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Blue Cross Blue Shield

dzalphakilo

Banned
Can anyone explain to an idiot how the medical insurance game is played?

I have pretty good insurance. Any emergency room visit is covered, good dental, prescription drug and the all, however, I've always scratched my head on what the doctor bills, and what is paid.

Going for an MRI tonight for my back and the girl told me my insurance would cover everything but $120. I told her I usually wait for the insurance "bill" to come in the mail, then pay it. She says no problem. I asked her how much this MRI would normally cost. She told me $1200:shitHitFan:

Now, I really think this Chiropractor I've been going to is a quack. Long story, but I finally "demanded" that I want an MRI done (still having issues with the back, even though this doctor said things are "progressing"). Look at her bill in the mail, heck, they charge $120 a visit, and I pay $3.50. The straw that broke the camels back is that last week she gave me, for lack of better terms, a "shocker" for my lower back to stimulate my mucles. Next visit I go to bring it back (because it dosen't seem to help), and she tells me not to worry, that they charged my insurance company. Well, I ask her what if they don't cover it, what happens. She said that they will just ask for it back. I then ask her how much they charge for it, and she tells me $300!!! I called my insurance company today to tell them not to cover it, that I don't want it.

Bottom line, because I have insurance, I feel like a cash cow for this doctor.

Just seems like I'm in the wrong racket.

How does the medical profession determine what to charge for insurance?

Do both parties know beforehand what is going to be paid?

Bigger the insurance company, better the "rates"?

Just curious.
 

XeVfTEUtaAqJHTqq

Master of Distraction
Staff member
SUPER Site Supporter
1st. Don't use Chiropractor's they are not real doctors. Two years in some pseudo-school doesn't count and the whole theory behind them is such total BS.

2nd. It's a game with the insurance companies and the doctor's offices. The doctor's offices try to bill as high as possible, the insurance companies will push back as hard as possible. Both sides are trying to make money. They only "care" about you because they don't want to get sued for screwing you. The only thing that is protecting you is the legal system (which also wants to screw you but just needs a reason).

Your Chiropractor better not be interpreting that MRI on their own. They have zero training on that. My mom had a Chiropractor look at an x-ray of her back and tell her that her vertebrae was turned around 180 degrees. It took years for my mom to believe me that if her vertebrae was turned around 180 degrees that she would be paralyzed below that point. My mom just wanted to have an excuse for her problems other than the fact that she was over weight. She still does but that is another story.

If you have a bad back, go see an Orthopedic Surgeon and tell them to be roughly blunt with you. Take what they say with a grain of salt and think about it. If it totally doesn't make sense then get a second opinion. If it strikes close to home (i.e. you're fat, lazy, stupid) then they are probably right. Of course, they also might find a herniated disc and be able to actually do something about it other than crack your back and give you a massage.

PB
 

ddrane2115

Charter Member
SUPER Site Supporter
I once got a set of crutches from the hospital for a sprained ankle.......300 bucks to the insurance company. I took them back, contacted insurance company, asked they not pay that but buy the ones I had got at the pharmacy..........I think 24.00.

I also contacted.....forgive me, Hillary and her health care zombies about this, got a nice letter back from her.............dont have it now


As for the chiropractor..........a good one is worth a fortune, bad one is not worth getting rid of. I used one for 3 herniated/ruptured discs, with degenerative disc disease..........in ONE month I went from bent over and in pain.....sciatica, to playing golf.

Went to one for a work related injury........hurt me worse.
 

Hutchman

New member
Site Supporter
Last year I had some surgery. The ins. co, BCBS, would only approve it as outpatient surgery. I was going under general anesthesia and having my stomach cut open. Seems like more than outpatient to me. They allowed me 23 hours, which allowed me to stay overnight and recover some. The hospital bill, not including the surgeon's bill, for operating room and the overnight stay came to $18,000. BCBS paid $3,000 and both sides were happy. I just had bloodwork done. They drew 18 vials of blood. The office said it was a record for them. The bill was $1,200 for the labwork. BCBS paid about $150 and, again, both sides are happy. I guess it's all just a game, as PB says. I wonder though, what happens to the folks who don't have insurance? Would they have been liable for the full $18,000 for the surgery?
 

California

Charter Member
Site Supporter
what happens to the folks who don't have insurance? Would they have been liable for the full $18,000 for the surgery?
Probably.

The mother of a guy I worked with was given a hip replacement in the last month of her life, I think after she was no longer alert, and the family was billed $650,000. My buddy spent a year fighting it and got the charges down to a few thousand, basically hospice costs.

