# Looks like I might have a battle brewing..........



## paratrooper (Feb 1, 2012)

Last November, I had my right knee replaced. We have good insurance (Blue Cross / Blue Shield) and it covered the majority of the expense. We were very diligent in our actions to make sure that all the medical providers would be in the BC / BS coverage network.

My surgeon assured me they would be, as well as his scheduling assistant, as well as the hospital that I had my surgery in. We had some out-of-pocket expenses that we paid for ourselves. We paid off those bills as they came in.

Today, I received an envelope from BC / BS. Enclosed was a check made out to me in the amount of $530.00. Also enclosed, was a statement explaining that one of the surgical assistants was *NOT* in network. It went on to say that they would not cover the fee and it would be up to us to pay it. Total amount due was $5530.00.

We haven't yet received a bill for that amount. I assume since they sent me the check, the bill will be forth coming soon from said provider. I spoke to my wife about it, and she too, knew that we spoke to the above parties about in network medical providers.

I'm going to wait and just hold on to the check. I have six months to cash it. I'm going to wait and see if a bill does indeed show up. If it does, I will then contest it and fight it to the best of our abilities.

As I mentioned, we did our due diligence. We made sure that all medical providers would be in network. We went by what we were told and assured of.

If any of you are in the health-care field, and have some relevant advice, I'm all ears. Ain't no way I'm going to pay this without a fight.


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## tony pasley (May 6, 2006)

Good luck and start training for a 15 round match.


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## Cait43 (Apr 4, 2013)

Unless you are financially well off there is no such thing as good health insurance in America any longer..... That ship has sailed and was sunk by the greedy.......

Sadly not all people that work in a hospital are not necessarily in the "health insurance club" even if you are given assurances they are..... Its the insurance company loophole of PPO and non-PPO providers......

Good luck in your upcoming fight and keep us posted......

Did they say what the $530.00 check was for??????


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## Steve M1911A1 (Feb 6, 2008)

I suggest that you need a lawyer.
The lawyer will cost more out-of-pocket expense, but, by sending just a few letters, he might save you about half of what the bill comes to.
In any case, your first consultation, in which the lawyer figures out whether or not he can help you, should be at no charge.
He should also be able to closely predict what you will need to pay him for all of his work, if he takes your case.


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## neiljakson (May 5, 2017)

thanks for providing a great information about layer


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## hillman (Jul 27, 2014)

Possibly those assurances you got needed to be in writing, with a 'responsible' signature. Would at least give you and your attorney something to work with. "My word is my bond" seldom means much.


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## wirenut (Dec 16, 2015)

I think you are getting ripped off.
Deal with the medical for years with my wife's health just because that person is not in network the insurance should still pay some, just not as much as a person in network.
I don't understand these insurance companies, I live near 2 hospitals, same city insurance pays 90 percent to one and 80 percent to the other.
I don't know your provider but mine is self insured, so if I have an issue I can contact the trustees.
.
Good luck!!


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## pic (Nov 14, 2009)

Find out who did the billing , coding. What part of the procedure was not covered. Maybe they could re-bill, recode that certain procedure correctly and resubmit to insurance. 

If if everything seems to be on the up n up. The final bill is negotiable


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## win231 (Aug 5, 2015)

_There is no fraud like medical billing fraud._ They'll give up if you ignore them & don't pay it.

A few years ago I went to the ER after my sister tested me with her meter - blood sugar was over 500. I was there for 30 minutes, got one shot of insulin & the only doctor I saw stuck his head in the room, said _"I consider you diabetic"_ & left. The billing lady walked in & handed me a bill - $2,900.00. I gave her my credit card, she ran it, handed me a "PAID" invoice & I left.
A couple of months later, I started getting bills for $2,800.00 from medical centers hundreds of miles away that I'd never been to, from doctors I never saw. I phoned the ER & asked what the bills were for. Their explanation: "We sent your chart to other doctors for evaluation, so you have to pay them, too."
I said, "If you did that, it was nonsense & it wasn't necessary & I didn't request it, so you can pay them for their "evaluation."
They kept sending bills for a few months, then gave up.
They probably figure some people will just pay it & it's worth the cost of postage.


