The following content is considered nonlegal and nonbinding OPINION only, and does not legally assume any entity is responsible for the accuracy of any facts that may seem to be presented by any entity. Rather this is meant to be a starting point of research into the facts or truth. The standard of the reasonable person should be assumed with regard to any possible research into the facts or truth!
Insurance companies may hide behind ERISA by ignoring treating doctors, allowing accountants to make medical decisions, and then when caught try to lie their way out of problems.
ERISA applies to all employee benefits so it has been argued person cannot sue their insurance company or employer in state court if they have been denied coverage for a treatment or procedure. In effect the insurance company does not have to pay any benefits and/or often raises premiums or cancels plans when the health care costs are too high. Limited remedies for damages does not insure timely treatment because it forces cases into federal court and the insurer is not fined compensatory or punitive damages. If the patient dies and insurer refused to cover costs, due to the lack of punitive damages the insurer does not pay anything to patient's survivors.
Almost ALL health plans are geared to properly treating the most common or obvious cases and likely do not properly route patients to specialists.
Shriners Hospitals (for children),Insure Kids Now! (http://www.insurekidsnow.gov or 1-877-543-7669), some charity hospitals, Community Health Center Locator (http://findahealthcenter.hrsa.gov), Elder care locator (800-677-1116), Hill-Burton Free and Reduced cost care at hospitals (http://www.hrsa.gov/hillburton), Medicaid, Medicare,National Breast and Cervical Cancer Early Detection Program and Early Detection Program (NBCCEDP) (http://www.cdc.gov/cancer/NBCCEDP/) and Maternal and Child Health Services programs (http://mchb.hrsa.gov/programs/womeninfants/prenatal.htm or 1-800-311-BABY) offer free or low cost health care. PatientsLikeMe.com, curetogether.com, or other patient websites may be helpful.
About $24 million is paid out in MEDICAL MALPRACTICE CLAIMS PER ABOUT $1,000.00 WORTH OF INSURANCE PER YEAR, WHICH MAY SUGGEST ALMOST ALL MODERN MEDICINE IS A NEGATIVE VALUE SITUATION! ONE WAY TO REDUCE THIS RISK IS TO SWITCH TO A WELLNESS PROVIDER, AND TO HAVE A HEALTH SAVING ACCOUNT WITH A HIGH-DEDUCUTABLE HEALTH INSURANCE. Medical doctors shallow focus in on repair, replace & remove!
Off-label drug (non-FDA approved use for the drug), German drug (especially if drug companies has a history of fines against it), Drug FDA approved before 1950, generic drug, mutation-causing drug, purchased without prescription (especially on the Internet), or illegal drug, which might lead to death, or if any of the following was prescribed: Neurontin, Topamax, Seroquel, Risperdal, Bextra, Biaxin, Avelox, Tlazodone, Remeron, Zithromax, Zypexa, Levaquin, Zithromax, Cipro, Wellbutrin, Depakote, Yasmin was prescribed. Anti-convulsive, anti-infection, Anti-depressant, mood altering drug, psychiatric drug, painkiller class of drug (some have up to 90 % misprescription rate).Sex enhancer drug (perhaps have of those bought over the Internet are placebos).
Noninsurance company billing submission or software, which may be inferior to both Medicare and Medical controls, consumer protections.
Medicare medical billing submission or government billing program or government insurance carrier contractor, which may NOT be allowing compensation for the most modern medicine.
County type Insurance Plan, especially San Mateo or Bay Area, which may be inferior to normal GOVERNMENT GUIDELINES, AUDITS, AND OTHER QUALITY ASSURANCE MEASURES.
Showy, Clanlike or cultlike; Many relatives in organization; History of problems; Control politicians in the region; Few probes into problems; or they all seem to act the same.
Hospital stay was terminated as soon insurance coverage wouldn’t pay for stay, especially for psychiatric care.
Put into hospital after being abducted by ambulance service, especially for psychiatric care.
Put into hospital after business partners stole personal assets and/or medical professions helped possible illegal conservatorship get formed.
Practitioners accepted assignment (usually what the government is willing to pay for the service with the condition that is payment in full and the beneficiary doesn’t need to pay the practitioners) but the practitioner still bills for services and/or charges for services that were NOT rendered.
Hospital is largest employer in the region and/or One or few industries in region.
Government community and/or down economy with little other way than to use medical services and disability claims to bring money into the region.
Promotions based on seniority; therefore, the quality may be very weak.
City government or institution, which tends to have the weakest services, practitioners, management and are usually only supposed to concern themselves with diseases that spread.
County government or institution, which tends to have the weakest services, practitioners, management, and are usually only supposed to concern themselves with diseases that spread.
State government or institution tends to be used put persons on disability, can take some of the more challenging cases, but can be crime infested and likely the first institutions to be investigated by the government.
Chartable institution, which few may be willing to complain about, even if the service was poor, and often can be a place where some very competent practitioners like to do free and challenging work, and in some instances they can lose their tax exempt status if they bill the poor.
Private Hospital, which may tend to support private industry and not strong public policy or public health, but they may be very good at routine and/or unnecessary services, often called elective, which is usually cosmetic.
Teaching Hospitals tend to take trauma cases, and more advanced and complex cases.
