“No one told us about this basement thing.”

From the AP:

Superstorm Challenges Basement Definition

Irene Sobolov thinks the first floor of her house is just that. The federal government and her insurance company say it’s a basement.

The semantics, Sobolov has learned, are very expensive.

Sobolov and others whose lower-level apartments or businesses sustained water damage during Superstorm Sandy say the property they own is being classified as a basement, severely limiting what is covered under the National Flood Insurance Program.

“It’s the battle of the definitions,” said Sobolov, standing on concrete that a wood floor once covered. She says the damage to her home came when the sewer overflowed, sending a repellent brew of sewage, condoms and garbage water up through her toilet and drain. “No one told us about this basement thing.”

The basement classification has become a point of contention in Hoboken, a city of 50,000 across the Hudson River from Manhattan. Hoboken sustained major flooding when the Hudson jumped its banks and roared into the city during Superstorm Sandy, one of the strongest storms to ever hit the area. It is one of the densest cities in the country, and there are about 1,700 below-ground units that house people or businesses, according to Mayor Dawn Zimmer.

A spokesman for Senator Frank Lautenberg said people whose homes or businesses were classified as a basement are eligible for grants that are part of the $50.7 billion Sandy aid package approved by the House of Representatives Jan. 15. It is unclear how much will be allocated or what the rules will be.

While there may be some relief coming, the classification is leading some to call for changes to the National Flood Insurance Program, saying the basement definition unfairly punishes people who own property in cities.

The flood insurance rules “do not reflect the reality” of urban living, Zimmer told Congress last month.

“A store or apartment that requires you to walk down one or two steps is plain and simply not a basement,” Zimmer told the Senate Committee on Small Business and Entrepreneur-ship.

“For many people, that’s their primary residence. It’s where they have the kitchen, the bedroom,” Zimmer said in an interview. “It’s their home.”

Sobolov said she is challenging the assertion that her home was flooded because of her claim that what came up through the toilet and drain damaged her home. But because the insurance company declared her home flooded, she is also fighting the basement classification. There was about a foot of water and sludge in her home.

She and her husband have owned the home for 12 years and pay about $2,500 a year in flood insurance, Sobolov said.

“They collect our money for 12 years and only now it’s, ‘Oh, I forgot to tell you, we don’t cover you?’” she asked.

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89 Responses to “No one told us about this basement thing.”

  1. Mike says:

    Good Morning New Jersey

  2. grim says:

    Hat tip to Mike for the link

  3. grim says:

    From the Star Ledger:

    Nearly $400M in FEMA funds given to N.J. so far in Sandy’s aftermath

    About $400 million in aid from the Federal Emergency Management Agency has been sent to New Jersey since Hurricane Sandy hit nearly three months ago, data obtained from the state and federal governments show.

    The data is an early snapshot of what is forecast to be a Herculean recovery effort for the Garden State, which suffered a reported $36.9 billion in damage.

    Many property owners are still sorting through piles of paperwork and tattered belongings, while hard-hit towns are trying to close out cleanup efforts in order to focus on larger recovery issues.

    As the bills pour in, so do the aid requests to FEMA.

    More than $332 million has already been given to individuals involved in a slew of FEMA programs, including those that subsidize rent and hotel stays.

    And about $64 million have been paid to 98 municipalities, state departments and public entities, many of which are repaying debts incurred in Sandy’s aftermath.

    “It all went to cleanup,” Middletown Mayor Gerard Scharfenberger said of the $2.3 million his township received from FEMA. “You name it, and it had to be addressed.”

  4. grim says:

    From the Daily Record:

    New reality for middle class is uncertainty

    Four years ago Neda Donlin’s layoff seemed like both a blow and a blessing. After 12 years with a company as a project manager, she got a severance package.

    “I was head of household so we lost almost two-thirds of our family income,” said the 40-year-old, who has an engineering degree. “That was a big hit as far as our bills went.”

    On the other hand, she’d just had her first daughter six months earlier and liked not having to fly to New Zealand for business on a few days’ notice. Donlin figured she’d spend time with her daughter and look for a local job.

    “There are so many businesses in Parsippany but, for some reason, I can’t seem to find one,” she said. “As time goes on, it just becomes harder and harder.”

    Today, the Lake Hiawatha couple has a second daughter. Donlin has almost exhausted one of her 401K accounts. Her unemployment benefits last another 16 weeks. Whenever she goes to buy anything, she asks herself whether she needs or wants it.

    She hadn’t expected this life.

    The nature of, and demand for, paid work is changing and with it the standard of living formerly known as middle class. The transition in Morris County, as elsewhere, is not pleasant.

    Donlin is one of 4.8 million Americans who’ve been out of work more than six months. According to the U.S. Department of Labor, last month they accounted for 39.1 percent of the unemployed.

