Insurance companies, do they know they are being scammed? - Mothering Forums

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#1 of 52 Old 06-09-2006, 04:41 PM - Thread Starter
 
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I'm not one to feel sorry for big greedy corporations, but do insurance companies know how much they are being scammed by hospitals? Why do they put up with it?

One small example is that when I reviewed my hospital bill, each pill they gave me had it's own price tag. I remember that the throat lozenges were seven dollars each. I could have bought a large box of lozenges for that much! How does an insurance company not notice that?

And some bigger examples, why do insurance companies pay for inductions and c-sections and other procedures that were not medically necessary? I mean, sure, if a woman wants to choose something that's not medically necessary fine, she can also choose to pay for it! She can choose to get a nose job too, but insurance wouldn't pay for that so why do they pay for the c-section?

If insurance companies stopped covering inductions and c-sections that were not medically necessary how would that change things? Would women still be so eager to be induced because they are sick of being pregnant (or any other non-medical reason) when they knew they would have to pay for it, and pay for the c-section that may follow? Would they still go along with their doctor's non-medically based reasons for wanting to induce? Would they look into how to avoid a c-section if they knew it may not be covered? Would they stand up and fight their doctor when he wanted to push a c-section or induction for no clear medical reasons? Would doctors start learning quick how to deliver breech babies vaginally since a c-section is not medically indicated for a lot of breeches? Would doctors stop trying to scare women and force them into getting procedures done that the women would later be mad at the doctor for because she ended up having to pay for it? Would doctors start letting women VBAC because the women can't afford the repeat c-section? Would women start demanding that midwives be employed at their local hospital because they know that would be the best way for them to save money?

I just don't understand why insurance companies go along with paying for procedures and major surgery that wasn't even necessary. So if I don't choose the c-section that is just waiting there for me, can I just have the money? Or can I use it get the cosmetic surgery of my choice?

Shouldn't we all be complaining to insurance companies for covering surgeries and procedures that aren't medically necessary because don't our own premiums go up the more they have to pay to hospitals? Maybe instead of trying to educate women, we should try to educate insurance companies.
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#2 of 52 Old 06-09-2006, 04:53 PM
 
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When I was a very young child my parents took me to the doctor for a cold or something and they tried to charge my dad $10 for a single aspirin. This was over 27 years ago. My dad took out a nickel from his pocket, gave it to her and said "That'll about cover it" He didn't get billed any more for it.

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#3 of 52 Old 06-09-2006, 05:19 PM
 
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Originally Posted by jennica
I'm not one to feel sorry for big greedy corporations, but do insurance companies know how much they are being scammed by hospitals? Why do they put up with it?

One small example is that when I reviewed my hospital bill, each pill they gave me had it's own price tag. I remember that the throat lozenges were seven dollars each. I could have bought a large box of lozenges for that much! How does an insurance company not notice that?

And some bigger examples, why do insurance companies pay for inductions and c-sections and other procedures that were not medically necessary? I mean, sure, if a woman wants to choose something that's not medically necessary fine, she can also choose to pay for it! She can choose to get a nose job too, but insurance wouldn't pay for that so why do they pay for the c-section?

If insurance companies stopped covering inductions and c-sections that were not medically necessary how would that change things? Would women still be so eager to be induced because they are sick of being pregnant (or any other non-medical reason) when they knew they would have to pay for it, and pay for the c-section that may follow? Would they still go along with their doctor's non-medically based reasons for wanting to induce? Would they look into how to avoid a c-section if they knew it may not be covered? Would they stand up and fight their doctor when he wanted to push a c-section or induction for no clear medical reasons? Would doctors start learning quick how to deliver breech babies vaginally since a c-section is not medically indicated for a lot of breeches? Would doctors stop trying to scare women and force them into getting procedures done that the women would later be mad at the doctor for because she ended up having to pay for it? Would doctors start letting women VBAC because the women can't afford the repeat c-section? Would women start demanding that midwives be employed at their local hospital because they know that would be the best way for them to save money?

I just don't understand why insurance companies go along with paying for procedures and major surgery that wasn't even necessary. So if I don't choose the c-section that is just waiting there for me, can I just have the money? Or can I use it get the cosmetic surgery of my choice?

