Conference 7.286::digital

    Your question would be very appropriate in note 1128.  There are
    80 replies dealing with changing medical costs for our employer
    and us.

re: .0

You have discovered what a lot of people have known for a long time.  Some who
have less financial resources than most, take advantage of this and in effect
make the emergency room their family doctor.  Some medical plans discourage
this my making you pay $25 or so for each emergency room visit.  Others will
review the claim after the fact and disallow it, forcing you to pick up most/all
of the cost.  This obviously can cause hard feelings if someone in good 
conscience goes to the emergency room and later has to pay for it because the
claim is denied.  For example, in your case, some medical plans would have
disallowed your claim since your foot didn't turn out to be broken.  However,
you could have gone to the emergency room in good faith, not knowing whether
it was broken or not.

Bob

    
    RE: -.1
    
    In other words, some medical plans expect you to diagnose your own 
    ailment.  If you mis-diagnose, and your treatment turns out not to
    have required an emergency room, they won't pay.  Seems you should
    have known better.  However, if your own professional medical diagnosis
    was correct, and your condition did require emergency room treatment,
    they will pay.  Since even a doctor would get xrays of a bone to see
    for certain how it was broken, you're perhaps assumed to have xray vision.  
    I guess they don't mind you gambling with your own well-being.  
      

Are you sure you are not covered?  I don't have my benefits book here 
but I thought that the first $300 of medical expenses DUE TO AN ACCIDENT are
covered at 100% and not subject to a deductable.

But then again, I may be incorrect.  Why not call John Hancock at DTN 223-3300

    Re. .4
    	Yes you are right about the accident policy but the point I was
    trying to make is that if one usese that emergency plan all the time
    then we would have to larger insurance eventually. 
    	The point was that if we become smart shopper and use the emergency
    plan only when necessary then we all would benefit but currently the
    plan or the policy does not give incentive for people to do that.
    Jagdish

    Maybe Digital should have some sort of incentive plan to
    encourage and reward smart shoppers. 
    
    Save money on the medical plan, air travel (supersaver fares),
    lodging (econolodges), and you get some kind of "bonus points"
    that can be accumulated and exchanged for stock or cash or
    something.  I think this could save the company a bundle of
    money.
    
    d

RE: Note 1173.0 by PARITY::JOSHI 
>1. Goto the emergency room in one of the hospital as I have plan B. This would
>have costed company around $200.0 to $300.0 for the services(Conservative
>estimate) and costed me nothing.

    I have plan 2 and in Mass this means that John Hancock is my
    insurance carrier.  If I put a claim in John Hancock not Digital 
    pays the bill.  To the best of my knowledge none of Digital health
    plans have Digital paying off on any claims.  So you didn't save Digital
    any money you saved John Hancock or whoever your insurance carrier is
    some money.   
    
RE: Note 1173.7 by CURIE::DIMAN
>Maybe Digital should have some sort of incentive plan to 
>encourage and reward smart shoppers. 
    
    While I agree that employee should attempt to save the company money
    when and wherever possible, I don't think one should try to look for
    nofrills medical care.  Also as I said above, Digitals pays for your
    health insurance, not the actual health care.
    
    -Bruce

    

    Hmm, I would have based the decision whether to go to the emergency
    room *NOW* or to go home, apply ice, and see the doctor later
    solely on my own estimate of how much damage I'd done (translation,
    how badly it hurt).
    
    This holds true regardless of whether it's me that's paying or 
    someone else.  No, I don't have so much money I can throw it
    around, but a potentially broken bone outweighs quite a few
    other considerations as far as I'm concerned.

>                     <<< Note 1173.8 by YIELD::HARRIS >>>
>                   -< Digital doesn't pay medical bills. >-
>
>       John Hancock not Digital pays the bill.  To the best of
>   my knowledge none of Digital health plans have Digital paying
>   off on any claims.  So you didn't save Digital any money you
>   saved John Hancock or whoever your insurance carrier is some
>   money.   
    

        True, the insurance company, in this case John Hancock,
    paid the medical bill.  Who paid the premium on the policy
    that paid the claim?  You and Digital paid!  So in reality
    who paid the bill?  Ultimately, you the consumer, pays for
    everything, whether directly or indirectly.

    Regards,
    Peter Duke

re: .8 , .10

John Hancock does NOT pay any medical bills, other than the dental plan.