    Twenty-three percent of Morris County households – 40,753 – are struggling, according to a report issued by United Way of Northern New Jersey last August. Included in the statistic are those households whose incomes fall below the federally defined poverty line and so-called ALICE households that earn too much to be considered poor but too little to afford basic necessities.

    The ALICE acronym stands for Asset Limited, Income Constrained, Employed.

    Last year the Interfaith Food Pantry, based in Morris Plains, served more than 12,000 people by supplementing their groceries. It distributed 741,000 pounds of food—an 8 percent increase over 2011, according to spokesperson Carolyn Lake. Traditional populations, such as homebound seniors and minimum-wage earners, continue to use the pantry.

    “But over the past year we’ve been seeing people in their fifties who were formerly middle class but had been laid off,” Lake said. “Those administrator jobs are just not there anymore. These people have exhausted their savings, and may be paying two thousand dollars a month to COBRA.”

    Meanwhile, at the Morris County Office of Temporary Assistance there’s been a 163 percent increase in the number of households enrolled in the Supplemental Nutrition Assistance Program, still popularly known as Food Stamps.

  5. grim says:

    Everybody down in Washington for the inauguration?

  6. chicagofinance says:

    probably shore guy …..

    grim says:
    January 21, 2013 at 8:20 am
    Everybody down in Washington for the inauguration?

  7. Chuchundra says:

    I’ve personally hear a lot of those “Oh, that’s a basement” stories here on Long Island as well. If your firs floor is even a half inch below grade then it’s technically a basement.

  8. Mike says:

    4 Supposedly Morris is the eighth wealthiest county in the United States and 23% households are struggling?

  9. Fabius Maximus says:

    #4 grim

    One comment that sums up a lot of issues and is at the core of the problem.

    “and may be paying two thousand dollars a month to COBRA.”

  10. grim says:

    On one end you have: Dover, Wharton, Mine Hill, Victory Gardens, Mount Olive, Jefferson, Boonton, etc.

    And on the other you have:
    Madison, Chatham, Mendham, Harding, Mountain Lakes, Montville, etc

  11. The Original NJ ExPat says:

    Looks like someone “leaked” the secret ingredients of that LI Surge Protector beer.

    a repellent brew of sewage, condoms and garbage

  12. yome says:

    And no one Politician is willing to go head to head against the rising cost of health care.The solution, cut the entitlement of the elders. Cutting entitlement will not sole anything if cost is not controlled.The problem is the cost.This is where we need open trade.Let pepole buy health care needs in a country they can afford and medicare pay for it.Open the border for Doctors willing to be trained in the US and practice,to compete with locals.We just need to get a our health care cost inline with other develop countries.It is not the elders that is the problem.

    I forgot,they have a strong lobbyist

    “and may be paying two thousand dollars a month to COBRA.”

  13. The Original NJ ExPat says:

    And Rockaway Township, the biggest in MC by area, runs the gamut of incomes. I guess Morristown does too.

    On one end you have: Dover, Wharton, Mine Hill, Victory Gardens, Mount Olive, Jefferson, Boonton, etc.

    And on the other you have:
    Madison, Chatham, Mendham, Harding, Mountain Lakes, Montville, etc </i?

  14. Painhrtz - So Long and Thanks for all the Fish says:

    Dope is probably down there with knee pads on hoping to stimulate the Chairman O’s “economy”
    yome there are a multitude of ways to fix healthcare in this country first and foremost is getting the government out of it. State and federal mandates add just as much to the cost of healthcare as malpractice. Get doctors out of the CYA business. I get persistent throat infections since I still have my tonsils will go to the doctor for antibiotics as I can see the tell tale colonies at the back of my throat and they still order 400 bucks worth of lab tests. Worse for the truly ill. Telling grandma she is going to die and 50K worth of treatment to extend her by 2 months is not necessary either. It is an awful thing but reality is just that.

  15. The Original NJ ExPat says:

    Hoboken should just pull a reverse Woodland Park and rename the town West Manhattan. RE values would rise as rubes from the midwest moved in as the last wave of fools and then they could really jack their taxes.

  16. The Original NJ ExPat says:

    I remember about 20 years ago when Howard Stern was giving Tori Spelling a test to see how bright she wasn’t. One of the questions was, “What is the capital of New York?”. Her answer: “New Jersey?”

