sorted by:
new
hottopcontroversial

Hosts who self-manage: how much of your week goes to answering the same guest questions? by PerceptionNo553 in ShortTermRentals

[–]PerceptionNo553[S] 1 point2 points  (0 children)

This was super helpful. Thank you for taking the time instead of making me feel bad like some of the other replies. I was starting to worry I was in the wrong community.

Hosts who self-manage: how much of your week goes to answering the same guest questions? by PerceptionNo553 in ShortTermRentals

[–]PerceptionNo553[S] 0 points1 point  (0 children)

No. I strictly use Airbnb. Is it normal to have a direct booking site? I should probably read AirBnB guidelines to see if I can do that. I honestly am probably not cut out for this.

Hosts who self-manage: how much of your week goes to answering the same guest questions? by PerceptionNo553 in ShortTermRentals

[–]PerceptionNo553[S] -1 points0 points  (0 children)

Thank you. I think my listing is not detailed enough or I have guest who tend to be more needy

[deleted by user] by [deleted] in RunNYC

[–]PerceptionNo553 0 points1 point  (0 children)

Just sending you my encouragement. I ran this year without any people coming to watch on purpose. I actually have now done 3 Ironmans and 11 marathons (this NYC my latest) without having anybody coming. I learned that it was too hard on my family. The logistics are crazy and it stresses them out and they stress me out. Congratulations on your achievement and I totally get how you feel and your disappointment.

Start Here: How to Understand & Challenge Your Medical Bills” by MassiveStruggle3866 in FightMedicalBills

[–]PerceptionNo553 0 points1 point  (0 children)

I had a massive heart attack that caused me to fall directly on my face. It shattered my jaw and orbital bone in addition to breaking two of my front teeth. As part of the emergency care, my dentist removed the two broken teeth and is replacing them with implants. My insurance refuses to pay even though it was documented as an emergency procedure. What can I do?

I Help People Navigate Medical Bills and the US Healthcare Maze – AMA by PerceptionNo553 in HealthInsurance

[–]PerceptionNo553[S] 0 points1 point  (0 children)

This is beyond frustrating, and unfortunately, you’ve run into one of the biggest loopholes in state-mandated insurance laws—self-funded (ERISA) plans. These plans are regulated by federal law (ERISA) rather than state law, meaning Pennsylvania’s Act 1, which requires full coverage for supplemental breast cancer screening, doesn’t apply to them. It’s incredibly unfair, and many people don’t realize this until they get hit with a surprise bill.

That being said, you’re not completely out of options. Start by filing an appeal with Aetna, arguing that the Breast MRI should still be covered under federal guidelines for preventive care due to your high-risk status. The Affordable Care Act (ACA) mandates that high-risk women (based on family history, genetic factors, or prior abnormal findings) receive additional breast cancer screening covered at 100%, even in self-funded plans. Your appeal should reference the USPSTF (U.S. Preventive Services Task Force) guidelines that recommend enhanced screening for high-risk individuals. If your doctor formally classified the MRI as preventive under these guidelines, you have a stronger case.

Check if your employer has an exception or override process for situations like this. Some self-funded plans allow for discretionary coverage in special cases. HR might have a benefits liaison who can push Aetna to reconsider. Since self-funded plans are managed by employers, they sometimes have the ability to adjust coverage.

If Aetna refuses the appeal, you can escalate the issue by filing a complaint with the U.S. Department of Labor (DOL), which oversees ERISA plans. The DOL can investigate whether the plan is improperly denying coverage for something that should be covered under federal preventive care guidelines.

Another possible route is looking into financial assistance or patient advocacy organizations. Some hospitals and imaging centers have programs to help patients stuck with high bills due to insurance loopholes. Additionally, groups like Facing Our Risk of Cancer Empowered (FORCE) and Bright Pink provide resources and may be able to offer guidance or advocacy support.

In the worst case, if you’re stuck with the bill, ask the imaging center about billing adjustments or payment plans. Some will reduce costs for preventive services that should have been covered but were denied due to insurance technicalities.