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## paratrooper (Feb 1, 2012)

I'm not sure what the $530.00 was for. The statement that came with the check was rather vague. It did mention surgical assistance and a last name of the provider. 

We knew all about "in network" providers. That's why we made sure that my surgeon was aware of our concerns, as well as his surgery scheduling assistant. 

As a patient, there's no way you know who or what kinds of medical providers will be involved in your surgery. That's what the doctor and his staff are for. We thought we were playing it safe by also speaking to the hospital rep about the same concerns.

I think at this point, before I start making any phone calls, I'm going to wait and see if a bill does arrive. I don't want to fire any shots until I clearly see the whites of their eyes.


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## paratrooper (Feb 1, 2012)

My wife clarified the $530.00 check for me. She said that the check was sent to me instead of the out-of-network provider. If that provider had been in network, that's the amount that BC / BS would have paid him. 

So now I have a better understanding of what's going on. Now, I just wait to hear from the out-of-network provider and see what they say after I explain to them my side of the situation.


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## win231 (Aug 5, 2015)

From what I've experienced, doctors are getting concerned about where health coverage is going & they're trying to soak insurers & patients for everything they can, while they can.
My regular endocrinologist charged $265.00 for labs. At my last doctor visit (three years ago), I got a bill for $685.00. There were all kinds of B.S. charges for things I never got. My favorite was "Nutritional Counseling." _*I was the one who provided the doctor with nutritional counseling *when she wanted to know how I lost 60 lbs. _ And I didn't charge her anything. Then there was an additional charge for "Vitamin D" & hormone levels - which were always included in previous labs.

Yeah...just separate a bunch of things that are part of the normal labs & add an extra charge for each one. "Creative Billing."


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## paratrooper (Feb 1, 2012)

Yeah, it can and does get ridiculous at times. For the most part, I don't need to see a lot of doctors. I'm pretty healthy for my age. I've only had two surgeries in my life. Once for a broken right collar-bone when I was 16 or so, and then for my right knee replacement last Nov. 

My 2.5 day stay in the hospital for my knee surgery came to a little over $55K. That's what the hospital billed BC / BS. I think my insurance paid them a little over $8K for the stay. 

It's mind boggling what the medical field charges.


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## win231 (Aug 5, 2015)

You wouldn't believe what I've gone through with dentists. Some of them are even more creative.....


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## tony pasley (May 6, 2006)

No mind boggling when you consider that Uncle Sugar is paying 70% of what the DR. charges and insurance network providers only pay a % of the charges so the Dr. has to jack up charges to offset what those don't pay to get what they need to run their office pay off loans and make a living.


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## win231 (Aug 5, 2015)

tony pasley said:


> No mind boggling when you consider that Uncle Sugar is paying 70% of what the DR. charges and insurance network providers only pay a % of the charges so the Dr. has to jack up charges to offset what those don't pay to get what they need to run their office pay off loans and make a living.


Doesn't apply to me; I'm a cash patient & they still try to rip me off. It's greed; nothing more.


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## pic (Nov 14, 2009)

Probably the anesthesiologist bill , hope I spelled that correctly, lol. Next time stay awake and watch. Kidding.

Maybe you died on the operating table and they had to call in extra help to revive you.:smt033

You're gonna mess up your credit rating ,lol. 

Good luck , 

:smt1099


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## paratrooper (Feb 1, 2012)

pic said:


> Probably the anesthesiologist bill , hope I spelled that correctly, lol. Next time stay awake and watch. Kidding.
> 
> Maybe you died on the operating table and they had to call in extra help to revive you.:smt033
> 
> ...


Yeah, I'm not sure exactly what the charge was for. I guess I'll find out soon enough if / when the bill arrives. I'm already formulating a plan in my head on how I'm going to approach it, what I'll say, and what I might suggest, as to how we resolve it.