  17. yome says:

    Pain,
    All other develop countries offer socialized health care and yes government did not get out of the way and they are doing fine.We pay more on everything from medicine to hospitals. Maybe we can look at the monopoly we are giving drug companies due to patent rules.We need to be able to negotiate drug prices just like other countries.Test are being done too in other countries but at a fraction of the cost we pay.It is not the Government that is the problem,it is the rules that were incline better for the hospitals,doctors and drug companies.Revisit this rules? I favor open trade health care and let medicare pay for procedure.A person should be able to by his drugs outside the country with a doctors prescription in a practical amount and drugs not being confiscated at the border

  18. grim says:

    Speaking of our bullshit healthcare system. Why the hell are so many doctors in hospitals not participating in any insurance programs?

    Got a whopper of a bill from the neonatologists, 5 figures. Coverage from my insurance? Zero. Coverage from the secondary? Zero? Huh? What do you mean insurance doesn’t matter? I wasn’t given a choice, nobody told me that they were non-participating (I asked), nobody informed me of these costs before hand. How is this legal?

    Talked to the neonatology group, who do you accept? Nobody was the answer. Wait a minute, you staff the neonatology group in the local “children’s hospital” and you don’t accept any insurance?

    What the hell is the point of insurance? And not one plan, but two separate plans.

    Talk to insurance, they are doing their darnedest to be completely unhelpful. Appeal. Sure. 3 separate faxes later, and a mail-in, and they have yet to even acknowledge the appeal. Clearly they try to make this process as complex as possible to try to get as many of their “customers” to self-pay. And this appears to be one of at least 20 appeals I’ll submit. Nobody actually accepts insurance?

    Should have just made up names and claimed we were illegals from Eastern Europe.

  19. The Original NJ ExPat says:

    Pretty soon these people will wise up, quit their jobs, and get on the public dole and experience worry-free, full benefit lifestyles. They might even hang signs outside their homes saying “ALICE doesn’t live here anymore.”

    Twenty-three percent of Morris County households – 40,753 – are struggling, according to a report issued by United Way of Northern New Jersey last August. Included in the statistic are those households whose incomes fall below the federally defined poverty line and so-called ALICE households that earn too much to be considered poor but too little to afford basic necessities.

    The ALICE acronym stands for Asset Limited, Income Constrained, Employed.

  20. Jill says:

    Yo #12: Why not just open up ethical suicide parlors if what you’re saying is “kill off all the old people”?

    I would say that the answer is to get the insurance industry out of the middle. Aside from catastrophic coverage, what value-added does the insurance industry provide? They take their cut and drive up overall costs. Insurance company CEOs and high level executives get ridiculous salaries and provide what kind of value?

    When I got out of college I was making $8500/year. My health insurance did not pay for regular checkups and I had a $100 deductible. None of this copay nonsense. A doctor visit was reasonably priced and I could make two or three payments if I had to. Insurance only kicked in if I were SICK — such as an abnormal pap, or a cold, or whatever. And I was able to pay my doctor bills. Now you have $20 copays and everyone goes to the doctor for the sniffles. Get this parasitical industry out of it and you’ll go a long way towards addressing both quality of care AND costs.

  21. The Original NJ ExPat says:

    Were the neonatology services in the basement? If so, not covered.

    -Sorry, couldn’t resist. Maybe you can take a page out of the insurers handbook. Write them a check for $200 and include a note telling them that’s what you consider reasonable and customary charges for neonatal services.

    Got a whopper of a bill from the neonatologists, 5 figures. Coverage from my insurance? Zero. Coverage from the secondary? Zero? Huh? What do you mean insurance doesn’t matter? I wasn’t given a choice, nobody told me that they were non-participating (I asked), nobody informed me of these costs before hand. How is this legal?

  22. yome says:

    One payer system will be my best choice. Seeing a doctor everytime you ha veva sniffle is not the problem. Primary Doctors gets paid either you see them or not and the co pay helps. Problem is when you need real care like hospitals and medication.

  23. grim says:

    I told the neonatal folks they would see me in court before I paid.

    Sorry, but why does this feel like a complete scam? It’s like the driveway contractors that go door to door, give you a good price, than at the end of the job have the 280lb monster come over, hand you over a bill for four times the estimate claiming they had to do additional work that was unexpected. Tattoo on his hand reads: F*ck you, pay me.

  24. grim says:

    And how does $4,000 a day make any sense at all for the doctor? We spent days in the NICU/Intermediate, the doctor came around once a day, maybe 15 minutes. What’s that come down to, $16,000 an hour? Should have became a neonatologist.

    You know, it’s for the kids.

  25. Painhrtz - So Long and Thanks for all the Fish says:

    Grim had the same problem with ours. Whole neonatal care was farmed out unbeknownst to us all of a suddent he bills start rolling in. Wife spent the better part of the year conducting appeals getting letters written yada, yada yada. kids are creaping in on a year old and the last check was finally mailed out. total cost was over 5 figs we got it down to a couple grand. It was f*cking ridiculous. Especially when you consider we cleared everything with insurance to make sure all was covered, and it was the physical hospital. All of their independednt contactors well you know the rest of that story.

    just keep your head up and continue working with inusrance. They are set up for you to give up, the billing physicains can help also as you are probably not the first person going through this. If your persistent like you were with housing the bill will be much less, though still ridiculous.