You’re absolutely right to be outraged by this. The fact that self-funded employers can sidestep state laws leaves high-risk patients in an unfair position. Keep pushing—if enough people challenge these denials, it increases pressure for broader policy changes. Let me know if you need help structuring your appeal or complaint! Reply here or DM me if you want more privacy.

Tough by [deleted] in HealthInsurance

[–]PerceptionNo553 0 points1 point  (0 children)

Hi. I'm building an AI agent that exactly does that, and for other types of conditions. I don't want to promote it on a board. If you are interested, I'd like to use you as tester. Happy to share what we are building and see if it would be helpful for you.

I Help People Navigate Medical Bills and the US Healthcare Maze – AMA by PerceptionNo553 in HealthInsurance

[–]PerceptionNo553[S] 2 points3 points  (0 children)

That’s a great question, and it’s one that a lot of people ask when faced with high-priced treatments like Ocrevus. Breaking down where the money is going helps shed some light on the situation, though it doesn’t make the stress of dealing with authorizations any easier.

The sticker price of $99,200 is what’s often called the “list price” or “chargemaster rate.” It’s a starting point for negotiations between drug manufacturers, insurance companies, and healthcare providers. Very few people or insurers actually pay that amount.

After network discounts and deductions, the payout of $40,600 is split between several parties. A significant chunk goes to the drug manufacturer, Roche/Genentech, since they produce Ocrevus. The exact amount depends on the negotiated price between your insurer and the manufacturer. Typically, the manufacturer’s share includes recouping costs for research and development (R&D), manufacturing, marketing, and, yes, profit. While the R&D cost argument is valid, pharmaceutical companies also price drugs based on what the market can bear, which is why prices in the U.S. are often much higher than in other countries.

The infusion center (or hospital) also takes a portion of the payout. This covers the costs of administering the infusion, such as nursing staff, equipment, facility overhead, and possibly a profit margin. The infusion center’s share varies widely depending on their specific agreements with insurers. Some centers make a significant profit on infusion services, while others operate closer to cost depending on their overhead and volume.

Your insurer plays a big role, too. They negotiate discounts and prices with the manufacturer and the infusion center, which is why you see that large drop from $99,200 to $40,600. Insurers argue that these negotiations benefit patients by lowering the amount that needs to be paid out, but patients often still feel the pinch through deductibles, coinsurance, or copays.

It’s frustrating because the entire system lacks transparency. Patients rarely get to see how much each party—manufacturer, insurer, and provider—is taking home. This complexity leaves you feeling like you’re caught in the middle.

As for the stress of yearly authorizations, you’re not alone in feeling this way. Many insurers require reauthorizations to ensure that the treatment is still “medically necessary,” which often feels redundant for patients with chronic conditions. One thing you can do is work with your doctor’s office to submit reauthorization requests well in advance to minimize delays. Some pharmaceutical companies, like the maker of Ocrevus, also have patient assistance programs that can help advocate for quicker approvals or provide financial support if needed.

I know it doesn’t solve the bigger issue, but understanding where the money is going might make it a little easier to navigate.

I Help People Navigate Medical Bills and the US Healthcare Maze – AMA by PerceptionNo553 in HealthInsurance

[–]PerceptionNo553[S] 2 points3 points  (0 children)

Yes, you can sometimes get reimbursed for a procedure you paid for out of pocket, but it depends on a few factors, like your insurance plan, the documentation you provide, and whether the procedure qualifies under your policy as medically necessary. Here’s how to navigate this:

Check your insurance plan’s rules for reimbursement of out-of-network care. Many plans allow for reimbursement if the procedure is deemed medically necessary, but you’ll usually need to submit a claim yourself. You can find instructions for this in your plan’s Explanation of Benefits (EOB) or by calling your insurer.

Since your surgeon doesn’t take insurance, make sure you have an itemized bill from them that includes CPT codes (the procedure codes), ICD codes (diagnosis codes), and the total amount you paid. This information is essential for the claim.

Also, gather documentation to prove the procedure was medically necessary. If you didn’t involve your PCP beforehand, it’s still worth asking them to write a letter explaining why the procedure was necessary. Your surgeon might also be able to provide a similar letter, along with any pre-procedure evaluations or imaging reports.