Shouldn't we all be complaining to insurance companies for covering surgeries and procedures that aren't medically necessary because don't our own premiums go up the more they have to pay to hospitals? Maybe instead of trying to educate women, we should try to educate insurance companies.
jennica,

:, to what you said about this, but don't think its going to happen in the real world.
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#4 of 52 Old 06-09-2006, 05:42 PM
 
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I totally agree with you Jennica. I got an itemized bill after my first baby and it was insane, $25 for one 800mg ibuproffen. And ITA about them not covering not medically indicated inductions and c-sections, but doctors would, as they do now, find something to say to explain how it is medically indicated. They already do this now all the time. Baby big, CPD, they can always come up with something.
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#5 of 52 Old 06-09-2006, 05:59 PM
 
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Originally Posted by mara
I totally agree with you Jennica. I got an itemized bill after my first baby and it was insane, $25 for one 800mg ibuproffen. And ITA about them not covering not medically indicated inductions and c-sections, but doctors would, as they do now, find something to say to explain how it is medically indicated. They already do this now all the time. Baby big, CPD, they can always come up with something.
jennica,

, to what Kimberly said to you. To bad if the doctors suggested to the patients, they should be paying for it instead. Also, for NICU patients as well, but don't think its going to happen in the real world.
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#6 of 52 Old 06-09-2006, 06:02 PM
 
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Unfortunately most of us end up paying for it anyway. Insurance premiums and co pays are ridiculous so much of the time. When I was working ft, we had BCBS which was not bad at all ($80/month for family), but when I started pt I lost my insurance and we had to pick up dh's...$287/month! Plus I don't think most insurance companies end up paying that much anyway - a lot of companies have deals worked out with the hospitals and doctors to only pay a certain percentage, I know this is the way BCBS works. Of course the amount YOU pay is a percentage of the original bill. :

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#7 of 52 Old 06-09-2006, 06:05 PM
 
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Unfortunately most of us end up paying for it anyway. Insurance premiums and co pays are ridiculous so much of the time. When I was working ft, we had BCBS which was not bad at all ($80/month for family), but when I started pt I lost my insurance and we had to pick up dh's...$287/month! Plus I don't think most insurance companies end up paying that much anyway - a lot of companies have deals worked out with the hospitals and doctors to only pay a certain percentage, I know this is the way BCBS works. Of course the amount YOU pay is a percentage of the original bill. :
jennica,

:, to what Kristen said to you.
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#8 of 52 Old 06-09-2006, 06:16 PM
 
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you know, I don't feel sorry for the insurance companies at all.

You know what's left off your itemized bill? Nursing care. We come with the room, just like the towels and the bendy straws. We cannot bill for our time, but the lab person who draws your blood can. One way for the hospital to recoup the cost of a pharmacy (in-house, 24 hours a day -- not cheap) and nursing care is to inflate the costs of things the insurance companies will pay for.

Besides, insurance companies don't pay the sticker price on hospital stays, only private pay patients do. Insurance companies pay their negotiated price, which is usually at least 40% lower.

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#9 of 52 Old 06-09-2006, 06:23 PM
 
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Originally Posted by maxmama
Besides, insurance companies don't pay the sticker price on hospital stays, only private pay patients do. Insurance companies pay their negotiated price, which is usually at least 40% lower.
Great, so they jack up the price for private patients.

On my hospital bill I got charged for Nursing care.

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#10 of 52 Old 06-09-2006, 06:29 PM
 
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Originally Posted by Belle
Great, so they jack up the price for private patients.

On my hospital bill I got charged for Nursing care.
It was declined/negotiated by your insurance company, I'm sure, because Medicaid and Medicare won't pay for nursing care inpatient and the majority of insurances will not pay for services that aren't covered by federal insurance. You can bill for anything you want, but having it paid for is another issue.

(There are exceptions that are required by state law, like BC and abortion are in WA, but this is a massive generalization.)