  26. nwnj says:

    #17

    Grim, was it midatlantic? Same thing happened to us at St Clare Denville. It should be illegal.

  27. yome says:

    We pay the highest in health care and ranked 37th in life expectancy from 35th.Japan is number one . Even Cuba has longer life expectahcy than us.And the politician says we are living longer

  28. nwnj says:

    #27

    What is your point other then being a drone? US is a stratified society, you’ll have to look a bit deeper to get real number and not an average.

  29. nwnj says:

    “than”

  30. Juice Box says:

    re # 22 – Out-of-network, I feel for ya Grim. Every single time I go near a hospital I dread running into an out-of-network Doctors. The Doctors claim they don’t participate due to low reimbursement rates, but if you compare what they bill you directly for services you will see they are running a racket based upon the need for emergency services. Not to say that the insurance companies aren’t a racket either. Either way the patient here is a pawn.

    Your best bet is to get your company’s HR dept involved, if the Hospital was
    In- Network according to NJ laws your insurance company has to pay them.( I am no lawyer, and this if what I have heard from my own HR dept.) I would
    have your HR Dept call up their sales people from the insurance company to press the issue internally if necessary.

  31. chicagofinance says:

    grim: Consider it outsourcing. Instead of the doctor staffing up to deal with insurance companies, they outsource the brain damage to you. If the revenue number is finite per patient (or even dropping), and costs are rising (administrative and liability insurance), then the only thing to do is see more patients (reduce quality of service) or else reduce costs (outsource insurance company brain damage to you)…….

    Painhrtz – So Long and Thanks for all the Fish says:
    January 21, 2013 at 10:32 am
    Grim had the same problem with ours. Whole neonatal care was farmed out unbeknownst to us all of a suddent he bills start rolling in. Wife spent the better part of the year conducting appeals getting letters written yada, yada yada. kids are creaping in on a year old and the last check was finally mailed out. total cost was over 5 figs we got it down to a couple grand. It was f*cking ridiculous. Especially when you consider we cleared everything with insurance to make sure all was covered, and it was the physical hospital. All of their independednt contactors well you know the rest of that story.

    just keep your head up and continue working with inusrance. They are set up for you to give up, the billing physicains can help also as you are probably not the first person going through this. If your persistent like you were with housing the bill will be much less, though still ridiculous.

  32. chicagofinance says:

    Freedom of speech….as long as it is OK with us….

    For whatever reason, the organizers behind last night’s StartUp RockOn Inauguration Celebration in DC decided to invite a rapper who once called President Obama “the biggest terrorist” to headline their event.

    According to reports, the aptly named Lupe Fiasco performed 30-minutes of a verse from his anti-war song “Words I Never Said” before being escorted off the stage by security because he refused to move onto another song.

    Josh Rogin, staff writer for The Cable, described the encounter via tweet. “So Lupe played one anti-war song for 30 min and said he didn’t vote for Obama and eventually was told to move on to the next song.”

    He continued, “Lupe refused to move to the next song so a team of security guards came on stage and told him to go.”

    The party’s organizers insisted Fiasco was not booted for rapping over and over, “Gaza strip was getting bombed, Obama didn’t say [bleep] / That’s why I ain’t vote for him, next one either.”

    HyperVocal, one of the companies involved with the event, responded to the incident with an official statement.

    “Lupe Fiasco performed at this private event, and as you may have read, he left the stage earlier than we had planned. But Lupe Fiasco was not ‘kicked off stage’ for an ‘anti-Obama rant.’ We are staunch supporters of free speech, and free political speech.”

  33. Fabius Maximus says:

    #14 pain

    I refer you back to my previous answer on CYA.
    http://njrereport.com/index.php/2012/01/24/mortgage-settlement-near/#comment-495538

  34. Willow says:

    Long time reader – haven’t posted in a very long time.

    Grim,

    We’re going through something similar – son hurt his back during swim practice last Monday, took him to the ER and they want him to see a neurologist. The neurologist they sent his records to does not take our insurance. Neither do the four other neurologists we called. While we can submit the bills to our insurance, they won’t pay anything close to what the doctors will bill and then we’ll be stuck paying the difference. We do have Bollinger’s and they should pay for the difference since he was injured while participating in a school sponsored sport but we can’t know until we submit claims. We took him to a pediatric orthopedist he’s been to before and he told us most neurologists don’t take insurance and so now we’re taking our son to an orthopedist who specializes in the spine who does take our insurance. This should be okay because the resident neurologists he saw in the ER did not see his injury as one requiring surgery but we shouldn’t have to make these choices.