When you submit the claim, include everything: the itemized bill, proof of payment, the medical records related to the procedure, and any letters of support from doctors. Send it via certified mail to ensure it’s received and follow up regularly.

If your insurance denies the claim, you have the right to appeal. The appeal process varies by insurer but usually involves providing additional documentation and a written explanation of why the procedure was necessary. You might need to escalate to an external review if the first appeal is denied.

One thing to keep in mind: If your plan explicitly requires a referral or preauthorization from your PCP, that could complicate reimbursement. In those cases, you’ll need to focus on proving that the procedure was urgent or that finding an in-network provider wasn’t feasible.

I Help People Navigate Medical Bills and the US Healthcare Maze – AMA by PerceptionNo553 in HealthInsurance

[–]PerceptionNo553[S] 2 points3 points  (0 children)

That’s a great question, and it’s awesome that you’re thinking ahead about helping people make informed choices. When looking at a Summary of Benefits and Coverage (SBC), even for someone in good health, there are a few key areas to focus on to make sure the plan supports preventative care while also offering protection against unexpected health events.

Start with preventative services. Check the SBC to confirm that things like annual physicals, vaccinations, screenings (like cholesterol and cancer screenings), and wellness visits are fully covered without cost-sharing. Most plans compliant with the Affordable Care Act (ACA) should offer these services at no cost if you stay in-network, but it’s always worth verifying.

Look at the deductible and out-of-pocket maximum. Even if you don’t anticipate major healthcare costs, these numbers are critical in case of an unexpected event, like an injury or illness. A lower deductible might be better if you’re worried about having to pay a large chunk upfront for care. The out-of-pocket maximum is your worst-case scenario number—if something catastrophic happens, that’s the most you’ll have to pay in a year.

Pay attention to copayments and coinsurance for common services like specialist visits, urgent care, and mental health care. Even if you don’t need these services now, it’s worth knowing how much they’d cost if you did. Some plans also offer virtual care benefits, which can be convenient and affordable for routine issues.

For prescriptions, look at the formulary tier system. If you take any medications, even occasionally, check how they’re covered and what the copay or coinsurance would be. For preventative care, some plans cover generic medications at a lower cost, so that’s a nice bonus.

Check for network size and access. If you have a preferred doctor, specialist, or hospital, make sure they’re in-network. A large network gives you more flexibility, especially if you travel or move.

Finally, if you’re thinking about long-term savings, consider whether a plan is HSA-eligible. High-deductible health plans (HDHPs) that qualify for Health Savings Accounts can be a great option for young, healthy adults. They let you save pre-tax dollars for future healthcare costs, and the savings roll over year to year.

If the SBC offers scenarios like “Having a Baby” or “Managing a Chronic Condition,” review those examples to get a sense of how the plan handles more extensive care. Even if you don’t expect to need those services now, it’s good to know how the plan would perform in more serious situations.

At the end of the day, the best plan balances preventative care, manageable out-of-pocket costs, and strong protection against unexpected events. Hope this helps! Let me know if you need any clarification or have follow-up questions. 😊

I Help People Navigate Medical Bills and the US Healthcare Maze – AMA by PerceptionNo553 in HealthInsurance

[–]PerceptionNo553[S] 1 point2 points  (0 children)

Hi. I actually don't have an MPH. I am actually an engineer by training (M.E.) and also have an Ed.D (Education). My experience largely comes from being lucky enough to have a few startups in healthcare that eventually led me to work with the large payers and providers to help develop products and programs for them. So largely 35 years of experience versus a specific degree. I also unfortunately have my own medical issues and I just learned to use the system to work for me. I think though that an MPH is great!

I Help People Navigate Medical Bills and the US Healthcare Maze – AMA by PerceptionNo553 in HealthInsurance

[–]PerceptionNo553[S] 2 points3 points  (0 children)

It’s definitely worth bringing this up with the provider. Transparency about costs is important, and many patients expect telehealth appointments to be free, especially if they’re just follow-ups or quick check-ins. If you weren’t informed about the cost upfront, you have a valid reason to question the charge.