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#11 of 52 Old 06-09-2006, 06:29 PM
 
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Originally Posted by maxmama
Besides, insurance companies don't pay the sticker price on hospital stays, only private pay patients do. Insurance companies pay their negotiated price, which is usually at least 40% lower.
: In most cases, the payment to the hospital is negotiated at a specific level for each procedure regardless of what the itemized charges are. The only people who are expected to pay the full itemized bill are the uninsured. :

One important thing to remember is that it is not the insurance companies you should be feeling sorry for, it is usually the employer who is actually paying the bill. Most insurance companies only act as a third party administrator, and the employer is actually the one paying the bills. This is true for most medium and large employers. If you ever feel like ranting against the insurance companies, they are probably only doing what the employer has asked them to do. Employers can change who and what they cover.

The reason that most "elective" inductions and c/s are covered is that physicians indicate on the medical records and bills that it was medically necessary. If the Dr. says it is necessary, the insurance company cannot do much to disprove that.

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#12 of 52 Old 06-09-2006, 06:40 PM
 
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Originally Posted by maxmama
you know, I don't feel sorry for the insurance companies at all.

You know what's left off your itemized bill? Nursing care. We come with the room, just like the towels and the bendy straws. We cannot bill for our time, but the lab person who draws your blood can. One way for the hospital to recoup the cost of a pharmacy (in-house, 24 hours a day -- not cheap) and nursing care is to inflate the costs of things the insurance companies will pay for.

Besides, insurance companies don't pay the sticker price on hospital stays, only private pay patients do. Insurance companies pay their negotiated price, which is usually at least 40% lower.
But our pay is included with the room fee. I am not sure I get it. There is the price of the room per day which, at my hospital at least, covers the nursing staff, the supplies used except for the "exception" items (which I'm not sure how they decide which items are exceptions or not, regular pacifiers included with the room, purple preemie soothies charged different, pump kits included, breast shields not included, and so on), pharmacy items are charged seperate. We used to itemize but insurance companies will only pay $XX for the cost of the room per day so we just included everything in the price per day and don't itemize anymore, like we don't tell the insurance company we used 146 30cc syringes. Anyway. Probably way TMI

Otherwise I agree with what you are saying. I don't feel sorry for insurance companies either per se, but I think the whole system could use an overhaul.
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#13 of 52 Old 06-09-2006, 07:06 PM
 
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Yeah at $500+ a night for the room, I'd hope to goodness that wasn't just covering the cost of the sheets.
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#14 of 52 Old 06-09-2006, 07:28 PM
 
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less than a year ago my sister and I birthed baby boys 8 days apart inside a hospital. Although we both had health insurance (different kinds) I asked her to see the bill that was sent to her insurance company and compared it to mine just for kicks.

She had a routine birth that involved CFM, IV fluids, Epidural, etc. I also had a routine birth except I did not have an iv or even heplock, I didn't have CFM and I didn't have an epidural. I had no internventions of any kind during the birth (except a shot of pit in the leg afterwards, she had hers through iv). My birth had to have cost the hospital less than hers. She also had more medical staff involved with her birth. I had a doula and was pretty much left alone until the very end. In the labor/delivery section of our bills she had some extra charges for the epi and such. Then I had something called "other" which pretty much made up for it. Our bills were only a few dollars difference. I guess they figured they were going to get their money out of me no matter what. Not sure how "other" flies with insurance companies, lol...but it did.

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#15 of 52 Old 06-09-2006, 07:37 PM
 
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About the expensive medications...

You are paying for the doctor to write the order.
You are paying for the unit secretary to transcribe the order.
You are paying for the pharmacist to check if there are any possible interactions with other medications you may be taking.
You are paying for the pharmacy tech to deliver the medication to the unit you are on.
You are paying for the nurse to administer the medication according to the six rights of medication administration.
You are paying extra for the medication because it comes individually wrapped to prevent medication errors.
You are paying for the little plastic or paper med cup.