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## Cait43 (Apr 4, 2013)

win231 said:


> _There is no fraud like medical billing fraud._ They'll give up if you ignore them & don't pay it.


You are correct with "they'll give up".... My insurance company(Cigna) did just that, they sent it to a collection agency.. Took a year to the date with numerous phone calls and letter writing to finally get the bill paid...

Currently in another no pay by Cigna battle over flu shots for the wife and me......


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## Cait43 (Apr 4, 2013)

paratrooper said:


> My wife clarified the $530.00 check for me. She said that the check was sent to me instead of the out-of-network provider. If that provider had been in network, that's the amount that BC / BS would have paid him..


Sounds about right for BC/BS out of network payment of 10%........

Ah the good old days when health insurance meant they paid virtually the entire bill... God Bless America......


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## tony pasley (May 6, 2006)

Here is your out of network expense.


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## wirenut (Dec 16, 2015)

Wait till you have to deal with medicare.
My wife just got out of hospital and if you are kept overnight for observation, medicare will not pay for observation.


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## shootbrownelk (May 18, 2014)

paratrooper said:


> Yeah, it can and does get ridiculous at times. For the most part, I don't need to see a lot of doctors. I'm pretty healthy for my age. I've only had two surgeries in my life. Once for a broken right collar-bone when I was 16 or so, and then for my right knee replacement last Nov.
> 
> My 2.5 day stay in the hospital for my knee surgery came to a little over $55K. That's what the hospital billed BC / BS. I think my insurance paid them a little over $8K for the stay.
> 
> It's mind boggling what the medical field charges.


I had my right knee replaced last September. The bill for the Hospital stay & Surgeon was over $80,000.00. You got off cheap IMO. I totally agree. The prices that hospitals and doctors is out of control...unless you happen to be an illegal alien..then it's free!


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## wirenut (Dec 16, 2015)

shootbrownelk said:


> I had my right knee replaced last September. The bill for the Hospital stay & Surgeon was over $80,000.00. You got off cheap IMO. I totally agree. The prices that hospitals and doctors is out of control...unless you happen to be an illegal alien..then it's free!


My wife had two stents, so far it's over $200k and that does not include Docs fee.....


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## paratrooper (Feb 1, 2012)

shootbrownelk said:


> I had my right knee replaced last September. The bill for the Hospital stay & Surgeon was over $80,000.00. You got off cheap IMO. I totally agree. The prices that hospitals and doctors is out of control...unless you happen to be an illegal alien..then it's free!


The $55K I stated was just for the hospital stay. Not sure what the surgeon fee was, but after all was said and done, it was probably on par with what you experienced.


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## Bisley (Aug 24, 2008)

From what you posted, it sounds similar to a situation I had the last time I had a colonoscopy. The clinic/hospital double-billed the anesthesiologist fee, claiming that two anesthesiologists were present. The insurance company rejected one and the hospital said they always did it this way and that I had to pay it. I told them that my insurance company explained to me that I did not owe it because they knew the insurance would only pay for one, because one was all that was necessary. The clinic said I had to pay, and I told them to go jump in the lake. They sent me bills and threatening letters for a year, turned it over to a collection agency, and finally gave up. My credit rating is still over 800.


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## desertman (Aug 29, 2013)

I think that everyone in this country should just say: "Screw it we're just not going to purchase health insurance anymore." A nationwide boycott is in order. If there's no money coming in from insurance companies to pay for medical care, then the whole shit house goes up in flames. It's headed in that direction anyway as it is in the process of bankrupting every man, woman and child in the United States. That's probably about the only way that anyone who can do anything about the outrageous cost of medical care in this country will do anything about it. Because it will have a profound affect on them too. Our insurance premiums have more than doubled since "Black Militant Care" was implemented. The big question is: How much longer can this be sustained? Where the hell is all of this money going to justify these types of rate increases? Tinkering around the edges is just not enough. The entire system needs to be overhauled so that everyone will be able to afford to purchase their own insurance while getting the care they need.