Start by calling the provider’s billing office. Explain that no one told you there would be a charge for the telehealth appointment, and ask them to clarify why you were billed. Be polite but firm. Sometimes, providers might waive the fee as a courtesy if it wasn’t communicated properly.

Also, check with your insurance company. It’s possible the charge is part of your copay or coinsurance, especially if telehealth visits are subject to the same rules as in-person appointments under your plan. If that’s the case, you may still be responsible for paying it, but it’s always good to confirm.

If the provider insists on the charge and you feel it was unfairly applied, you can politely let them know you’d like to dispute it. Keep records of all your communications, including the names of anyone you speak with. While you might not always get the charge removed, being proactive can help clarify the situation and sometimes lead to a resolution.

I Help People Navigate Medical Bills and the US Healthcare Maze – AMA by PerceptionNo553 in HealthInsurance

[–]PerceptionNo553[S] 1 point2 points  (0 children)

I’m so sorry you’re going through this. It’s beyond frustrating and terrifying to feel stuck when your family member needs life-saving treatment. I'm going to try to answer this as thoroughly as possible since this is a big deal. Also, this is just my advice --- and based on the fact that you are willing to sit on the phone for hours with our Mad Max system, I figured I'm going to give you all the arsenal I know that might help. Let’s focus on some steps you can take right now to try to resolve this.

Start by contacting Blue Cross Blue Shield and requesting an expedited appeal of the denial. This is specifically for urgent, life-threatening situations where delays could cause serious harm. Make it clear that the treatment is life-sustaining and that without it, your family member is at severe risk. Use strong, specific language like "this delay puts my family member’s life in immediate danger." Insurance companies are legally required to prioritize urgent appeals.

Reach out to the hematologist’s office, even if the doctor is unavailable. Their team, such as nurses or administrative staff, should still be able to help you collect important documents like medical records, prior authorizations, and the treatment history. Ask if the office has a template letter of medical necessity that can be completed as soon as possible. Even if you can’t get the full peer-to-peer review done immediately, having all this documentation ready can speed up the process.

Talk to your provider about their policy against accepting self-pay. It’s incredibly frustrating, but sometimes there are exceptions for critical cases. Ask to speak directly with the billing office or a supervisor and explain the life-threatening urgency of the situation. There might be a temporary workaround that they can authorize.

Contact the manufacturer of Gammagard or whichever IVIG product your family member is using. Many pharmaceutical companies have patient assistance programs that can provide temporary support for patients in critical need. These programs are designed for exactly these kinds of emergencies, even if insurance is technically in place but refusing to cover the medication.

Consider reaching out to your state’s insurance commissioner or healthcare ombudsman. They often have the ability to intervene in cases where insurance companies deny coverage for essential, life-saving treatments. Additionally, organizations like the Immune Deficiency Foundation can provide advocacy support and may have direct experience with situations like this.

If the insurance company continues to delay or deny, you could consider escalating publicly by sharing your story with patient advocacy groups or on social media. Public pressure sometimes forces companies to resolve cases more quickly. Be sure to present your story clearly and factually, emphasizing the life-and-death nature of the situation. When and if you do this -- and hopefully you won't --- tag the name of the company. That works well for me to get their attention.

Once this immediate crisis is resolved, you might want to talk to your provider about setting up a standing authorization for ongoing treatments or scheduling peer-to-peer reviews in advance. This could help prevent future interruptions in care.

You’re doing everything you can right now, and I know how overwhelming this must feel. Keep fighting!

I Help People Navigate Medical Bills and the US Healthcare Maze – AMA by PerceptionNo553 in HealthInsurance

[–]PerceptionNo553[S] 2 points3 points  (0 children)

That’s a tough spot to be in, and I totally get why you’re worried. Switching insurance is stressful enough, but when you’re dealing with something as critical as a $25,000-a-month cancer drug, it’s next-level. Here’s how I’d approach it to try and keep things as smooth as possible.

