Insurance Company Reform

gr8rnpjt, RN · Oct 21, 2005

Hi everyone - I'm interested in opinions from nurses regarding health insurance company reform. From the perspective of you all - nurse practitioners, DON's, managers, floor nurses, etc.
As a nurse working in the insurance business, I think I may shed light on an interesting perspective
What are your burning issues?
The large corporations want to pay next to nothing for their employees to be covered. The employees don't want to pay anything out of pocket, and they both want everything and everything covered. We lose money when people go "out of network" and we end up getting charged by a hospital without a contract 50-100 timesthe usual and customary that we would be charged by our network facilities. What I mean is there will be a 50-100% markup on every item, every drug, every procedure, so a normal $30,000 claim ends up being a $300,000 claim. The hospitals say you have no choice but to pay it, the patients say we want freedom to go where we want to go, the doctors say I want to write prescriptions for the latest drug but it is not on our formulary so the patient ends up paying rediculous prices and blaming the insurance company!!!
What would you think about an insurance company actually asking employers, producers and providers what needs we have?
We do, every day. We send out customer satisfaction forms to the patients, the providers, the hospitals and all ancillaries. Most people throw them in the garbage.
What would you tell them?
We would like you to know that it is not so hard to stay in the network, use the meds that are approved in the formulary, pay your copays and realize, if you had to pay out of pocket what we pay when you are sick, it would bankrupt you.
Do you realize that 90% of your insurance dollars are spent on 30% of the population? the people with chronic heart, circulatory, lung, and endocrine (diabetes) problems, and combinations of all the above.
What is your image of insurance companies?
We want you to know that the face you don't see is a consumer just like you. we eat the same foods shop at the same stores, patronize the same facilities, worship at the same churches as all of you. We pray for our loved ones, cry, laugh, eat sleep and live next door and around the corner from you. were human beings too and we all do the same: bleed, cry, give birth and die. We want the same things you do, to stay healthy and keep our loved ones close to us and healthy too. We care and we are here to keep you healthy too.
Thanks for letting me get that out,
any nurse working for any insurance company

allnurses Guide · Oct 22, 2005

Thank you so much - awesome post and great information.

steph

webbiedebbie · Oct 22, 2005

Wow...this sure changes my way of thinking about insurance companies!!!!!

When you say people go "out of network"...why are they doing that?

Thank you for opening my eyes. I look forward to seeing what others have to say.

allnurses Guide · Oct 22, 2005

Wow...this sure changes my way of thinking about insurance companies!!!!!
When you say people go "out of network"...why are they doing that?
Thank you for opening my eyes. I look forward to seeing what others have to say.

I believe that is when they use services or providers that are not part of the already set up network of services and providers that the insurance company has agreements with.

We had a new insurance company come in and the local dentist, who has always been in the network, decided not to join as he didn't agree with some of the agreement. It took complaints from the employees to get the insurance company to change what the dentist didn't like and he ended up joining.

Anyway - someone inside the industry could explain better than me.

steph

grannynurse FNP student · Oct 22, 2005

I believe that is when they use services or providers that are not part of the already set up network of services and providers that the insurance company has agreements with.
We had a new insurance company come in and the local dentist, who has always been in the network, decided not to join as he didn't agree with some of the agreement. It took complaints from the employees to get the insurance company to change what the dentist didn't like and he ended up joining.
Anyway - someone inside the industry could explain better than me.
steph

Funny, if my daughter and her family attempt to go 'outside network' their insurance company pays only 50% of their allowable fee. She is responsible for the remainder. And believe me, the facilities go after her not the insurance companies.

Grannynurse:balloons:

CCL"Babe", BSN, RN · Oct 22, 2005

As a nurse who works for an insurance company, I agree with gr8rnpjt wrote.

What most people don't realize is that your employer is the one who contracts/pays the insurance company to manage their money.

In other words your employer decides what benefits you will recieve and how much you will pay for your insurance.