Thats why a $0.05 tylenol (or other inexpensive medication) can cost $15.00 for one dose.
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#16 of 52 Old 06-09-2006, 08:00 PM - Thread Starter
 
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I didn't mean to say that I feel sorry for the insurance companies. I meant that they are dishing out thousands and thousands of dollars, whether they are only paying a percentage or not, for procedures and surgeries that are totally elective. I'm not even talking drugs for pain, just the induction drugs and c-sections. I'm wondering why they do it. If c-sections are pushed in hospitals for fear of litigation, why aren't insurance companies who end up footing the bill refusing coverage? And as far as doctors making up medical excuses, I thought that was only to persuade the patients. I thought the recent reported increase in women supposedly choosing elective c-sections was skewed because they take the data off medical records which state "elective cesarean", which usually comes as a shock to the women who were told they had to have a c-section for some bogus reason by their doctors. So now I'm confused, are all the medical records that state "elective cesarean" actually elective cesareans and not just doctors pushing c-sections? Because I don't remember the percentage but it was high. If they were actually elective on the mother's part, that would explain the increase of c-sections, as recently reported, and refuted. And as far as employers choosing what is covered, the way I understand it is that employers choose a plan. Insurance companies provide the plans that can be chosen from, so they don't have to offer covering anything elective, they are just choosing to do so. I wonder if they know this and it benefits them somehow to cover elective surgeries, or if they are being totally scammed by the hospitals.
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#17 of 52 Old 06-09-2006, 08:35 PM
 
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Originally Posted by mara
But our pay is included with the room fee. I am not sure I get it. There is the price of the room per day which, at my hospital at least, covers the nursing staff, the supplies used except for the "exception" items (which I'm not sure how they decide which items are exceptions or not, regular pacifiers included with the room, purple preemie soothies charged different, pump kits included, breast shields not included, and so on), pharmacy items are charged seperate. We used to itemize but insurance companies will only pay $XX for the cost of the room per day so we just included everything in the price per day and don't itemize anymore, like we don't tell the insurance company we used 146 30cc syringes. Anyway. Probably way TMI

Otherwise I agree with what you are saying. I don't feel sorry for insurance companies either per se, but I think the whole system could use an overhaul.
this is a sore point for me, because this is a country that values people based on their visible cost/benefit ratio. You know as I do that nursing care is why people are hospitalized -- the 24-hour nursing assessment and care. By not pulling out our costs and saying, "This is the value of the nursing care you received", it both devalues nursing care (because if it was important they'd charge for it, right?) and creates the $500 room concept another poster referred to. Nurses' time is valuable as well as expensive, and I want it recognized as being valuable. Unfortunately, in this society it means you have to tack a dollar value on to it.

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#18 of 52 Old 06-09-2006, 08:37 PM
 
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Originally Posted by jennica
And as far as employers choosing what is covered, the way I understand it is that employers choose a plan. Insurance companies provide the plans that can be chosen from, so they don't have to offer covering anything elective, they are just choosing to do so. I wonder if they know this and it benefits them somehow to cover elective surgeries, or if they are being totally scammed by the hospitals.
Medium- and large-sized companies and local/state governments often self-insure. They're not then required to follow most rules of insurance provision in the state they're in and they do have an incentive to contain costs and to remove benefits.

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#19 of 52 Old 06-09-2006, 08:47 PM
 
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Originally Posted by maxmama
this is a sore point for me, because this is a country that values people based on their visible cost/benefit ratio. You know as I do that nursing care is why people are hospitalized -- the 24-hour nursing assessment and care. By not pulling out our costs and saying, "This is the value of the nursing care you received", it both devalues nursing care (because if it was important they'd charge for it, right?) and creates the $500 room concept another poster referred to. Nurses' time is valuable as well as expensive, and I want it recognized as being valuable. Unfortunately, in this society it means you have to tack a dollar value on to it.
maxamama,

:
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#20 of 52 Old 06-09-2006, 09:36 PM
 
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Originally Posted by maxmama
this is a sore point for me, because this is a country that values people based on their visible cost/benefit ratio. You know as I do that nursing care is why people are hospitalized -- the 24-hour nursing assessment and care. By not pulling out our costs and saying, "This is the value of the nursing care you received", it both devalues nursing care (because if it was important they'd charge for it, right?) and creates the $500 room concept another poster referred to. Nurses' time is valuable as well as expensive, and I want it recognized as being valuable. Unfortunately, in this society it means you have to tack a dollar value on to it.
I don't quite understand why nursing care is not covered. I agree that's the whole point of being hospitalized. When I had my dd in the hospital the nurses were easily the most positive aspect of her birth. My nurses were angels and I can't speak highly enough of them. But on my bill I was charged $1000 a night for my non-intervention birth. I'm wondering if my costs were inflated because I didn't require any interventions. This has got me thinking.

