Conference 7.286::digital

    .0
    >Is there a conference or an address to send concerns about Health Care
    >Coverage?  I am not just talking about PSA type information.  I have
    
    try these ones, i think the first one is what you want, the second
    sounds seems to be about really weired stuff but all to his own as
    they say.
    
>Healthcare Market		MR4SRV::HEALTHCARE			    3212
>Holistic Health & New Age Topics VAXCAT::HOLISTIC			     571
    
    hope this helps.
    
    \bye
    \nasser

Try checking out the Medical file, the file is to be used for discussions 
pertaining to the various aspects of the Medical field such as:

        HMO's and Insurance issues
        Doctors
        Diagnosis
        Hospitals


It's located at VMSZOO::MEDICAL

Hope that helps....dianne
        

  Don't bother with HEALTHCARE; I think it is oriented toward (computer-buying)
Digital customers in the health care industry.
  HOLISTIC is not a good forum for HMO discussions unless the procedure you want
to talk about is unconventional.
  I agree with -.1 that the best forum is VMSZOO::MEDICAL. 

    Has anyone else noticed that instead of reimbursements they seem to be
    getting letters from the insurance/hcra admin group saying that they
    have received your form and are contacting the
    doctor/dentist/chiropractor/etc for additional information?
    
    I thought the standard forms you send in had the needed information,
    and that's why they are standardized as such.
    
    I understand the occasional need for additional information, but in my
    case it appears to have become routine.
    
    Has this happened to anyone else?
    
    

    re: .4
    
    We have seen this with John Hancock Dental. Our dentist said they are
    notorious for doing this as a way of slowing down payment and/or
    reducing the amount eventually paid. Told us that they try and wear
    the dentist down by forcing them to keep doing yet more paperwork.
    
    Class act, huh.
    
    /Thorgan

    There are no class acts within the Insurance industry. 
    
    Jim C.
    

    re:  .4
    
    Me too,,, I've been getting letters from Hancock Dental saying
    something like "we have received the forms,and *will* pay the
    dentist ...." (emphasis mine,,,seems like they used to say "we
    recieved the forms and *have* paid...")
    
     My last submission was for work done in Nov. 92,,paid by Hancock
    in late Jan, 93!!!
    
     My dentist and I are not happy campers at this point.
    
    Doug

    
    I too have had this occur.  In September 1992, there was a procedure
    done (had to be done immediately), and the bill was sent to John
    Hancock.  In October, John Hancock sent a letter to the dentist for
    clarification.  Another letter was sent in November to the dentist.
    I then confirmed that the dentist had written back and provided
    the supporting information.  In December I then received something
    stating that this expense was "pre-approved" so I could submit the
    bill.  In January, I called to check what was going on since the
    original bill was submitted in September.  So finally, I got a
    check.
    
    CIGNA (my husband's dental insurer) does an EXCELLENT job.  Not so
    for John Hancock.
    
    

    I recently checked with my dentist regarding John Hancock's coverage
    of 80% of only part of the bill based on "reasonable and customary" 
    charges.    My dentist's office told me that John Hancock covers 80% 
    of the full amount for MCI employees here Colorado Springs, but covers
    80% of only part of it for Digital employees.  
    
    My suspicion is that they haven't really done a survey and can't supply
    a list of qualified dentists/doctors and their reasonable and customary 
    charges.  I've had John Hancock since I was in MKO, OKO, and CXO and my 
    experince indicates to me that there is just an arbitrary reduction.
    
    1) Who makes this determination and how do I appeal?
    
    2) Where is the standard by which these claims are reduced and how are
       they determined?  How often is this standard, if it exists, updated?
       Has a copy of the standard, if it exists, been filed with the Depts
       of Labor and Insurance for the states where this insurance plan is 
       being practiced?
    
    3) To whom do I address my formal complaint now that I've got some data
       to back me up?   (I've already tried going through my boss.)
    
    
                                    Kurt

    The Digital Medical/Dental programs are managed by John Hancock,
    the MCI program is probably John Hancock's Dental Coverage Insurance.

    
    Re: .9
    
    It may be even worse than you think.  My wife is having oral surgery
    done on this coming Thursday and we live in NH.  It was explained to
    me this way:
    
    	The dental plan will pay 60% of the "reasonable and customary"
    	charge for dental procedures based on a standard for what is
        "reasonable and customary" for charges within the area where the
    	dentist practices.  We were asked for the US Post Office Zip Code
    	for the dentist's office.  Given that and the codes for the
    	procedures, the John Hancock office in Maynard was able to tell
    	me what they list as the "reasonable and customary" charge for
    	those procedures for that geographical area and that they would
    	pay up to 60% of those charges with a yearly dollar limit of
    	$1000, *IF*, that is, the "dental board" after reviewing the
    	claim, found it all in order.  John Hancock routinely sends all
        claims sent to them to some "dental review board" (I don't know
    	the formal name of it) which looks them over.  The review board
        determines whether all the work done was necessary.  After that
    	review is done, John Hancock will then actually pay 60% of the
        "reasonable and customary" charges for the dentists zip code only
    	for that portion of the work that is covered and which the review
    	board agrees was all appropriate.
    
    fwiw,
    Steve
    
    

    I was advised by DEC that before you I had work done I should send in 
    an estimate for a pre-review of what DEC will pay for.  I did just
    that.  (Excuse me while I split my sides with laughing at the memory.)    
    It took so long for them to get back to me, by the time they did the 
    policy was changed and it landed up costing me $1000 more that they said 
    it would.  

    re: .11
    
    and our cost go up to pay for the review board's expertise...!!!
    

    
    Re: .13
    
    > and our cost go up to pay for the review board's expertise...!!!
    
    Yup.  So what else is new.
    
    On a related note it was recently reported that the HMO my wife belongs
    to, Healthsource, which started in Concord, NH is acquiring all kinds
    of other HMOs all over the country and made a $90,000,000 profit last
    year.  All the while they are consistently whittling away at the
    coverage they provide.
    
    A local health care provider wrote an interesting letter to the local
    paper to the effect that our health care premiums should be going to
    providing HEALTH CARE and not capital for profit making companies to
    fatten the pockets of stock holders.  I'm no socialist, but I can't
    think of any better example of behavior that is going to bolster Bill
    Clinton's push for a national health care solution.   I just hope
    his solution doesn't throw the baby out with the bath water.
    
    fwiw,
    Steve
    
    

I just got a notice saying my claim was referred to American Dental Examiners
for review.  They also say they do not make such requests routinely.  Hmmm.

This concerns a charge for $1800.00.  The work has already been done.  If JOohn
Hancock doesn't pay, to whom do I appeal this?

Thanks

-G

    
    Re: .15
    
    That was it.  American Dental Examiners who the JH agent said would
    review the claim for my wife's dental surgery which is on the order
    of a $2100 charge.  I, however, was left with the impression that it
    was routine.
    
    Steve
    

Extracted from the reply from my PSA:


	Secretary
	U.S. Employee Benefit Claim Appeal Committee
	Digital Equipment Corporation
	MSO2-3/C7
	111 Powdermill Road
	Maynard, MA   01754

You need to send a letter detailing your issue and mail to above address.
The Benefit Claim Appeal Committee will review your claim.  You will 
receive written notice of the Committee's final decision within 60 days
after you request that your claim be reviewed.