Tort reform would be a good place to start as the cost of malpractice insurance is astronomical. Which eventually gets passed on to the consumer. In addition and in order to cover every square inch because of the possibility of a lawsuit. Doctors often prescribe unnecessary tests and procedures just to cover their asses. Somebody has to pay for all that. Being that most politicians are trial lawyers it's unlikely that they will do anything that affects their bottom line. But the day of reckoning is soon approaching. When the insurance industry finally collapses they too will find themselves shit outta' luck. As there will be no one left to pay for medical care for anyone rich or poor alike. Insurance is almost like socialism as those paying for insurance are paying for the medical care of others whether they have insurance or not. They are now beginning to run out of other people's money.

Single payer is not the answer either as it will put the same corrupt politicians who got us into this mess in the first place in charge of our healthcare decisions including who shall live and who shall die. I find it amazing that this countries best and brightest minds can't come up with something that will benefit all Americans and not just a chosen few. As usual those of us in the middle always end up getting screwed the most. The wealthy can well afford their own insurance and medical care. The poor are automatically taken care of as the medical care providers have to take care of them and will never get blood out of a stone. It's those of us who have any type of personal assets that they can go after and has the most to lose.


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## paratrooper (Feb 1, 2012)

Bisley said:


> From what you posted, it sounds similar to a situation I had the last time I had a colonostomy. The clinic/hospital double-billed the anesthesiologist fee, claiming that two anesthesiologists were present. The insurance company rejected one and the hospital said they always did it this way and that I had to pay it. I told them that my insurance company explained to me that I did not owe it because they knew the insurance would only pay for one, because one was all that was necessary. The clinic said I had to pay, and I told them to go jump in the lake. They sent me bills and threatening letters for a year, turned it over to a collection agency, and finally gave up. My credit rating is still over 800.


That's good to know. I hope that it doesn't come to that, but if it does, it is what it is.

As far as I'm concerned, it was the responsibility of the surgeon and his staff to make sure that all medical providers were within the BC / BS network. I made that abundantly clear to them what insurance I had and the stipulations involved.

I'm just not gonna roll over and play dead on this.


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## Cait43 (Apr 4, 2013)

wirenut said:


> Wait till you have to deal with medicare.
> My wife just got out of hospital and if you are kept overnight for observation, medicare will not pay for observation.


Medicare changed there plan a few years back and will only pay on hospital bills for a two or more day stay.... One day is now considered observation and is not payable under Part B... The health insurance companies have followed suit.... You now have to meet certain criteria to be admitted for two or more days..... God Bless America........


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## win231 (Aug 5, 2015)

Bisley said:


> From what you posted, it sounds similar to a situation I had the last time I had a colonostomy. The clinic/hospital double-billed the anesthesiologist fee, claiming that two anesthesiologists were present. The insurance company rejected one and the hospital said they always did it this way and that I had to pay it. I told them that my insurance company explained to me that I did not owe it because they knew the insurance would only pay for one, because one was all that was necessary. The clinic said I had to pay, and I told them to go jump in the lake. They sent me bills and threatening letters for a year, turned it over to a collection agency, and finally gave up. My credit rating is still over 800.


Same here. They'll tell you how it will ruin your credit if you don't pay, but it won't do squat. I lease a new car every three years which requires good credit - never had a problem; credit rating is around 780 WITH their B.S. I always tell them, "Please feel free to report it to my TRW...I'm shakin." They're hoping you'll be scared & allow yourself to be ripped off with that threat.