My buddy's occupation? Auditor of government procurement contracts. He challenged the hospital for evidence supporting every line item in the invoice then challenged them to support the medical necessity of every item. At some point they realized a medical quality review board might rule against them if it ever got to that - and that's where he was headed.

He figures he simply bought back his inheritance, with a few months work.
 

mak2

Active member
The doctor's offices try to bill as high as possible, the insurance companies will push back as hard as possible. Both sides are trying to make money. They only "care" about you because they don't want to get sued for screwing you. The only thing that is protecting you is the legal system (which also wants to screw you but just needs a reason).


I wish I could use the quote thing like the rest of you guys but this is quoted from PBinWA. I go on and on about this stuff and it seems like I'm talking to myself.

Insurance companies are not even a little afraid of your lawyers. They have High rise buildings full of attornies. So do hospitals, drug companies and doctors.

Why do you think it takes seven years to get a drug on the market in the US, when it has been saving lives in Europe for years. IT IS THE MONEY. The delay is the people who have the money are making grants for studies. They control the structure of the studies by where they put the money.

If doctors get a procedure approved through one of these studies the medical profession start providing it, then the insurance companies incrase your premiums. Simple. Every one profits but you. The system in America is based on Greed. Why does no one in the US see that?

I know how bad the government screws up everything, but I truly believe it would do better running healthcare than the greedy bast$%ds running it now.
 

ddrane2115

Charter Member
SUPER Site Supporter
Probably.

The mother of a guy I worked with was given a hip replacement in the last month of her life, I think after she was no longer alert, and the family was billed $650,000. My buddy spent a year fighting it and got the charges down to a few thousand, basically hospice costs.

My buddy's occupation? Auditor of government procurement contracts. He challenged the hospital for evidence supporting every line item in the invoice then challenged them to support the medical necessity of every item. At some point they realized a medical quality review board might rule against them if it ever got to that - and that's where he was headed.

He figures he simply bought back his inheritance, with a few months work.

This is showing the medical field and its greed. Why, I am assuming this person was near death, would they do a hip replacement for someone on their death bed and then bill this outrageous amount. I assume again there was no medical need.
 

ddrane2115

Charter Member
SUPER Site Supporter
I know how bad the government screws up everything, but I truly believe it would do better running healthcare than the greedy bast$%ds running it now.


American medical folks have gotten used to getting anything and everything they want simply by opening their mouths. Insurance companies have gotten used to pushing the medical folks around by simply saying we wont cover that at that cost or for that length of time. Be on medicaid or medicare with a supplement and that changes. In my experience that gets it to a point of anything goes. If we changed to a government managed health care system ( I would love it), then more than half of the professionals would leave, or provide only private care functions to the wealthy that dont care or mind paying. Medical professionals that are used to making big dollars are not going to change. Medical school costs a small fortune, opening a practice is costly, government regs are costly. A one doctor practice can cost over 300K just to open with a building and all the sundries. Add some staff and some hospital fees for using them (yes docs pay for the priviledge to send you to a hospital) and you have an enormous cost.

My point is, it is not only the medical profession. Everyone has their hands out. If the government came in and took over, you would see one of the biggest crashes in this coutries history. Having worked in a medical supply field, I can tell you that a dental chair that sells for $7000.00 dollars would sit unsold if the government said we will pay $3000.00 and you get to install it. What would be required is for the government to take control over the whole ball of wax, price control, supply, education, patient disbursment, drug introduction for new drugs, insurance companies............it just is not going to happen this way.

For this to work, a new and completely separate system would have to be introduced, with government having control from day one. Then people would have a choice, free no cost medical care, or pay thru insurance or other means. Would not take long till the pay side would be broke..........first I would tell my employer I no longer need insurance....have 100,000 people tell that to their employers.....wont be long till the insurance companies get the message. Employers that provide medical coverage can now have a way out of this, and may provide more income due to NOT having to buy coverage.

This could go on and on and on........I see no end, and no winner
 

California

Charter Member
Site Supporter
Wrong audience.

If Michael Moore says there is a health care crisis, then there isn't a health care crisis! it's as simple as that.
 

mak2

Active member
Doctors, hospitals, insurance and drug companies have formed a truly symbiotic realtionship. In governemtn ran healthcare where at the professionals going to go. The make "good" money but not the obscene amounts only a few doctors make anyway. I have never ever heard of a doctor paying to send a pt to a hospital. Hospitals compete for patients and doctors. They have to have prividliges which require credentialing but that is not something they pay.

What would crash? you would just have $3000.00 dental chairs that provided the necessary postions for less, what is wrong with that?