  35. freedy says:

    Speaking now is poet Richard Blanco. He is the first Hispanic & openly gay American to deliver the inauguration poem.

    This is what it’s come to in America.

  36. gryffindor says:

    I’ll add a small perspective, working on the other side (though I am not a physician). When you call my office, I have no idea if I accept “Horizon.” There are like 100 different permutations of Horizon. Some allow you to go out of network, some don’t. If I call Horizon, they do not have a clear breakdown of the 100 permutations and what each one covers and doesn’t cover so that I can educate myself and then help educate you. It all depends on what plan your employer picked. There is a number for providers to call, but good luck getting a human based in the US who can help you.

    Then there is almost no training on how the heck I am supposed to bill and insurance company for what I did. I look at you and tell you your problems = Exam = $50. Insurance company wants me to write a code corresponding to 10 different kinds of exams, will only cover certain kinds exams certain times per year, etc. I went to school and residency for a long time, but coding and paperwork are not taught in medical school. I am supposed to fill out a piece of paper with some codes and fees and then wait for the insurance company to send me a check. If they don’t send a check, then I get to chase the patient. At this point, the patient is mad that I am chasing them because in their mind, the exam was supposed to be “covered.” So now the insurance company has pit me against the patient. Again, it’s not like I log into a magical section on the Horizon website where I will clearly know which exam is covered and what is not covered.

    I could hire an army of people to chase Horizon to figure out exactly which exam is covered to ensure we will get paid. Now I have become an employer managing employees who are doing tasks that have nothing to do with the patient’s exam, only the payment end of the exam.

    The easiest solution for me is to cut this middleman crap and not take insurance. Some people will stay and pay me the $50, some won’t. But I work in an elective field so I can turn people away without feeling bad. Neonatolagy is a little different so I’m sorry you are going through this grim.

  37. Libtard working from home (sleep deprivation has left me with an annoying sore throat and cold) says:

    Pretty soon, I expect some entrepreneurial doctors to offer a la carte healthcare with some strong malpractice disclaimers that the patient must sign. I’m surprised some haven’t gone this route already.

    I love that my children’s pediatricians are the type who tend to let things heal on their own. All three doctors there are no-nonsense. I doubt any of them drive German cars either. Best example was Gator Jr’s instep which developed shortly after he learned to walk. It was really bad and his doc told him we have two choices. Either get him fit for corrective braces or see if it heals itself which they expected it to do. It took almost three years, but he no longer trips over his own feet. It was pretty bad.

  38. yome says:

    #27
    was that for #26 not #27?

  39. Painhrtz - So Long and Thanks for all the Fish says:

    freedy been seeing commercials for that on Cablevision. Dude is an old hippie whatever. Jackson is no different that many souther jeresy towns lots of Sand, Pine Trees and not much else.

    Fab tort reform is not the single answer, it is a complex question. But when you have GPs deciding not to practice medicine because of malpractice insurance costs it raises a red flag. Look at what Gryff described above. no consistent coding language for billing and oyour dealing with 20 different types of coverage within the same system.

    I all for dumping insurance with the exception of catastrophic anyaway. Insurance does nothing but drive up costs in relation to compliance and staff to navigate their ridiculous rules. Hell look at some of the elective procedures out there. Lasik, Botox etc they have to charge what the market will bear. Another way to drive down costs get rid of the ridiculous medical restricitions on enrollment. It should be hard to get in but keeping the numbers artificially low so as not to “flood the market” with doctors also inflates prices. They should go to graduated degrees like the rest of the world. Would also do wonders to bring down cost with access to care. Their is no magic bullet, but allowing the market to be freer which I know is difficult for you libs to understand would do more to moderate costs than any government intervention.

  40. Painhrtz - So Long and Thanks for all the Fish says:

    medical school restricition on enrollment

  41. yome says:

    This are cash only patient.No? Will this not happen by eliminating insurance?

    “Lasik, Botox etc they have to charge what the market will bear”

  42. gryffindor says:

    Remember when you drive down Route 3, it is not my name on the Stadium. It is Metlife – a company that has successfully eliminated the humans when you call them. I have patients asking me questions about their Metlife claims. I tell them I get the same robots they do when I call, but I’m happy to help them if they learn something else and need my help with a paper or signature. One even works for Metlife and still can’t get past the robots to get help with the plan her employer sold to itself and administers itself.

    I’ve yet to hear a patient say “Metlife saved my life! “

  43. yome says:

    #28 nwnj

    It means our health system is not prolonging our lives compare to other countries.After paying double of what other developed countries,we are dying younger in our hospitals compare to other countries though you can blame it on lifestyle but that is a different argument.

