Who decided if med service is payable?

Discussion in 'Politics' started by mattskramer, Aug 9, 2009.

  1. mattskramer
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    mattskramer Senior Member

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    There has been this issue with respect to the health care debate about who you want as the medical care decider. Who should decide what you need? Who can decide for what care the provider can be compensated? Basically, unless you have the money in your pocket to cover your medical care or if you have a very charitable doctor, neither you nor the doctor makes the decision.

    If, and when, you get Medicare insurance and/or Medicaid insurance, see a doctor and have your claim filed under Medicare or Medicaid for compensation, I think that it will be highly likely that the government will get access to your health information (medical record). Medicare will probably ask for a lot of your medical history in order for it to determine if the services that you are now receiving are necessary and even then it might contend that the service was not necessary.

    I’ve worked for several years for a private health insurance firm. To this day as I think about it, I am surprised my how often the insurance company for which I worked required stacks of medical records as proof of the medical necessity for the service for which the doctor is requesting payment – and even then it might contend that the service was not necessary. I am very leery of private health insurance companies. I am not saying that government-run health care will be any better. They will both readily and eagerly collect premiums in some fashion (via tax or via the subscriber or via the subscriber’s employer) and they will both be stingy and reluctant to pay out benefits when those benefits (payments for expensive medical services) are warranted.

    People complain that with “government run health care” you are trusting the government (not the doctor) to decide what is in your best interest with respect to medical services that you may need. Well. With private insurance you are practically doing the same thing. Just replace government with private insurer. Do you want some corporate business man miles away deciding what medical services are financially justified and warranted (especially if that business man making medical decisions for you is working for an insurance company that is in the red financially). “Hmmm. I don’t think that this medical service was necessary for this patient. In the interest of money…ooops. I mean that in the interest of not being too wasteful, we deny this claim”.

    My father had several meetings with his doctor who readily agreed that an ambulance trip to the hospital had been medically necessary. (He was having a freak heart attack with no family member in town to assist him.) After sending 5 different letters arguing the medical points on behalf of my dad and supplying the insurance company with stacks upon stacks of medical records (he and his doctor had to jump through many hoops) within the required time limit (watch out for that “statute of limitation” or “timely manner” clause) my dad finally won the argument. After all of that, the insurance company only paid its required portion after my dad met his deductible.

    When it comes to debates over government run heath care versus private health care, don’t resort to this line of thinking. “Who do you want to decide your care”? Unless your doctor is generous or you have lots of money, someone besides you and your doctor is likely going to decide (a government agent or a private health insurance employee) in either case
     
    Last edited: Aug 9, 2009
  2. editec
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    editec Mr. Forgot-it-All

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    A very sensible post here,

    Kudos for coming at this issue like an adult.

    Like you while I know that what we have is failing us, I have my doubts that our government's plan is going to fix a damned thing, and as many of the partisans have noted, the potential harm it might do isn't something we can entirely ignore either.

    If I seem wishy-washy bout this problem, it's because I actually understand that problem outside of the normal political rhetoric channels that most of you seem to be relying on.

    In this arena I am not exactly a clueless layman. Not that I'm an expert, I'm just expert enough to see that most people truly don't relly get why HC isn't like most other industries.
     

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