chiropractic services'.  Some HMOs cover
        chiropractors and others don't.  Both the Digital Medical Plans
        and HMOs have fine print and coverage limitations.

        It is a nice feature with HMOs that you know if treatment will
        be covered before you have the treatment--there is no submit the
        forms and wait to see if it gets bounced.

        					B.J.

    
    	Hmm.  Reasonable and customary. . .
    
    	While under Plan 2 I needed hospitalization for several months.
    	I was left owing over $700 because insurance would not pay.
    
    	I require doctor ordered lab tests on a regular basis.  No bill
    	has been reinmbursed in full and many not at all.
    
    	In moving and shifting care to a new physician I find that 
    	"necessary" treatment is questioned and I am faced with
    	approximately $2000 to pay out of pocket.
    
    	Unfortunately, I am "forced" to stay with Plan 2 because of
    	court-ordered support to my ex.  Whoopee!

>    	Unfortunately, I am "forced" to stay with Plan 2 because of
>    	court-ordered support to my ex.  Whoopee!

You mean they won't let you use plan 1?

I have had Digital Medical Plan 1, the cheaper of the two plans.
I chose the cheaper plan because I had never been hospitalized for
anything other than having babies.  I took the gamble so to speak.

On December 27 last year, I fell skiing.  The story is too long
to bore you with the details, but I was on crutches for 6 weeks,
physical therapy for almost two months, then knee surgery (1/2 day in
the hospital), and four more months of physical therapy (3 times a
week, 6 months total).

My experience with DMP 1 has been very good.  That means no surprises.
My hospital bill was "customary".  I had to pay $400 of it.  I reached
my out-of-pocket limit for the year of $1200.  Each physical therapy
session was about $60 - $80 and that charge was accepted as "customary".
I paid 20% until I reached the $1200.  All the rest of my expenses were
covered after that.  There was no "reviewer".  My doctor was in charge.

Your friend had a terrible medical plan.  I don't believe that could
happen here.  At least my experience tells me that it couldn't, but
that's all I have to go on.

Now I'm grappling with Healthnet (Harvard Community), DMP 1, or opting
out and getting coverage from my hubby's job (Blue Cross through the
Federal Government - similar to DMP 1 but cheaper.) I have a son who is a
full time college student at Dartmouth.  He is on a quarter system and
is working in Colorado (and skiing) for three months, attending U. Cal.
Santa Barbara for the next three months, and then will be back in New Hampshire
for the summer session.  The HMOs scare me when I think about his needing
medical care during this year.  I also don't have one HMO site to go to.
I live in Stow, Mass.  I would have to change everything and I don't think I'm
prepared to do that right now.  And, in spite of many people's good experience
with HMOs, I am hesitant to loose my freedom of choice.

Life is interesting.

Barbara

re Note 1302.1 by PSW::WINALSKI:

> Your case 2 (the hassle over physical therapy) certainly could happen with any
> traditional insurance plan.  Not having to worry about such things is one of
> the plusses of HMOs.

        Of course, the reason you don't have to worry about this with
        an HMO is that they are both insurer and provider, therefore
        you wouldn't get the physical therapy if they didn't want to
        pay for it.

        Bob

RE: .7

>        Of course, the reason you don't have to worry about this with
>        an HMO is that they are both insurer and provider, therefore
>        you wouldn't get the physical therapy if they didn't want to
>        pay for it.

That isn't what I was talking about.  The difference I meant to point out is
that with a traditional insurance plan, your doctor prescribes physical
therapy (or whatever), you get the therapy, and then when the bills come in,
you find out whether the insurance company is going to pay the full amount,
or whether you'll get stuck with some or all of the cost.  With an HMO, if an
outside service such as PT is precscribed, you find out at that time whether
or not it will be fully covered.  Most HMO plans say that all outside services
are fully covered, if they are prescribed by a Plan physician.