I think the transistion would be much less painful than you think. If you think our government cannot provide high quality equiptment and personnel to staff an industry, look at our military machine. The worlds greatest fighter planes, most advanced equiptment of all types and an incridiblely well trained staff.
 

Deadly Sushi

The One, The Only, Sushi
SUPER Site Supporter
Wrong audience.

If Michael Moore says there is a health care crisis, then there isn't a health care crisis! it's as simple as that.

Wrong. If you can think for yourself and NOT be another mindless lemming that listens to the right wing (which I was) advertisements like Limbaugh or Hannity you WOULD see that OUR system of PAYMENT of health care SUCKS!!!

Want PROOF??? Look at the 1st post of this thread. Either lie to yourself or have a heart and common sense.
Dude I WAS the HARDEST of hard conservatives. The last 3 years I woke up.
 

waybomb

Well-known member
GOLD Site Supporter
Wrong. If you can think for yourself and NOT be another mindless lemming that listens to the right wing (which I was) advertisements like Limbaugh or Hannity you WOULD see that OUR system of PAYMENT of health care SUCKS!!!

Want PROOF??? Look at the 1st post of this thread. Either lie to yourself or have a heart and common sense.
Dude I WAS the HARDEST of hard conservatives. The last 3 years I woke up.


So we can get it free from the government, right? Once again, I call BS! The only money the government gets and can use to pay for things comes from private people. We are the only true consumers. Get over it.

YOU will not get free health care for your aledged ailments. You can not become another leach on the rest of society. Get over it and become the master of your own problems. Cry baby.
 

mak2

Active member
Damn nice boat waybomb. Very Republican of you. Capitalism is almost always the answer, but when it is something that no price can be set by the individual on (ones health) free market just doesnt work. If you really need these pills I have in my hand, and I say how much you got? when you really need it to live, you pay. You dont have enough cash for me I organize your friends and have you pool your money (insurance) then take that.

I at least understand universal healthcare is not free, but right now we have the worst of all possible seneraios.
 

waybomb

Well-known member
GOLD Site Supporter
Damn nice boat waybomb. Very Republican of you. Capitalism is almost always the answer, but when it is something that no price can be set by the individual on (ones health) free market just doesnt work. If you really need these pills I have in my hand, and I say how much you got? when you really need it to live, you pay. You dont have enough cash for me I organize your friends and have you pool your money (insurance) then take that.

I at least understand universal healthcare is not free, but right now we have the worst of all possible seneraios.

And how is it the worst possible......?

I don't seem to be having a problem getting health care. Most of those wanting free health care are jealous that others can pay for it and want to be leaches instead of doing something about it, like taking on a couple of jobs, starting a business, or just plain working, like those of us that did and aren't complaining about health care costs.

Sure, I'd like "free" health care, but I am not delusional. NOTHING is free. The money only comes from one group of taxpayers - individuals. Take my incentive away to do hard work to earn good money and maybe I'll move to a tax haven so the leaches can't have my money. Oh, ya, the leaches complain when some actually do get fed up and do move. Again, jealousy at play.

MR Sushi complains about his ailments and how little money he has, but he does have a $330 monthly payment on a car; his choice. Sell it and buy something cheap and ugly. Take a second job. Even at McDonalds or wally world - they are always hiring. Even 20 hours per week at 7 bucks. That's $7280 per year extra. But that's real work, and many are way above lowering themselves to that level. Some of us that are comfortable now actually did those things when we were younger. But then, we never had a sense of entitlement.

As for your pill anology, if you want to sell them and make a profit, you'll have to lower your rate per pill, or, if I see a demand, i might make them and sell at an acceptable level.

And I suppose you think the drug companies are greedy bastions of corporate evil. Well, who took the risks to discover the drugs and go through all the red tape to get them approved? Since you are complaining, go get backing and get into the drug business. See how much you have to charge for solutiuons that take years of expensive scientists' time, and expensive, very expensive laboratories, buildings, etc. Yes, a single pill can get expensive when one considers the millions of investement and risk accompanying that pill.

Yes, capitalism works. Don't see too many wonder drugs coming out of, say, Iran.
 

waybomb

Well-known member
GOLD Site Supporter
Damn nice boat waybomb. Very Republican of you. quote]

Thanks for the compliment. But your views are skewed somehow. I'd bet there are just as many democrats with boats as republicans with boats. I would also bet the median size boat of both is also very close.

