Today I am going to talk about insurance because it is often at the center of what services you can get for your child. Not all insurances are the same and not all coverage is the same. Knowing what your coverages are is extremely important when you are deciding what insurance plan you choose. Trust me the old saying of you get what you pay for is true when it comes to insurance so you have to do your research. What I am really saying is if you choose a plan that is cheap, you are going to get bad coverage. Making things worse is that when you deal with Medicaid plans, it is even different from state to state, they are not all the same. So my friends, where you live makes a huge difference in your services. I have touched on this before but I am going to do it again for people who have missed my old posts.
As many as you know, I am in the disabilities industry so I have information that most do not. This is another one of those things that I say is not widely advertised, and is not just given to people. The unfortunate fact is the people who work in customer service at the insurance companies often don’t even know their insurances coverage criteria or rules. I often tell people if you want to get to the truth you are often going to have to speak to a manager. The truth is also that customer service is a different department than authorization, so they just don’t know what they should. There are often arguments between medical suppliers and customers because the supplier often knows the rules and tells them to customers, yet when the customer speaks to customer service at the insurance they contradict it. This my friends puts the supplier and customer at odds, and makes the customer believe the supplier isn’t telling the truth. Let me tell you most of the time the supplier does know the truth because they have to if they want to get paid. Listen everyone, a supplier is not going to supply a service, or any medical equipment that costs them more to buy or supply then they are going to get reimbursed. The second part to this if if a supplier is able to sell something they want to sell it so if they tell you they can’t, there is a reason.
Just to keep this simple, if you go to a store to buy something and the cost is $50 then you should know the store you bought it from paid less than that or they would not sell it to you for that price. There are times that isn’t the case, like when they are trying to get rid of excess, or poor selling inventory but for the most part they won’t sell for less. So when it comes to insurance if they are only willing to pay $20 to a supplier for something the supplier has to pay $50 to purchase, you can see why the supplier won’t provide it. To put this is plain everyday English the insurance company makes the supplier a bad guy by telling a customer we pay for that product so not sure why they won’t provide it. Well maybe they should tell the customer they only want to pay half of what the product costs and tell them the truth. This thing is they won’t because they want you mad at the supplier not them, and if they were honest they know the customer is going to argue with them for it being their fault. Look people not any one of us would do this either we can’t take a loss like that and stay in business. Now the thought out there is that a supplier makes extra profit on other products and services so it makes up the difference. Well I am here to tell you that is blatantly false because the disability industry makes the lowest profit margins of everyone. Why is that, well because it isn’t really a cash market, and most of the money comes from insurance companies and not individual people. When we talk about retail business the prices are based on what people will pay, and the mark ups can be 200%. Don’t you wonder why they can keep dropping their prices and still stay in business, well that is why.
Now I am going to add another wrinkle to the problem. Insurance companies pay by diagnosis and allowable’s. so if you want a certain medical service of product, you need a diagnosis to qualify for that product or service. So to put this simply, if you want a CPAP machine, you need to be diagnosed with sleep apnea or an airway restriction. If you are not diagnosed with that then you don’t get that equipment paid for by insurance. The second part of that is if you want the top of the line CPAP machine, you likely won’t get it because the insurance companies allowable pays less that that machine costs the supplier, so they are going to offer you a machine that is less expensive to buy. To make this worse allowables are different from insurance company to insurance company and their contractual agreement with the suppliers. So one supplier may not get the same allowable as another so some suppliers may tell you that they can’t provide what you want because their allowable isn’t good.
Confusing right, well I have been in this industry for 13 years and the rules keep changing so it is hard for even me to keep up with everything. I am really trying to help people, and I do that everyday, I often say I could not work in my business if I didn’t care about what I do and who I do it for. I have said this before, if it weren’t for my children I would not do what I do because it is frustrating to deal with all these rules and regulations. Let me tell you almost everyone without fail in this industry does care about what they do because they often feel the same as I do. No not all of them understand everything we go through in a day but they do know the frustration of the industry so they often care more than you think.
Now I am not saying the insurance companies are evil because they have rules and they have budgets they have to follow. People really need to understand that money has to come from somewhere and it is not never ending. People make a big deal about politicians and how they can control this but it isn’t that simple. Medicare/CMS is in many ways more powerful than any one politician. It literally takes an act of Congress to get rules changed, so that is many politicians not just one. In all honestly they laugh at politicians because day to day they do what they want. Something else important you should know is Medicare makes the rules and then commercial insurance plans then say we follow Medicare guidelines, so basically they say we do what they do. Now when it comes to Medicaid there are only three states left that don’t follow Medicare guidelines, the rest of them do. That said some states have exceptions so they will cover extra but it isn’t common. The allowables are different between Medicaid as well.
In the end where you live and what insurance you have makes a huge difference. States that have a lot of state funding tend to be better places to be, so the north is often far better than the south. The trade off however is that those northern states are more expensive to live in so you have to consider this. There are however places in those expensive states where it is less expensive, you just have to go out and find them. This takes time and research so it isn’t an easy task. I could literally talk for hours on this subject because it is so complicated. My advice to everyone is spend the time, do research, and ask a lot of questions. As always this is not easy but there is help out there, look into case workers and autism centers for help, they often know the truth. What you don’t want to do is just do something quickly, because of you do, you might be very disappointed with your results.
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