Eight years ago, a dentist tried a hard sell on an implant to replace an old bridge. I asked if a replacement bridge would work, since it doesn't involve extensive surgery. I also informed him that (unless it's an emergency), implants are not a good idea for a diabetic. He said, "No...only an implant would work." It was easy to see why he wanted to do an implant; the bridge is $3,000.00 & the implant is $6,000.00 with the same amount of work for the dentist either way. After more discussion, he admitted a bridge would work. I had reservations about letting him do the bridge since he was disappointed, but since he was our family dentist for 12 years, I figured I could trust him. Big mistake. After he cemented the bridge & the anesthetic wore off, something didn't feel right when I tried to eat; I couldn't chew on the side where the new bridge was. When I looked in the mirror, I could see why. There was a big gap between the top & bottom molars on that side. He had to have seen that the teeth were too short & he cemented them anyway, apparently to teach me a lesson about not agreeing to get the implant. When I went back to him to show him the bridge, he tried to give me some BS, saying "Your teeth shifted." I suggested he save that one for the tooth fairy. I consulted several other dentists who said they've never seen such poor dental work. The bridge would have to be done again but they explained that I'd have to wait a year for my gums to fully heal before doing more trauma to the area. It wasn't a fun year for eating - I could only chew on one side.

I gave the original idiot dentist a choice: Refund the $3,000.00 so I can have another dentist do the bridge again or I'll dispute the charge on my credit card & they'll bill you back for it. _He suggested I let HIM do the bridge again. _
I said, "No way; I'd have to be a bigger fool than you to let you anywhere near my teeth again." 
He said he wouldn't give me a refund. I said, "Fine."

By then, the other dentists I saw about re-doing the bridge must have contacted him because he phoned me & had me pick up a refund check for $3,000.00 & sign a waiver.

It didn't end there; I sent the credit card company (Care Credit) the $3,000.00, then they tried to bill me for added interest. I explained the law to them - they are not allowed to add any interest during a charge dispute. They kept sending bills, I kept throwing them away & they gave up after a couple of years.


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## paratrooper (Feb 1, 2012)

win231 said:


> Same here. They'll tell you how it will ruin your credit if you don't pay, but it won't do squat. I lease a new car every three years which requires good credit - never had a problem; credit rating is around 780 WITH their B.S. I always tell them, "Please feel free to report it to my TRW...I'm shakin." They're hoping you'll be scared & allow yourself to be ripped off with that threat.
> 
> Eight years ago, a dentist tried a hard sell on an implant to replace an old bridge. I asked if a replacement bridge would work, since it doesn't involve extensive surgery. I also informed him that (unless it's an emergency), implants are not a good idea for a diabetic. He said, "No...only an implant would work." It was easy to see why he wanted to do an implant; the bridge is $3,000.00 & the implant is $6,000.00 with the same amount of work for the dentist either way. After more discussion, he admitted a bridge would work. I had reservations about letting him do the bridge since he was disappointed, but since he was our family dentist for 12 years, I figured I could trust him. Big mistake. After he cemented the bridge & the anesthetic wore off, something didn't feel right when I tried to eat; I couldn't chew on the side where the new bridge was. When I looked in the mirror, I could see why. There was a big gap between the top & bottom molars on that side. He had to have seen that the teeth were too short & he cemented them anyway, apparently to teach me a lesson about not agreeing to get the implant. When I went back to him to show him the bridge, he tried to give me some BS, saying "Your teeth shifted." I suggested he save that one for the tooth fairy. I consulted several other dentists who said they've never seen such poor dental work. The bridge would have to be done again but they explained that I'd have to wait a year for my gums to fully heal before doing more trauma to the area. It wasn't a fun year for eating - I could only chew on one side.
> 
> ...


My wife had some dental work done recently, and she's having issues with it. The dentist she went to, apparently got tired of her coming back to him, so he told her not to return.

She went to another dentist and he confirmed to her that she was right in her complaint and that he was quite surprised that a fellow dentist would tell a patient not to return.

So, she got all of her x-rays and documentation from her dentist and filed a complaint with the state licensing board. She sent it all off and just a few days ago, received confirmation that it had been received and was given a file / reference number. Hopefully, within a couple of months, she will know what will occur.