There are more than enough democrat stinkpotters, just as there is more than enough republican blowboaters. I do not believe polical affiliation has anything to do with boat ownership.
 

mak2

Active member
I, as opposed to Sushi (who I have blasted so bad I felt guilty), have outstanding insurance. I pay a lot for it, so do you. I NeVer said free. You immediately flip to the party line.
I am saying the greed makes for a more inefficent system than the incompetence of the govermtent. You dont have a choice not to buy those pills we were talking about, I am Eli Lily and have the patent.
I could site so many examples but I type so slow it would take all night. I have to go get my kid right now.
 

waybomb

Well-known member
GOLD Site Supporter
You immediately flip to the party line.
Um, where did I do that? You're the one saying my boat is very republican of me.

As for Lilly - do you belive their profits are outlandish? What should they be? I am not a stockholder in them. So I ask, what was their profit last year? And how many pills did they manufacture. And how much per pill could be taken away to meat your optimal and fair profit?

They probably made hundreds of millions. But they also probabaly made billions of pills. A penny a pill, well, I'll let you prove your point.

And, As for your kid - just wait till the child is between 13 and 19. You ain't seen nuthin yet! Good luck!!!
 
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waybomb

Well-known member
GOLD Site Supporter
LLY made 2.6 billion on 15.6 billion revenue. 16.7%
21.9 billion is balance sheet assets. 11.9% on assets.

What's a fair rate of return on investment? The stock market historically earns 10%. If LLY went out of business and invested in some Dow Jones index type of investment, they'd earn 10% with almost no risk. So their premium is 20% on top of that, or 2%, for all the risk they take.

Last year, I made 17%. This year I am running about 10%, depending on the day, lately. I think most anybody's portfolio made that kind of money, so why can't LLY?

Maybe they should just get out of business and let everybody get sick and die.

Oh, and they paid $755,000,000 in income tax, not counting all the FICA taxes and other bennies for their employees.

I have no idea how many pills they made, and they make other things besides pills, but I'd bet it was more than 2.6 billion pills / medical devices. So, if you remove $1.00 cost from each, at 2.6 billion units, they'd make ZERO dollars. 50 cents each halves their profit.

Tell me again about the evil drug companies that bring these life-saving medicines to market at huge risk?

Something from www.elililly.com website:
Cost of New Pharmaceutical

Average cost to discover and develop a new drug
Average length of time from discovery to patient
$800 million to $1.2 billion
10 to 15 years
 
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mak2

Active member
I type so damn slow I was still typing while you posted your reply so i had not seen that. I read last year sometime the averge democrat in congress made some significant amount more than the republicans. I think it is difficult to be funny on line but the boat comment was meant to be funny.
The party line comment was about "free healthcare" implying anyone who want universal healthcare is a freeloader. Seem to hear that alot from my republican friends. I dont claim to have the answer to research and developement question, but the military establishemnt, which makes very little from the public from cutting edge stuff is still very creative and produces the greatest equiptment in the world.

I just picked the pill thing at random, and Lilly's becasue it is local and half my family work or have worked there.

I am just telling you, I see how things work every day and the examples of greed are everywhere. Some things you really do not see unless you are intimately involved in the process.
 

mak2

Active member
For example, a pt I recently talked to brought in a CPAP machine he got at another hospital in the area. The CPAP is a flow generator that keeps a person with sleep apnea airway open. The sleep study that determines a pt has sleep apnea costs about $1100.00 total, then another appt is made and the pt comes back for the titration that determines what to set the machine at for approx the same price. The machine cost about 800.00. So the total is about 3000. About 95% of the time OSA is accurately diagnosed by the primary care provider. So 95% of the time a pt could be sent home with an auto titration machine from the doctor's office, it does cost about 950. There are many studies in Canada and England that demonstrate the effectiveness of the autotitration machine is even greater than the 3K version. Probably 3-5% of patients require both studies. Now consider how many patients this hospital has per night at least 4 pts 5 nights per week. that is 20 x $2050 x 52. I will do the math later but it is simply greed. The last doctor I talked to about this knew about the studies and stated sometime it would be done that way in the US too, so hurry up and get as many people as possible in the system. This is not where I work we have a differnet system, but that is how it owrks in the private sector. this I know I see it every day. That is awful dang close to stealing, espically when these pts are told they have to do the studies to get the machines and ahve to have the machine or they might die.
 

mak2

Active member
about 2,132,000 -107,000 (5%)=2,025,000 in excess per year of a more effective treatment modality
 

Junkman

Extra Super Moderator
Damn nice boat waybomb. Very Republican of you. Capitalism is almost always the answer, but when it is something that no price can be set by the individual on (ones health) free market just doesnt work. If you really need these pills I have in my hand, and I say how much you got? when you really need it to live, you pay. You dont have enough cash for me I organize your friends and have you pool your money (insurance) then take that.