  44. yome says:

    Medical tourism is a growing business in Asia. People with and without insurance from the US comes to Asia to do procedure with cash only.They claim it is still cheaper to pay cash in asia than getting it done with insurance in the US. This is where I claim medicare should pay for this procedures if they are cheaper than in the US.

    http://www.forbes.com/sites/miguelforbes/2012/11/27/medical-tourism-is-a-massive-opportunity-for-emerging-nations-like-thailand/

  45. grim says:

    I spent 15 minutes in IVR hell this morning only to find out that their call centers are closed today.

  46. Juice Box says:

    re: # 45 – They celebrate MLK day in India?

  47. cobbler says:

    Make it single payer for basic coverage (define what basic coverage is using common sense) and invest 10% of the savings in fraud prevention. Put malpractice reform in place. Pay the docs’ medical school tuition if they agree to participate, and discriminate in med school admissions against those who don’t. Sell supplemental private insurance at the market rate to those who want to buy it. Enjoy.

  48. Anon E. Moose says:

    As much as I hate government intervention, one change I would be in favor of (if accompanied by a full and total repeal of Obamacare) is full parity in payments. The insurers and docs can negotiate the rates they want to provide a level of service to me specified in the insurance contract. I should be free to go outside the network if I want. This whole $0 out of network crap pisses me off. I shouldn’t have to leave money on the table (or more to the point, in the insurance company’s pocket) because I choose not to go in network.

    I did manage to get an out-of-network behaviorist consultation paid through my insurance. It seems that the didn’t have one single in-network provider of this specialty in a county of 1.3 million people. They wanted me to go to the Bronx. I had an interesting conversation with a phone jockey sitting in rural NH who didn’t quite see the problem with driving only 25 miles in afternoon rush hour across Brooklyn and Queens.

  49. Anon E. Moose says:

    ChiFi [30];

    Does that make Grim an independent contractor? If he’s on the hook for the anything that insurance won’t pay, he should get to keep the difference if he gets the docs to accept less than whatever the insurer coughs up?

  50. grim says:

    Why don’t doctors bill by the hour? Billing is easy, here is my hourly rate, here is the amount of time I spent. Procedure-based pricing? Huh? When the hospital is billing for all other ancillary charges as a result of the procedure? The doctor isn’t providing anything other than time. Bill by the hour. No coding, nothing like that. I suppose the concern those in the industry would have would be that this would open the kimono just a bit too far.

    Reasonable and customary becomes very easy. When I talk a friend of the family that owns a pretty active auto repair business how he does it, he says it is easy, he looks up the estimate in a software package that tells him what to charge, if it costs more, he eats it, but nobody can contest his estimates, they are exactly the same as everybody else would charge. He works with every single insurance company, no problems there either, they all expect that the shops they work with use the same estimation software. Done. Here is the job, here is the estimate, here is the rate.

    That business is just as complicated as medicine. I’m not trying to be facetious here, I’m being serious. The number of makes, models, and years of cars he services varies significantly more than the human anatomy, yet he can tell me exactly what it costs to change a transmission on a ’94 Buick Lasalle, versus changing the air conditioning compressor of a 2002 Honda Civic.

    The reason it doesn’t, and won’t ever change, is because it is all about the money. The complexity and opaqueness of the system is absolutely intentional. Walk through a hospital and marvel at all the technology, look nurses walking around with computers and tablets, the barcodes and scanners, RFID tags, even the network connected peristaltic pumps, amazing! The truth of it all is that all of that technology has nothing to do at all with treatment and outcomes, and everything to do with billing. Spend enough time there and you’ll realize that 90% of what goes on revolves around a hospital’s primary mission of being a billing machine. If an alien stepped foot on this planet and walked into a hospital, I wonder if they’d think it was an accountancy practice before they realized it was a place of medical treatment.

  51. Painhrtz - So Long and Thanks for all the Fish says:

    Grim much like this

    http://www.youtube.com/watch?v=arCITMfxvEc

    Insurance removes the patient from cost if they knew how much they were paying and on the hook for it most people would be like screw you I don’t want that. It is about transparency which hospitals are loath to do because then that would show how much administrative costs drive up healthcare at the krankenhaus.

  52. Anon E. Moose says:

    Good point on “book time” estimates.

    I had a friend who went through a similar hell when his father literally collapsed on the street from a brain disorder that ended his life about two years later, with considerable diminished capacity towards the end, leaving my friend (an attorney) to do much of the negotiating with doctors and insurance.

    What he came to realize is that the medical billing/insurance situation is what it is because the doctors want it that way. Doc wanted insurance because it took the pressure off of wondering if they would get paid at least something. All the complex claim forms, diagnosis codes, docs write them. If they wanted it to be fixed, it would get fixed.