Military Hospitals can be institutions of last resort.
Psychiatric Hospitals can have many complaints against them.
Kaiser or HMOs may be nearly exempt from litigation, or effectively nearly exempt from litigation; therefore, it may be especially wise to bring witnesses, get to emergency room, especially for ANY sensory problem or any other possible problem that will cause long-term damage, such as long term pain in the head, or go to a charity, or state institution for a second opinion.
Deceitful, especially regarding forged signatures, including on informed consent forms, statements made privately. Often it may be best to consult an attorney before getting the treatment and/or surgery and to secretly videotape and/or record conversations.
Overbilled, false bills.
Prejudiced or suspected Civil Right Violations.
Harasses or rude, Stalks, Irrational, Negligent or Refuses to do evaluation, even minor care.
Prior convictions of crimes, Abusive or use of unnecessary force, Sleeps on job, False documentation used to obtain position, or Rock star and/or entertainer with suspicion of false identification with history of addiction likely there to abuse position.
Fear the worst out of this person.
Excessive fees for lab tests, shipping and handling, interpretation.
Possible complex computer problem, which could be due to wrong address, names, social security problem found by biller, or billers even colluding together to steal private information previously mentioned for billing purposes, or the computer was misprogrammed and/or hacked, especially for double billing, etc.
Ignores requests, especially for copies of records.
Lies, cheats or steals, and this can be done by many conspiring together especially in a region because entire groups can dominate a region, or act as a family business.
Practitioners have been in same position for more than five years.
Practitioners have been in same region for less than five years.
Excessive fees for lab tests, shipping and handling, common and inexpensive items, which usually come from the same suppliers, often for a very small cost to the biller.
Excessive fees for many small surgeries done at the same time, which may need to be billed for a reduced rate.
Excessive fees for visits in hospital after surgery without new diagnosis or complications, which are usually considered part of the surgery fee.
Excessive fees for chemotherapy visits and drugs far beyond what the government usually allows, especially when the biller accepts assignment.
Excessive fees for many different complex surgical procedures done at once, and/or for the possible co-surgeon and/or assistant surgeon and/or other staff.
Excessive fees for nursing home visits by doctor, especially for clipping toe nails.
Excessive fees for ambulance or emergency service care getting to hospital, or other medical institution.
Volunteers and/or staff suspected of wrongdoing and/or working at the institution to get priority care for their self, friends and family, or to play with the equipment.
Tests needed to be done many times and interpreted many times due to errors and incompetence.
Equipment failure Equipment failure at the institution, especially if it resulted in damage to the patient.
Negligence at the institution, especially if it resulted in damage to the patient.
Malpractice at the institution, especially if it resulted in damage to the patient.
Invasion of privacy or theft of records, at the institution, especially if it resulted in damage to the patient, which may be very, very common because some many have access to records and because institutions tend to be overly public, poorly guarded, especially if it resulted in damage to the patient.
Criminal misconduct at the institution, especially if it resulted in damage to the patient.
The Health care profession is a high stress and high risk profession and that it might attract persons with problems and they may constantly deal with person with problems, and may sometimes not deal well with persons with problems. AT LEAST TWO HEALTHCARE SERIAL KILLERS ARE KNOWN TO EXIST: NURSE CHARLES CULLEN AND LOS ANGELES ANESTHESIOLOGIST DR. JOHN KAPPLER; THEY WERE ALLOWED TO WORK DESPITE MANY INDICATIONS THAT THERE WERE PROBLEMS WITH THEIR BEHAVIOR, WHICH SUGGESTS THAT ABUSE IN THE MEDICAL PROFESSION IS COMMON, AND LIKELY EVEN MORESO IN A DOWN ECONOMY WHEN THE GOVERNMENT DOES NOT HAVE THE RESOURCES TO PROPERLY INVESTIGATE COMPLAINTS! GOOD HEALTH PLAN SHOULD HELP PREVENT THIS, BUT OFTEN THEY MAY ENABLE IT BECAUSE THEY MAY ATTRACT THE WORST PROFESSIONALS AND PAY THEM THE LEAST! DOCTORS OFTEN ARE NOT LEGALLY REQUIRED TO TELL THEIR PATIENTS THEIR DIAGNOSIS! The Feds often have a high amount of overpayment amount before they will open an investigation, or they may need to see a serious crime before they will act. Most people to not know where or how to complain to the administrative, legislative, or judicial branches of the government, or to the state government to try to get a license revoked. Often, it is the Federal government that will go to the state government and insist a license gets revoked. The media may be of some help getting an investigation started, but they may have a major conflict of interest in these cases because of their advertisers. It used to be that insurance companies bit on the Medicare, Medical and Medicaid contracts I suspect partly to fill their minority quotas and to try to do fraud control to reduce their co-insurance payments. Now these contractors may treat the contract as pure programming exercises, and most of the claims may be automated. Therefore, internal and external fraud may be almost impossible to detect. THIS MEANS YOU MUST COMPLAIN USUALLY TO MULTIPLE PLACES OR EVEN DO ALL YOUR OWN MEDIA AND PUBLICITY. ALSO, FEW LAWYERS WORK THESE CASES.
The cost of Health Plans, Insurance, Hospitals does not mean it has high value, or reflect its value.