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#21 of 52 Old 06-09-2006, 09:49 PM
 
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Originally Posted by maxmama
It was declined/negotiated by your insurance company, I'm sure, because Medicaid and Medicare won't pay for nursing care inpatient and the majority of insurances will not pay for services that aren't covered by federal insurance. You can bill for anything you want, but having it paid for is another issue.

(There are exceptions that are required by state law, like BC and abortion are in WA, but this is a massive generalization.)
My mom is a NP and she bills Medicare...
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#22 of 52 Old 06-09-2006, 09:51 PM
 
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My mom is a NP and she bills Medicare...
NPs are independent providers. RNs are not. For billing purposes, NPs aren't nurses.

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#23 of 52 Old 06-09-2006, 09:55 PM
 
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I feel your pain. It's one of my big gripes. This has nothing to do with birth, but my dd2 has medical problems. She was tube-fed from 3-26 mos and each month we would get supplies for her feeding tube, a pump rental, other things. For a short time she was getting formula, too (special formula for her tummy problems).

Wanna hear some of the prices?

Feeding pump rental: $10/day*
Bags for feeding pump, one per day: $7 each
Syringes: $5 each at 4 per month
Extension tubes for g-button: $20 each at 4 per month
G-button: about $300 at one per 3 mos.
Formula: $3/8 oz can at 4 cans per day

*The rental pump was a cheap one that kept breaking. I exchanged it four times. It was also not portable. Finally with my doctor's persuasion they bought one for my dd that is tiny and fits in a backpack. The retail price is around $2000 but insurance paid almost twice that! The backpack for the pump was amost $200. It's just a small insulated backpack. Nothing special about it other than the pump fits in it nicely. The formula cost double through home health than if I had bought it at the store.

My dd's supplies came through home health, which was in charge of purchasing and delivering the supplies. They routinely charge double what the supplies actually cost and charge the full amount back to insurance. Not only does it cheat the insurance companies, but it also artificially inflates the lifetime benefits of the patients (many companies have a lifetime limit of how much they will pay for a patient and then they no longer will cover them).

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#24 of 52 Old 06-09-2006, 11:29 PM
 
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*The rental pump was a cheap one that kept breaking. I exchanged it four times. It was also not portable. Finally with my doctor's persuasion they bought one for my dd that is tiny and fits in a backpack. The retail price is around $2000 but insurance paid almost twice that! The backpack for the pump was amost $200. It's just a small insulated backpack. Nothing special about it other than the pump fits in it nicely. The formula cost double through home health than if I had bought it at the store.
Just curious what pump costs $2000? I know the Medela Lactina's retail for about $1000. The pump in style back pack goes for about $300-$350. It sounds like some prices were inflated here.

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#25 of 52 Old 06-09-2006, 11:35 PM
 
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Just curious what pump costs $2000? I know the Medela Lactina's retail for about $1000. The pump in style back pack goes for about $300-$350. It sounds like some prices were inflated here.
It's a feeding pump that delivers formula from a bag through a tube and into her tummy. It's similar to an IV pump in the way it functions. The bags must be replaced every 24 hours. There are two pumps: the Kanagroo Pet and the Zevex Enteralite. The Zevex is the one we own. The Pet is technically portable but not for a toddler or child. The Zevex was made with children in mind. Here's a pic of her wearing it at age 14 mos!