    The final analysis for my friend was that his father had little to nothing in the way of a probate estate (some life insurance, and other survivor assets that passed outside of his will). He told the docs to go hang — go fight the insurers and you’re welcome to whatever you can get from them. His father was essentially judgment-proof.

  53. grim says:

    Nom – Is this all just a big tax fraud with the intent to show huge annual losses to reduce the overall tax liability? For example, bill out-of-network to the tune of $10k. Eventually settle with insurance for $1k. Does the Doctor claim $1k in income and $9k in losses, versus simply claiming $1k in additional income?

  54. Comrade Nom Deplume says:

    [53] grim,

    Possibly, though I don’t see how. The losses are not actual losses and I can see IRS being all over that like burnt on toast. From an accounting perspective, it represents a receivable of 10K and a later reversal of 9K of said receivable. So it was as if 9K never happened.

    If the taxpayer is an accrual basis payer and recognized 10K in income in one year and a reversal in a later year, then your presumption is correct, but there is no net tax loss in that situation (assuming rates don’t change). If the taxpayer is cash basis, then the 9K loss isn’t recognized because it is nonexistent. There is only 1K in income.

  55. Comrade Nom Deplume says:

    [46] juice,

    No, they are celebrating over there today but for a different reason.

    http://www.ndtv.com/article/india/barack-obama-s-re-election-good-for-india-says-business-chamber-290815

  56. relo says:

    53: Grim,

    Probably the opposite. I would imagine the receivables get scrubbed dutifully via allowance for doubtful accounts.

  57. gryffindor says:

    #53 – grim

    I don’t think it works that way. From my simple tax filings the past few years, I get taxed on the money I actually collected minus expenses. I’m not aware of any docs deducting a loss on what they were supposed to collect.

  58. Buying Hunt says:

    Grim – Regarding out of network doctors at in network hospitals. There is hope.

    We have 5 kids. Except for our kid born at Kaiser Permanente in CA (where everything is through them so no BS), every time we had a huge bill from the anesthesiologist and the insurance said they wouldn’t pay it.

    We just called the doctor and asked for their appeal letter. They usually have a form letter for apealls (some time it has useful bs like citing some NJ law for newborn hearing tests, for example), but if not just write one yourself.

    Then mail it to the insurance company. No phone calls. No waiting on hold. You’ll get a new EOB and they will sometimes have paid all of it, sometimes part of it. When they paid part of it we appealed again and they paid the rest.

    It just got automatic.

    I think they are preying on the sucker who gets angry and upset at the insurance gods but ultimately just roles over and pays it. Just like JJ would say about girls when he was in high school: you might as well see what you can get away with. If some poor schmuck coughs up $3k then the insurance company might as well let him.

    Not sure if it will apply to your insurance or not, but it did for us with three different insurance companies in two different states.

    We never paid more than the flat copay for having a kid even though it was claimed we owed a combined $12k or more over the years.

    Buying H

  59. relo says:

    ps – sorry to hear about the bs you’re going through. You’ll wear ‘em down eventually.

    I may have told this story before, but when my oldest was maybe 11, he needed an operation (hernia) and it was scheduled. We were in a window where company for which I was working insurance hadn’t kicked in yet and had our own, if I recall. Anyway it wasn’t covered. When I called to confirm the day prior, Docs office said hospital cancelled. No available “tables”. WTF? I called the hospital which told me the Doc’s office cancelled, guess billing administrator thought they weren’t going to get paid. I called the Doc back and told them of my conversation with the hospital and after stuttering and stammering got to the heart of it. I asked if they take cash? Billing administrator said yes but had to be paid that day by x o’clock. The procedure was done the next day as originally scheduled. I wondered how many uninsured patients at the emergency room that day ever paid dollar one.

  60. relo says:

    60: Paid negotiated rate. Would have charged insurance much more.

  61. Nomad says:

    Grim #17 – Given the hassle from the insurance company for you as a younger and very bright person – imagine what the 80+ year olds who are sick go through with all the medical insurance BS.

    Jill #19 – Cleveland Clinic is actually thinking of setting up their own insurance company and getting rid of the middle man. I believe they already have a contract with Wal-Mart for a set price on a specific menu of services for their employees.

    Fair Health out of New York city is trying to bring transparency to the gap in pricing from in network vs out of network – one issue is I believe they are trying to get their pricing data from a United Health subsidiary.

    http://www.fairhealth.org/

    Castlight Health I believe has a program where they go to large employers, get boatloads of data on what various procedures cost and setup baseline reimbursement rates for the employer. If you as an employee get a lower price, you keep the difference and if you go to a doc whose price is above the baseline, you pay the extra out of your pocket.