If the insurance company does not manage the money wisely, they will either lose the account or they will lose money. A large disaster can put an insurance company out of business if they do not have a reserve.

Another note- I have been treated better as an employee with the insurance company I work for than any hospital I have worked in previously.

allnurses Guide · Oct 23, 2005

Funny, if my daughter and her family attempt to go 'outside network' their insurance company pays only 50% of their allowable fee. She is responsible for the remainder. And believe me, the facilities go after her not the insurance companies.
Grannynurse:balloons:

I still went to the same dentist and it is as you said - only 50% paid.

Neither the insurance company nor the "facilities" went after me . .. I probably did a poor job of explaining what "networks" were.

steph

allnurses Guide · Oct 23, 2005

As a nurse who works for an insurance company, I agree with gr8rnpjt wrote.
What most people don't realize is that your employer is the one who contracts/pays the insurance company to manage their money.
In other words your employer decides what benefits you will recieve and how much you will pay for your insurance.
If the insurance company does not manage the money wisely, they will either lose the account or they will lose money. A large disaster can put an insurance company out of business if they do not have a reserve.
Another note- I have been treated better as an employee with the insurance company I work for than any hospital I have worked in previously.

Thank you for the information.

steph

webbiedebbie · Oct 23, 2005

So, which would be better...HMO or PPO. I get so confused.

And, lets see if I am getting this right...say I have a physician that I have been seeing for many years and that physician is not within the new insurance plan that I have picked...or that physician is no longer a part of that plan...I need to find one that is of course.

My big question is: Why are there differences? Wouldn't it be easier for everyone if all insurance paid the same? I realize there is some competition involved with insurance companies, but in this day and age the bottom line is we need better coverage for everyone because healthcare costs seem to be going up because the coverage is not appropriate to everyone's needs, and we as the consumer's are getting caught up in it.

That is why I am having trouble deciding which would be better for me. I worked for a hospital that changed insurance companies 4 times in the 5 years I worked for them! The last one WOULD NOT pay for any anesthesia for surgeries!!!!!

People have to claim bankruptcy because of medical costs...and you can say it might have been from "credit cards" but those cards were used to pay for the cost of healthcare. I also think it is a shame that medical costs go on your "credit record". I do like seeing the "spending accounts" that are offered to cover those expenses, but I don't agree that if those funds are not used, they are lost.

I don't know what the answer is and I may never see it in my lifetime.

I anxiously await to see what others will have to say. This is a very interesting thread!

grannynurse FNP student · Oct 23, 2005

I still went to the same dentist and it is as you said - only 50% paid.
Neither the insurance company nor the "facilities" went after me . .. I probably did a poor job of explaining what "networks" were.
steph

I really do understand what going outside network means. It means that a person chooses to use a physician, lab, facility not part of their coverage. My daughter recently had surgery. It was done by a surgeon, in a facility, within my SIL TOS limits. Her cost $249. Had she chosen someone outside her TOS, it could have cost her $40,000 plus.

You are fortnate that neither the dentists or facility chose not to 'go afyer you'. This will change as people become more and more responsible for their own paymeny.

Grannynurse:balloons:

allnurses Guide · Oct 24, 2005

I really do understand what going outside network means. It means that a person chooses to use a physician, lab, facility not part of their coverage. My daughter recently had surgery. It was done by a surgeon, in a facility, within my SIL TOS limits. Her cost $249. Had she chosen someone outside her TOS, it could have cost her $40,000 plus.
You are fortnate that neither the dentists or facility chose not to 'go afyer you'. This will change as people become more and more responsible for their own paymeny.
Grannynurse:balloons:

I had to take my 4 year old to a pediatric dentist - not in our "network" and the insurance only covers 50%. Even with the deductible.

I'm interested in the original questions in my post - have a friend working on some PR with an insurance company (does not work for the company) - I was fascinated by some things I learned.

I recently attended a conference on depression and one of the participants was an insurance company - they were amazingly compassionate about trying to help. Guess I just am interested in other's perceptions.

Thanks - steph