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## win231 (Aug 5, 2015)

paratrooper said:


> My wife had some dental work done recently, and she's having issues with it. The dentist she went to, apparently got tired of her coming back to him, so he told her not to return.
> 
> She went to another dentist and he confirmed to her that she was right in her complaint and that he was quite surprised that a fellow dentist would tell a patient not to return.
> 
> So, she got all of her x-rays and documentation from her dentist and filed a complaint with the state licensing board. She sent it all off and just a few days ago, received confirmation that it had been received and was given a file / reference number. Hopefully, within a couple of months, she will know what will occur.


I also filed a complaint with The Dental Board. I sent photos & statements from three other dentists. After a few weeks, they sent me a letter, suggesting I take legal action. Perhaps in your state, they are helpful, but here in CA, they are completely useless. They are comprised of a group of dentists who provide the _illusion _of helping patients, while supporting bad dentists. Same with the Medical Board & CA Bar. The only reason my dentist was forced to give me a refund was because the other dentists I consulted to re-do the bridge were contacting him & he realized his reputation was being ruined.


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## paratrooper (Feb 1, 2012)

*GREAT NEWS!!*

The office manager from my surgeon's office just called me. I had left her a voice mail message. I explained to her what was going on and she said not to worry, that the person "not in network" was my surgeon's assistant. She said that although he is not a surgeon, he is indeed, a provider that is in network.

She went on to say that BC / BS has misconstrued this in the past. She told me to stop by the office, sign the check over to them, and they would take it from there. She also said that they would indicate on my records that all has been paid for in full.

So, I don't know if I dodged a bullet or not, as I was ready and prepared for battle. It now looks as if there will be a peace treaty. :smt038


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## tony pasley (May 6, 2006)

Wait till nurse Goodbody calls


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## paratrooper (Feb 1, 2012)

tony pasley said:


> Wait till nurse Goodbody calls


Would that be RN Angelina Lovelyhips? :mrgreen:


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## tony pasley (May 6, 2006)

Post 21 explains


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## Bisley (Aug 24, 2008)

paratrooper said:


> *GREAT NEWS!!*
> 
> The office manager from my surgeon's office just called me. I had left her a voice mail message. I explained to her what was going on and she said not to worry, that the person "not in network" was my surgeon's assistant. She said that although he is not a surgeon, he is indeed, a provider that is in network.
> 
> ...


Doctors, especially specialists, rely heavily on their office staff for their livelihood. The good ones see a patient every fifteen minutes with very few short breaks, when they are not performing 'procedures,' and they perform their scheduled procedures back to back, all day long, with a few emergencies thrown in for good measure. Many have no clue about whether they are being paid, except on payday.

Meanwhile, the office manager and staff are dealing with the patients and insurance companies. They 'write off' or 'adjust' hundreds, if not thousands of dollars a month from the deadbeats who simply will not pay, or the honest people who cannot pay. They are busy filing and re-filing claims to insurance companies or government agencies that automatically reject claims, some, until they are threatened with claims to the state insurance board, or the state attorney general's office. Their phones ring constantly, and a high percentage of those calls are from people who can not possibly understand how the system works, and are either ranting, pleading, or are just too ignorant ( not to be confused with stupid) to understand the answers to their questions. Most of them ask questions that cannot be answered without some research, and are therefore forced to wait for a callback that may never come. It's like herding cats, and even the dedicated professionals (of which most are not) can barely maintain some semblance of control over what is going on.

The health care system is a giant cluster**** that sucks in billions of consumer dollars and is therefore a target for corruption of all sorts...especially government. It was difficult, before Obamacare, and is now impossible, for both patients and doctors. It is unfixable by the government, and it will never be fair unless it goes to a cash and carry system that can be negotiated on a one-to-one basis, between doctor and patient, with assistance from legitimate,_ unsubsidized_ insurance companies that compete for the business.

The government should levy taxes to aid that small portion of the public who cannot take care of themselves, and let everybody else take care of their own business - face-to-face. Government 'administration' multiplies the cost of health care exponentially, under the guise of 'charity,' and those who pay their own way must also pay for ten others and a gigantic bureaucracy that serves only itself.


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