I at least understand universal healthcare is not free, but right now we have the worst of all possible seneraios.

I hear that both Cuba and Bermuda both have free health care. If you want to go to live in Bermuda, you need to apply for permanent residence, which is very rarely granted. If you want to go to Cuba, just get some rickety old boat and set your sails. When you land on the island, present your weapon and you will get free room and board, plus free medical care. You will have the best of all worlds.... :moon:
 

mak2

Active member
Why the moon Junk? Cant discuss a topic without degenerating into disrespectful banter?
 

dzalphakilo

Banned
1st. Don't use Chiropractor's they are not real doctors. Two years in some pseudo-school doesn't count and the whole theory behind them is such total BS.

2nd. It's a game with the insurance companies and the doctor's offices. The doctor's offices try to bill as high as possible, the insurance companies will push back as hard as possible. Both sides are trying to make money. They only "care" about you because they don't want to get sued for screwing you. The only thing that is protecting you is the legal system (which also wants to screw you but just needs a reason).

Your Chiropractor better not be interpreting that MRI on their own. They have zero training on that. My mom had a Chiropractor look at an x-ray of her back and tell her that her vertebrae was turned around 180 degrees. It took years for my mom to believe me that if her vertebrae was turned around 180 degrees that she would be paralyzed below that point. My mom just wanted to have an excuse for her problems other than the fact that she was over weight. She still does but that is another story.

If you have a bad back, go see an Orthopedic Surgeon and tell them to be roughly blunt with you. Take what they say with a grain of salt and think about it. If it totally doesn't make sense then get a second opinion. If it strikes close to home (i.e. you're fat, lazy, stupid) then they are probably right. Of course, they also might find a herniated disc and be able to actually do something about it other than crack your back and give you a massage.

PB


This is the second DC I've ever been to. If this would of been the first DC that I had seen, I'd agree with you 120% and never would of went in the first place.

Apparently my MRI was already refered to an MD by the DC (without my knowledge), and the DC just read the opinion of the MD during my visit yesterday.

The MRI has pointed out that there is an issue that needs to be addressed. What I find unnaceptable is now the DC want to change the "course of action" on how to try and fix this issue (without surgery).

I already had/have A neuro surgeon lined up that I trust and know is good. I guess now either I have the DC or MD who read my MRI refer me to him. Bottom line, I should of just went to this guy in the first place.

Another thing I'm finding interesting. "Referals". When I called the neuro surgeons office, the girl mentioned that I had to have myself refered to their office.

Personally, I'd be afraid if the goverment took over health care. They have a tendancy to fubar things.

Does seem like organized crime without the violence at times.
 

waybomb

Well-known member
GOLD Site Supporter
I type so damn slow
The party line comment was about "free healthcare" implying anyone who want universal healthcare is a freeloader. .

On typing - me too. I'm a pecker. One finger - sometimes two.

Anyone is a big word. I don't believe anyone wanting free health care is a freeloader.

But I'd have to say, there are way more able bodied people that could go it on their own if they weren't so dam lazy and entitled. All I have to do is look across the river from where I live and see almost an entire town of them. It is sad. They have $20,000 donks in front of their $1,000 house, while wearing $1500 in clothes, and complaining about "the man".

Makes me sick.
 
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Cityboy

Banned
Wrong audience.

If Michael Moore says there is a health care crisis, then there isn't a health care crisis! it's as simple as that.

It's the wrong audience if one is looking for a MM hug-fest. MM has his own agenda and has aligned himself with what many people consider the lunatic left.

If you have to invoke MM to support your position on government monopoly health care, your argument is pretty weak. Better look for back-up elswhere.

Honestly folks...would you really want Hillary or George and their legislative cohorts in charge of your healthcare??
 

waybomb

Well-known member
GOLD Site Supporter
Honestly folks...would you really want Hillary or George and their legislative cohorts in charge of your healthcare??

Hell NO!

And that's my point to Sushi. He must start taking responsibility for his predicament. If he keeps waiting for handouts, he'll be in a never ending downward spiral. Nothing is free, even if the cost is zero. People don't seem to understand the effects of prostituting themselves to the welfare state and welfare state of mind.
 

mak2

Active member
Hell NO!

People don't seem to understand the effects of prostituting themselves to the welfare state and welfare state of mind.

Why do you see the evils of governemnt incompetence, yet completely dismiss the greed of the current system? I just want change. The current system is terrible.
 
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