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Avoid being scammed! “What You Should Know About Health Insurance Before Buying”

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For many of us, finding the right health insurance plan, can be a tedious task. When selecting a plan, you might need a psychic. COAST Surgery Center of Huntington Beach, CA explains why. We tend to pick a plan that fits our needs for today, but those needs change. So unless you have a psychic to tell you how your health, your family situation, or if your financial situation will be in the future, how will you really know what plan is best for you?

Most of us are clueless as to how insurance plans work and insurance companies don’t make it any easier to understand. There are tools to help us purchase a plan but it almost seems like we would need a PhD just to understand them. Once we have decided on an HMO or PPO, we may soon realize we have picked the wrong plan because many of us don’t really know what our policy covers until we need surgery and then we’re told it’s not covered or our co-insurance is super high. That’s when we realize our plan has too many restrictions and conditions.

“Wasn’t that the whole reason for purchasing the PPO plan and be able to see any physician we want?”

Those who work in medical billing have experienced how insurance companies use tactics that many of us don’t know about. We are deceived into buying a PPO plan without clearly understanding how they work. When we purchase a PPO plan, it’s mainly so we are able to see any doctor without having to be tied to a network or require a referral from a Primary Care Physician (PCP). After paying a higher premium for months or even years, something happens to you and you need a specialist. After carefully selecting the best specialist to treat you, the insurance calls to ask why you have selected that specialist. Here’s where the tactic begins. Although, they shouldn’t be contacting you, naturally, you respond that this doctor is experienced and has a good reputation. The insurance representative would then inform you that since you are using an out-of-network specialist, they will not cover the procedure as much as their in-network specialists and then hint that you should switch to their in-network specialist.

Most out-of-network doctors and facilities usually get paid Medicare rate, meaning very little. Therefore, patients may get hit with the responsibility of what the insurance doesn’t pay and they never tell us that. Insurance companies know our fear of having to pay more out of pocket if they don’t cover as much. So do we then switch to an in-network doctor or pay more out of pocket? We chose our physician for a good reason and we cannot risk our health to just any doctor. Wasn’t that the whole reason for purchasing the PPO plan and be able to see any physician we want?

Insurance companies should not use tactics to scare us when we are in a stressful situation. They are taking advantage of our vulnerability to coerce us into making an irrational decision. If we are out-of-network, they are not supposed to suggest that we go in-network when verifying coverage. Insurance companies will continue to make money, while patients, physicians, and facilities providers lose. Health plans are constantly changing and premiums are increasing each year, while coverage is getting reduced. So before you buy, make sure you get the right information for not only your needs today, but for when you do actually use the coverage.

If you feel that you have been scammed or mislead into purchasing a plan that isn’t right for you, you can file a complaint with the Department of Insurance at 800-927-4357 or with the Department of Managed Healthcare at 916-324-8176.

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WHY HEALTH INSURANCE COMPANIES AVOID PAYING CLAIMS

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Health insurance is supposed to be a safety net—a financial buffer to help cover medical costs when life throws a curveball. But if you ask any provider or patient who’s tried to collect on a claim, they’ll tell you, “Insurance companies don’t play fair.” In fact, many go out of their way to avoid paying out, delay the process, or set up confusing roadblocks that frustrate both doctors and patients.

Insurance companies make it so hard to get paid because profit is their priority. At the end of the day, health insurance companies are businesses. And like all businesses, they have one main objective: maximize profits. Every claim they pay out cuts into their bottom line. That creates a built-in incentive to delay, deny, or underpay whenever possible.

Even small denials, when multiplied by thousands of claims a day, can result in massive savings for insurers. Insurance policies are loaded with fine print, technical jargon, and changing criteria. Providers are often expected to navigate complex billing codes, formularies, pre-authorization procedures, and specific documentation requirements—all of which can change without much notice. This constant state of fluctuation increases the chances of providers making an error, giving insurers the excuse they need to deny or delay a claim.

Pre-authorization is one of the most common tactics used to stall or prevent payments. It requires providers to get approval in advance for many tests, treatments, or medications—even those considered standard of care. The process can be so drawn-out and inconsistent that some providers give up or delay care, leaving patients in limbo.

Insurers frequently deny claims based on minor technical errors, such as misspelled names, incorrect billing codes, lack of “medical necessity” (even when a doctor deems it necessary), or missing documentation (often something that was never clearly requested) In many cases, the care was valid and needed—but one small mistake is all it takes to trigger a denial.

Some experts refer to it as the “three D’s”: Delay, Deny, and Defend. Their goal is to wear people down. Insurance companies know that if they make the process frustrating enough, many patients and providers will give up on pursuing the money altogether. Time-consuming phone calls, appeals processes, and re-submissions become a full-time job. Many doctors and clinics can’t afford to keep up with.

In some cases, insurers will pay less than what was agreed upon, or use so-called “silent PPOs” to undercut contracted rates. Providers often don’t even realize they’ve been underpaid until months later, by which point the appeals window may have closed. This subtle tactic lets insurers save money without outright denying care—flying under the radar of most busy practices.

In recent years, insurers have begun using algorithms and artificial intelligence to flag and auto-deny claims at scale. While these tools are promoted as efficiency boosters, they can result in denials that lack nuance, context, or human judgment. This can be particularly harmful for complex or rare conditions, where standard guidelines may not apply. This impacts patients and providers in many ways; doctors and hospitals must hire full-time billing and coding staff just to stay afloat, patients are often left with surprise bills or denied access to necessary care, and healthcare costs rise as administrative work eats up time and resources. In short, when insurers deny payment, everyone else pays the price—whether it’s through stress, delayed care, or rising premiums.