Digital is self-insured.  John Hancock simply administers the plan for Digital.
Look at either your hospitalization card or any EOB from John Hancock you
received in the past year.  Digital, in effect, sets aside a pot of money each
year to pay the claims.  If there is money left over at the end of the year,
great.  If they run out, they come up with more.

Bob

    re: .11

    Now I can say self-insured, I can also say I was very wrong.  I just
    took a look a John Hancock Health Plan Claim form and at the top it
    says "Claim Processor Only*"  The * refers to a line at the bottom
    that says "John Hancock does not insure benefits under the Plan.  Your
    Employer is solely responsible for determination of entitlement to,
    and payment of, any amounts due under the Plan".

    Sorry for the misinformation, but I still feel that you have to think
    about your own health before worrying about saying the company $'s.

    Re: Last few --
    
    Right on, Bob. John Hancock handles the paperwork; Digital pays the
    bill. 
    
    A few other points:
    
    For accidents, costs are paid at 100% with no deductible, to a maximum
    of $300. Expenses must be incurred within 90 days of the accident.
    There is nothing in the policy that says treatment must be in the
    emergency room or any other place. If you submit your claim, and clearly
    indicate it is an accident, you (or the doctor) will be paid in full
    within these limits. If the claim has already been rejected, resubmit
    it with a note from the doctor that it was an accidental injury.
    Whether you want to do this or not is entirely up to you.
    
    It is true that the deductible saves Digital money. If this is the only
    claim you have this calendar year, and you did not indicate it was an
    accident, then you pay the full $126 (do I have the right amount? It's
    a few notes back) and Digital pays nothing. 
    
    However, if you have additional claims that eventually exceed the $175
    minimum, then for this claim you will end up paying $25.80 (20% of the
    $126) and Digital, through the medical plan, will pay $100.20.
    
    I certainly agree that medical costs are out of control. But I think we
    such get the facts straight and discuss it from there.
    
    Bruce

    One major point about J.H. medical coverage - don't fall into the trap
    thinking that a visit to the emergency room is covered no matter what
    it is for. As stated in a couple of notes already all claims are
    reviewed and payment is made - or not - based on many factors. 

    examples from personal experience: - 
    My son was bitten by a snake. emergency room visit paid 100%
    by insurance. ( fortunately it turned out to not be a poisonous
    variety.)

    I had a heart attack - emergency room visit paid at 80% after meeting
    deductible. 

    The difference being one was considered an "accident" because no
    one deliberately goes out looking to get snake bit and the other was a
    "medical emergency". I asked the person, "did you really think I
    planned on having that heart attack?" and got the answer, "No , but the
    plan is set up only to cover accidents and a heart attack is not an
    accident." 

    At yesterday's DVN, it was stated that the next major DTN in October
    will deal with how Digital will have to cope with the rising cost of
    employee health insurance.  It will be interesting to see what they
    come up with.  I know HMOs work well for some people, but I am not
    anxious to be forced to use one.  I assume that is the direction that
    we are going to be pushed in.

    Playing Devil's Advocate for a moment, I contend that it might have
    cost less to go to the ER than in other intangibles.  Consider that the
    person in .0 probably went to the doctor's office during business
    hours, figuring salary paid and lost productivity.  Also, having a 
    sprained ankle for a weekend is not very comfortable, so .0 was
    probably less rested due to the discomfort. That meant that they were
    less ready to do work for the rest of the week.  Lastly, the conditions
    of a sprain can be exascerbated by use of the ankle without propper
    treatment and support, making the injury worse and more protracted.  If
    the injury got bad enough to need physical therapy, then the costs are
    much higher.
    
    In short, one's health is more important than a couple of bucks and
    early treatment of an accident can actually save money.
    
    BobW

    RE .16 (paraphrased): "It's your health; money is no object"
    
        I think this is the mindset which has run our medical costs up
        to the point where they are intolerable.

    A couple years ago, I went to a dentist who a freind recommended.  The
    freind was a poor student, and said that not only was the guy a great
    dentist, but he was such a kind man that he even gave them a break on
    the price because they couldn't afford the work they needed.

    This same dentist charged me over double the "reasonable and customary"
    charge to take a little excess metal off the top of a cap, and 50% more
    than reasonable and customary on the checkup.  Could I have found that
    out ahead of time?  No.