If you are saying that a Plan physician will not prescribe needed treatments
because the HMO doesn't want to cover them, I admit that's possible.  It's
also possible (and equally unethical) for a non-HMO physician and a physical
therapist to run a scam where the physician prescribes unnecessary physical
therapy in exchange for a kickback from the insurance payments collected.
The bottom line is that by either payment method, you ultimately end up trusting
the medical judgement of the physician.

--PSW

re Note 1302.8 by PSW::WINALSKI:

> The bottom line is that by either payment method, you ultimately end up trusting
> the medical judgment of the physician.

        Perhaps we differ in basic philosophy.

        I believe that ultimately, I'm responsible for the course I
        choose.

        As a thoughtful individual, I will of course consult
        appropriate experts and give due consideration to their
        advice, but I will not delegate my responsibility to them.

        Bob

re .8:

>     with a traditional insurance plan, your doctor prescribes physical
>therapy (or whatever), you get the therapy, and then when the bills come in,
>you find out whether the insurance company is going to pay the full amount,
>or whether you'll get stuck with some or all of the cost.

You can always call the insurer before treatment and ask whether it's covered.

>If you are saying that a Plan physician will not prescribe needed treatments
>because the HMO doesn't want to cover them, I admit that's possible.  It's
>also possible (and equally unethical) for a non-HMO physician and a physical
>therapist to run a scam where the physician prescribes unnecessary physical
>therapy in exchange for a kickback from the insurance payments collected.

It may be equally unethical, but it's not equally likely.  Other notes have
talked about penalties for HMO physicians who authorize care that the HMO
deems too costly.  If your non-HMO doctor recommends physical therapy, you
don't have to go to the PT he recommends (unlike with an HMO), so the
likelyhood of kickbacks is minuscule.

Three years ago, in reply .2, I said that I'd never had a claim reduced because
it exceeded "reasonable and customary."  Now I have.

Has anybody appealed "reasonable and customary" to the U.S. Employee Benefits
Manager?  What argument did you use?  Were you successful?

If you prefer to respond offline, please do.

> Has anybody appealed "reasonable and customary" to the U.S. Employee Benefits
> Manager?  
    
    Yes.
    
> What argument did you use?  
    
    My wife and I got the exact same dental treatment approximately one
    week apart.  We live in the same house though we do go to different
    dentists in different locations.  We each see the same dentist we had
    been seeing before getting married.  The reimbursement amounts are
    different, which I think is unreasonable.  
    
> Were you successful?
    
    Are you joking?  Of course not.
    
    
    ------
    
    They also ignored my request for a list of dentist whose fees fall 
    withing the reasonable and customary guidelines.  No doubt because no
    such dentists exist.
                                              
                                        August

I'm particularly interested in the Digital Medical Plans, not in dental.

    re:.12
    The "reasonable and customary" rates are set on the basis of the
    PROVIDER'S ZIP CODE.  This means that your dentist and your wife's may
    be covered differently just because of the neighborhood they have their
    offices in!  (My dentist operates out of a house in a swanky
    neighborhood.  I'm sure it's treated favorably.)  Where you live makes
    no difference.
    
    And people wonder why doctors are so reticent to set up in the inner
    city....

>    The "reasonable and customary" rates are set on the basis of the
>    PROVIDER'S ZIP CODE.  
    
    I know.  So Digital encourages people to seek dental care from
    providers in expensive areas.  (Or least, doesn't discourage people
    from doing so.)  Of course, as my dentist says, his supply costs are
    the same as those in the more expensive areas.  His loans he has to pay
    back are as large.  Rent may be less but that is only a dentists'
    overhead.
    
    One more thing, don't bother calling all the dentists in your area to
    see what they charge for a procedure.  Even if you can prove that the
    actual reasonable and customary charge is greater than the "reasonable
    and customary" charge Digital uses, you won't win.  
    
    Accept what you get and smile.
    
                                    August

    re .13
    >>>I'm particularly interested in the Digital Medical Plans, not in
    dental.
    