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#26 of 52 Old 06-10-2006, 12:15 AM
 
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Originally Posted by jennica

If insurance companies stopped covering inductions and c-sections that were not medically necessary how would that change things? Would women still be so eager to be induced because they are sick of being pregnant (or any other non-medical reason) when they knew they would have to pay for it, and pay for the c-section that may follow? Would they still go along with their doctor's non-medically based reasons for wanting to induce? Would they look into how to avoid a c-section if they knew it may not be covered? Would they stand up and fight their doctor when he wanted to push a c-section or induction for no clear medical reasons? Would doctors start learning quick how to deliver breech babies vaginally since a c-section is not medically indicated for a lot of breeches? Would doctors stop trying to scare women and force them into getting procedures done that the women would later be mad at the doctor for because she ended up having to pay for it? Would doctors start letting women VBAC because the women can't afford the repeat c-section? Would women start demanding that midwives be employed at their local hospital because they know that would be the best way for them to save money?
I can tell you that some insurance companies TRIED this sort of 'refuse to cover it' approach when VBAC became 'the thing to do'. Some insurance companies outright refused to cover an ERCS if mom didn't first undergo a TOL.

It backfired BIG TIME on them when they got their pants sued off by women who never wanted to attempt a VBAC in the first place ruptured and suffered the catastrophic consequences of either losing their uterus, losing their child, having a child that was permanently injured, and/or dying themselves.

Insurance companies quickly realized if they wanted to protect THEMSELVES from multi-million dollar lawsuits, they'd better leave the VBAC vs. ERCS issue up to the patient and physician, NOT the insurance company.

I can see the exact same thing happening if they ever tried to force a mother into delivering a breech vaginally as well.

I can assure you that most docs aren't out there putting down 'just for the heck of it' as the reason for induction and/or section. So how are the insurance companies supposed to determine who REALLY needed to be sectioned, who REALLY needed to be induced, and who is really lying about it, esp when all the coverage decisions are made after the fact?

The bottom line is that your routine vaginal delivery in a hospital today isn't really THAT much cheaper than a c-section anymore. Sure, the section costs a few thousand bucks more (at most, depending on what interventions are used during vaginal delivery). One huge $100 million lawsuit against the insurance company would negate any money they hoped to save for quite some time.
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#27 of 52 Old 06-10-2006, 01:18 AM
 
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Originally Posted by USAmma
It's a feeding pump that delivers formula from a bag through a tube and into her tummy. It's similar to an IV pump in the way it functions. The bags must be replaced every 24 hours. There are two pumps: the Kanagroo Pet and the Zevex Enteralite. The Zevex is the one we own. The Pet is technically portable but not for a toddler or child. The Zevex was made with children in mind. Here's a pic of her wearing it at age 14 mos!
Ah, I see. I was under the impression that it was a breast pump. My mistake. :

Heather Mike Married 8/1/99 Mom to Charlotte Aug 04, Nov 06, and Katherine Oct 07
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#28 of 52 Old 06-10-2006, 01:53 AM
 
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Insurance companies are making money hand over fist, they're not getting scammed. We the consumers are the ones getting scammed. Especially if you're poor and can't afford insurance as the costs are passed onto you if you self-pay.

anna kiss partner to jon radical mama to aleks (8/02) and bastian (5/05)
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#29 of 52 Old 06-10-2006, 11:55 AM
 
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Quote:
Originally Posted by jennica
I thought the recent reported increase in women supposedly choosing elective c-sections was skewed because they take the data off medical records which state "elective cesarean", which usually comes as a shock to the women who were told they had to have a c-section for some bogus reason by their doctors. So now I'm confused, are all the medical records that state "elective cesarean" actually elective cesareans and not just doctors pushing c-sections? Because I don't remember the percentage but it was high. If they were actually elective on the mother's part, that would explain the increase of c-sections, as recently reported, and refuted.
If a mother has a repeat c-section, either because of her choice (she didn't want to try to VBAC) or because of her doctor's advice (she had a classical incision, this baby is estimated 4lbs larger than the last one, whatever....), then that repeat c-section is classified as an "elective repeat." That might explain some of the statistics.
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#30 of 52 Old 06-10-2006, 12:22 PM
 
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Great thread! Maybe someone can explain this one:

With my first baby, we were charged a $1000 flat fee for "Nursery care". My baby was with me the entire time. I called the hospital to ask about it, and they told me that it was "standard procedure" for any newborn. So basically, I was paying for other women to have their babies kept in the nursery while they slept, while I was up every hour feeding and caring for my own. The insurance company paid for it as well! If I would have had to pay it, I would have fought it all the way and they wouldn't have seen a cent.
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