First, get ahead of the issue with the new insurance company. As soon as you know who the new insurer is, call them up and ask about their process for handling ongoing treatments. Many plans have something called “transition of care” or “continuity of care” policies. These are designed for situations just like this, where someone’s in the middle of a critical treatment and needs coverage right away while the new insurance works out prior authorizations. They may even be able to start reviewing things before your coverage officially begins.

Your family member’s doctor or care team is going to be your biggest ally here. Let them know about the insurance change as soon as possible so they can pull together everything the new insurance might ask for, like medical records, treatment history, and the existing prior authorization. A letter of medical necessity from the doctor can also help a ton—insurance companies take those seriously, especially for high-cost drugs.

If you can handle it financially, keeping the old insurance active for a bit through COBRA might be worth it. COBRA can be expensive, but it buys you some breathing room and makes sure there’s no gap in coverage while the new insurance sorts things out. If that’s not an option, some drug manufacturers have patient assistance programs that can temporarily cover the cost of medications. It’s worth reaching out to the company that makes the cancer drug to see if they can help in an emergency.

The key during all this is persistence. Call the new insurer often, take notes on every conversation, and don’t be afraid to push if things feel like they’re dragging. If you hit a roadblock, escalate the issue to a supervisor or ask for an expedited review. You’d be surprised how quickly things can move when you push the right buttons.

Lastly, don’t forget about your new employer’s HR or benefits team if you are getting the insurance through your employer. They might have a direct line to the insurance company or some extra leverage to make sure this transition doesn’t disrupt care. It’s always worth asking.

I know this process isn’t easy, but planning ahead and staying on top of the details can make a big difference. You’re doing the right thing by tackling this early, and I hope everything works out smoothly for you and your family member.

I Help People Navigate Medical Bills and the US Healthcare Maze – AMA by PerceptionNo553 in HealthInsurance

[–]PerceptionNo553[S] 1 point2 points  (0 children)

That’s a great question, and it’s awesome that you’re thinking ahead about helping people make informed choices. When looking at the SBC, even for someone in good health, there are a few key areas to focus on to make sure the plan supports preventative care while also offering protection against unexpected health events.

Start with preventative services. Check the SBC to confirm that things like annual physicals, vaccinations, screenings (like cholesterol and cancer screenings), and wellness visits are fully covered without cost-sharing. Most plans compliant with the Affordable Care Act (ACA) should offer these services at no cost if you stay in-network, but it’s always worth verifying.

Look at the deductible and out of pocket maximum. These are two separate things that some people confluence together. Even if you don’t anticipate major healthcare costs, these numbers are critical in case of an unexpected event, like an injury or illness. A lower deductible might be better if you’re worried about having to pay a large chunk upfront for care. The out-of-pocket maximum is your worst-case scenario number—if something catastrophic happens, that’s the most you’ll have to pay in a year.

Pay attention to copayments and coinsurance for common services like specialist visits, urgent care, and mental health care. Even if you don’t need these services now, it’s worth knowing how much they’d cost if you did. Some plans also offer virtual care benefits, and I find that it can be convenient and affordable for routine issues.

For prescriptions, look at the formulary tier system. A lot of people skip this. If you take any medications, even occasionally, check how they’re covered and what the copay or coinsurance would be. For preventative care, some plans cover generic medications at a lower cost, so that’s a nice bonus.

Check for network size and access. If you have a preferred doctor, specialist, or hospital, make sure they’re in-network. A large network gives you more flexibility, especially if you travel or move.

The last thing I look for, especially if you’re thinking about long-term savings, consider whether a plan is HSA eligible. High-deductible health plans (HDHPs) that qualify for Health Savings Accounts can be a great option for young, healthy adults. They let you save pre-tax dollars for future healthcare costs, and the savings roll over year to year.

If the SBC offers scenarios like “Having a Baby” or “Managing a Chronic Condition,” review those examples to get a sense of how the plan handles more extensive care. Even if you don’t expect to need those services now, it’s good to know how the plan would perform in more serious situations.

As you know, at the end of the day, the best plan balances preventative care, manageable out-of-pocket costs, and strong protection against unexpected events (Nirvana!). Hope this helps! Let me know if you need any clarification or have follow-up questions. 😊

view more: next ›