    See my note regarding our DEC Plan in this conference 2454.0. I had
    trauma care which I had no input on. Now if I had told the air crew
    to fly south instead of north maybe things would have been different.
    But the point of my case is that I was responsible for my own health
    care when I could NOT offer input. Only some help from corporate
    managed to salvage my sanity. I still ended up paying out LARGE amounts
    of money because I wanted to put the matter behind me. The insurance
    industry finally wore my family down. They are *MOST* uncaring and
    unreasonable. 
    -Mike Z.

I ended up paying $700 out of a $2100 surgery for reconstruction after
breast cancer which was supposed to have been paid in full according
to the Digital Medical Plan I was using at that time (4 years ago).  
$500 was to cover what they call a Z-Plastey which is where a "Z" 
is cut across a scar in an armpit to allow full extension and use of 
my arm and $200 was to cover for a part of the reconstruction that
was above the "Reasonable and Customary" fees.  The doctor and I both
wrote letters and made phone calls and they still denied payment.  It
was medically necessary for me to have the Z-Plastey to have use of 
my arm and not be considered disabled.  

Seems to me it would have been a better move for the insurance pay
for the Z-Plastey and had a able-bodied person working instead of 
having a disabled person unable to have use of their arm and not be
able to work daily for 8 hours at a terminal.  

Judy

re .18:

If your surgery can be delayed until January, you can sign up for JH at
open enrollment time.  Have you checked whether JH would pay?

    re:.18 et al
    
    Obviously, Healthsource takes the term HMO seriously.
    
    Healthy Members Only.
    
    I think of them as DDPs:  Discount Doctors' Plans.  We cure 'em as we
    get around to it, if we feel like it.

re: .20

  Hi Ed, 

  Nice to see that you are still around!

  After seeing the way that they increased the cost of the DMPs
  I would not be surprised if you couldn't afford the DMPs the 
  next time around.

  It is a hard one to call.

  dave

I asked for all the "fine print" at ZKO from the HMOs who sent representatives
during open enrollment. Out of 3 reps, one had no contracts with them, one gave
me their personal copy & one had plenty.  They all varied on what was covered,
especially in areas like organ transplants - some covered more types than others.

						Trace

    re:         <<< Note 1302.21 by CARAFE::GOLDSTEIN "Global Village Idiot" >>>
                            -< what HMO stands for >-
    
    
    >Obviously, Healthsource takes the term HMO seriously.
    >
    >Healthy Members Only.
    >
    >I think of them as DDPs:  Discount Doctors' Plans.  We cure 'em as we
    >get around to it, if we feel like it.
    
    I'm sorry to hear about ILUVNH::BADGER's situation but mine has been
    very positive.
    
    I can't speak for other folks, but when I was diagnosed with cancer 2
    and a half years ago, I was sent on the way to a non-HMO surgeon who
    was an expert at dealing with my type of cancer within 15 minutes of
    being diagnosed by the HMO doctor.  I had the surgery and after a
    relapse chemo all provided by the best folks in the area. I was sent to
    Dana Farber Cancer Institute in Boston to talk to the experts there and
    I was provided with the latest (expensive) anti-nausea drugs. I'm
    currently in an expensive rigerous followup protocol.  The only bill
    I've had to deal with is the $5 co-payment each time I see my
    oncologist. It is possible that other doctors in the same HMO might
    have handled things less favorably.
    
    Although I'm sure that there are lots of problems with lots of HMOs (as
    there are with non-HMO doctors as well), I'm one very satisfied
    customer of my HMO so far.
    
    Of course, 8-) your mileage may vary.
    
    Paul
    

    What HMO was this? Healthsource?
    
    Lisa

    re:   <<< Note 1302.25 by BOSEPM::RODERICK "Speak softly & wear a loud shirt." >>>

    >What HMO was this? Healthsource?
    >
    >Lisa
    
    Matthew Thornton - Hitchcock Clinic in Bedford.
    
    
    Paul