    You say, why not?  Well, shortly after the dentist fiasco, I went on
    vacation and lifted something the wrong way.  I ended up needing a
    hernia repair.  The doctor fiasco fresh in mind, I tried very hard to
    get a handle on costs.  Well, there were only two surgeons within 50
    miles, so I ended up getting the second opinion with the only
    alternative to the one who would do the operation.  He charged 105.00
    for a 3 minute consult ("yup, it's a hernia, ought to get it fixed").

    I went to the hospital and surgeon to try to find out the total cost of
    the operation, to see if it would be within the insurance limits.
    Neither would tell me anything useful.  "Well, you never know what
    might happen.  We'll do whatever we need to do to ensure you health."
    So I called JH to find out what was a reasonable charge.  "We can't
    tell you that information.  Give us a quote, and we'll tell you whether
    it's reasonable."  Catch-22.  I finally gave up and got the thing done.

    The system is set up so that it is virtually impossible to ascertain
    ahead of time what the cost will be.  Without this information, it is
    impossible to "shop" for the best price.  When I have tried to "shop,"
    I've been given that same line about "it's your health, why are you
    worrying about the bill?  Anyway, the insurance will cover it."

    I hate the idea of an HMO.  I was in one before, and got herded around
    like a sheep.  Always an hour long wait, 2 minutes with the doctor, "I
    don't have time to answer your questions, go talk to the nurse."  But
    unless we fix the system, we're not going to have a choice.  As long as
    prices and benchmark prices are kept a secret, there is no way for a
    consumer of medical care to make an informed decision.  What's funny
    is, the HMO model has the same problem.  The consumer still has no say,
    but, as pointed out elsewhere, the ability to choose only healthy
    customers has kept HMO costs down so far.

>    RE .16 (paraphrased): "It's your health; money is no object"
>    
>        I think this is the mindset which has run our medical costs up
>        to the point where they are intolerable.

The first thing I said was that I was playing Devil's Advocate on the issue.

When you look at the costs involved, a $125 vs $300 decision is based on the
whole cost picture rather than just the medical costs.  Money *AND* Health are
*BOTH* objects to consider.

That said, I agree that medical costs are out of control.  The tactic I've used
if JH pays R&C after a doctor has charged me more is to go to the doctor and
say, "Hey why?".  One of my wife's doctors is real aggresive *for* her patients
when JH pays less than she charges.  This doctor keeps a chart of the current
comparable charges in the area.  If JH (or another insurance company) pays less,
this doctor takes it to the state insurance comissioner on behalf of the 
patient.

BobW

    
    Don't know if DEC or JH do this, but in a previous job we were provided
    with a real incentive to help keep costs down.  If we saw double billing,
    unperformed-services billing, or anything that could have been done in
    a cheaper fashion, we were entitled to a good fraction of the money 
    saved.  The company just sent us a check for that fraction.  
    
    	Dave 

    
    
    when it comes to insurance companies the public gets screwed and
    tattoed.
    
    the medical industry is not much help either.
    
    my son had to get 4 stiches on his forehead, no major operation mind 
    you,  in and out in about 20 minutes (not counting waiting 45 minutes in
    waiting room).
    
    i almost flipped when i got the bill    $900.00 
    
    thank god i have an HMO and it only cost me $15.00 co payment but the
    medical profgession is getting away with charging these outragous
    amounts and the insurance companies pay it.
    
    dont worry the insurance companies are making huge profits, thats why
    every year costs go up, they got to make bigger profits every year
    also.
    
    so dont suffer go to the emergency room and get your $300 ice pack
    your going to have to paymore anyway next year.
    
    

    
    
      My view has always been that Medical costs are High because
    Insurance companies charge high malpractice premiums.  
    Hence, when you need medical care,  typically you end up paying
    the 20% that the service is really worth, and your insurance 
    pays the 80% "insurance cost", then simply collects it right back
    from the doctor in the form of yet higher premiums...  "profits"
    are the additional premiums they charge the general public...  :^)
    

re .17:

>    This same dentist charged me over double the "reasonable and customary"
>    charge to take a little excess metal off the top of a cap, and 50% more
>    than reasonable and customary on the checkup.

If this was under the Digital Dental Assistance Plan, the fact that you had
to pay doesn't mean that the dentist charged more that R&C.  The dental plan
isn't supposed to pay R&C.

    Would someone please give me a pointer to the process for appealing
    medical charges not paid by the insurance company?
    
    Thanks!

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