    Costs of elective medical procedures are widely known – trying to get the price of a triple bypass would be a different story.

    http://www.castlighthealth.com/

  62. Punch My Ticket says:

    grim [50],

    The looking glass beckons.

    Change a few terms and that very rant could be about realtors on njmdreport.com.

  63. Ernest Money says:

    Four more years of Bojangles and at the end, Honey Boo Boo will have her period.

    Please shoot me now.

  64. Ernest Money says:

    Health insurance is another legal racket. Only difference between those thugs and a Gambino crew knocking over vending machines are coats and ties.

  65. Ernest Money says:

    Want insurance? Bathe in Purel, and carry a .38.

  66. grim says:

    64 – I suppose, but the analogy would need to be something like:

    Buyer contracts to buy a home for the price of $250,000.
    Buyer makes mortgage commitments, completes inspections, etc.
    Buyer gets to closing, signs docs, gets keys.
    Buyer gets a secondary bill for the purchase of the home to the tune of $1,000,000, real estate agents billed an additional $250k for services rendered, lawyer bills another $500k, inspections and testing another $250k. The mortgage has been automatically adjusted to cover the additional amount.

    Sorry buyer, nothing we can do now, caveat emptor. Buyer asks agent why the home cost $1m more than anticipated. Real estate agent cites complexities involved in the billing process and the impossibility to estimate the actual costs involved in the purchase transaction, uncertainty that services provided by parties involved would be covered under the purchase price, etc.

  67. Mike says:

    I remember calling Horizon the first time for my Mom since there were some billing issues. Mom was in the beginning stages of Alzheimers. Horizon refused to talk to me unless I put her on the phone first. When I explained her situation that she could not tell you her birthday, social, address, phone number. the rep could care less. So I put my mother on all it did was kick in one of her paranoia episodes and made her go off the wall. It took forever before the paper work went through so I could speak on her behalf.

  68. gryffindor says:

    #68 grim – Medical procedures can be done cookbook style. Problem is when something doesn’t follow the recipe, the hungry lawyers come and take it all. So the response is to customize the recipe for every single person.

    Then when patients are removed from the costs, they demand gourmet chocolate chip cookies for the price of Shop Rite store boughts. Not only does the recipe have to be customized, it just got more expensive.

  69. WickedOrange says:

    New stroller about to hit Montclair

    http://www.youtube.com/watch?v=ERQHRo0fHGE

  70. Libtard working from home (sleep deprivation has left me with an annoying sore throat and cold) says:

    65…Clot

    Funniest thing I’ve read in a while.

  71. Libtard working from home (sleep deprivation has left me with an annoying sore throat and cold) says:

    I wonder which corporations blew their load on Romney and now made up for it by helping pay for the inauguration? Baa baa.

  72. Comrade Nom Deplume: To Tax what JJ is to Sex. says:

    [65] clot,

    Much of the research I read suggests we’ve past the tipping point and are on our way to eurostyle democratic socialism. And if we apply my variant of Occams Razor, I think it inevitable.

    “The best wealth is portable.” Attribution unknown.

  73. cobbler says:

    nom[74]
    If anything, we are moving away from it… Euromodel is high taxes on a broad base paying for high benefits for most everyone (healthcare, childcare, vacation money, housing allowance, car allowance, etc.), plus industrial policy keeping jobs in the country. Ours will be high taxes on a very narrow group and high benefits for a wider but still quite narrow group, and industrial policy favoring politically connected – best combo recipe for a disaster.

  74. McDullard says:

    #77 Re: Swiss turmoil on CEO pay…

    Even though most Swiss enjoy a very high standard of living, Minder’s campaign has struck a chord in a proudly egalitarian country increasingly unhappy with a growing class of super-rich unafraid to flaunt their wealth. Combine that with an undercurrent of xenophobia — many of the top-paid executives in Switzerland are foreigners — and you have a volatile mix. In another sign of discontent, parts of the country are also considering scrapping the tax breaks that have lured wealthy foreigners such as Formula One driver Michael Schumacher, pop stars Phil Collins and Tina Turner, and Switzerland’s richest man, Ingvar Kamprad, the Swedish founder of Ikea.

  75. Hhk says:

    Longtime reader, first time poster…wanted to chime in on the insurance issue. My personal experience was similar to a previous post. My oldest son was sick a few years ago and needed surgery and radiation. For the radiation he needed anesthesia every time. He had 30 something treatments. The anesthesia group that the hospital employed did not take our insurance so we kept getting bills for their work. I appealed each bill with a letter explaining that he was receiving treatment at an in network facility and that we were not given a choice to pick an in network provider. Our insurance took care of it from there. Seems your situation is similar in that you were not give an opportunity to choose in network provider for emergency care that was provided at an in network hospital. Do not pay anything until you have exhausted all appeals.

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