So although health insurance is supposed to provide peace of mind, too often, it feels like a battle. Between red tape, strategic delays, and vague policies, insurers have turned claim denial into a quiet art form. Until there’s more oversight, transparency, or reform, providers and patients will need to stay vigilant—document everything, ask questions, and never take a denial at face value.

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TẠI SAO CÁC CÔNG TY BẢO HIỂM Y TẾ TRÁNH TRẢ TIỀN BỒI THƯỜNG

Bảo hiểm y tế lẽ ra phải là một tấm lưới an toàn tài chính—giúp người bệnh chi trả chi phí y tế khi gặp khó khăn. Nhưng nếu bạn hỏi bất kỳ bác sĩ hay bệnh nhân nào từng cố gắng nhận tiền bồi thường, họ sẽ nói: “Công ty bảo hiểm không chơi đẹp.” Thực tế, nhiều công ty cố tình né tránh, trì hoãn hoặc tạo ra các thủ tục rắc rối để gây khó khăn cho cả bác sĩ lẫn bệnh nhân.

Lý do chính khiến việc đòi tiền bảo hiểm trở nên khó khăn là vì lợi nhuận. Các công ty bảo hiểm y tế là doanh nghiệp, và mục tiêu chính của họ là tối đa hóa lợi nhuận. Mỗi khoản bồi thường mà họ phải chi trả làm giảm lợi nhuận, vì vậy họ có động cơ để trì hoãn, từ chối hoặc trả ít hơn bất cứ khi nào có thể.

Ngay cả những khoản từ chối nhỏ, khi nhân lên hàng ngàn đơn mỗi ngày, cũng giúp họ tiết kiệm một khoản tiền khổng lồ. Hợp đồng bảo hiểm thường chứa nhiều điều khoản khó hiểu, ngôn ngữ kỹ thuật, và quy định thay đổi liên tục. Các bác sĩ phải đối mặt với mã hóa phức tạp, danh mục thuốc, quy trình xin chấp thuận trước và yêu cầu tài liệu chi tiết—tất cả có thể thay đổi mà không báo trước. Những thay đổi liên tục này khiến bác sĩ dễ mắc lỗi, và đó là cái cớ để công ty bảo hiểm từ chối hoặc trì hoãn thanh toán.

“Xin chấp thuận trước” là một chiêu trò phổ biến nhằm trì hoãn hoặc tránh phải chi trả. Nó yêu cầu bác sĩ phải được công ty bảo hiểm chấp thuận trước khi thực hiện nhiều xét nghiệm, điều trị hoặc kê đơn—even khi đó là phương pháp điều trị tiêu chuẩn. Quá trình này có thể kéo dài, thiếu nhất quán, khiến nhiều bác sĩ bỏ cuộc hoặc trì hoãn điều trị, làm bệnh nhân phải chờ đợi không biết đến bao giờ.

Công ty bảo hiểm thường từ chối chi trả chỉ vì lỗi kỹ thuật nhỏ—như tên bị đánh sai, mã hóa sai, cho rằng “không cần thiết về mặt y khoa” (dù bác sĩ cho là cần), hoặc thiếu tài liệu (nhiều khi là tài liệu mà họ không nói rõ từ đầu). Trong nhiều trường hợp, việc điều trị là chính đáng và cần thiết—nhưng chỉ một lỗi nhỏ cũng đủ khiến họ từ chối bồi thường.

Một số chuyên gia gọi đây là chiến lược “ba chữ D”: Delay (Trì hoãn), Deny (Từ chối), và Defend (Chống chế). Mục tiêu là làm người ta mệt mỏi và bỏ cuộc. Họ biết nếu gây đủ phiền toái, nhiều bệnh nhân và bác sĩ sẽ từ bỏ việc theo đuổi quyền lợi. Gọi điện, làm đơn khiếu nại, gửi lại hồ sơ… trở thành công việc toàn thời gian, mà nhiều phòng khám không đủ nguồn lực để theo đuổi.

Thậm chí có khi, công ty bảo hiểm trả ít hơn số tiền đã thỏa thuận, hoặc sử dụng cái gọi là “PPO âm thầm” (silent PPO) để trả giá thấp hơn mức trong hợp đồng. Các bác sĩ thường không phát hiện ra mình bị trả thiếu cho đến vài tháng sau, khi thời hạn khiếu nại đã hết. Chiêu trò tinh vi này giúp công ty bảo hiểm tiết kiệm mà không cần từ chối trực tiếp—âm thầm “né” khỏi sự chú ý của các phòng khám bận rộn.

Gần đây, các công ty bảo hiểm còn dùng thuật toán và trí tuệ nhân tạo để tự động từ chối hàng loạt hồ sơ. Dù họ nói rằng công nghệ giúp xử lý nhanh hơn, thực tế lại làm tăng số lượng hồ sơ bị từ chối mà không có sự đánh giá kỹ lưỡng hay cân nhắc hoàn cảnh cụ thể. Điều này đặc biệt nguy hiểm với những ca bệnh hiếm gặp hoặc phức tạp, khi không thể áp dụng quy chuẩn thông thường.

Hệ quả là: bác sĩ và bệnh viện phải thuê thêm người để làm công việc mã hóa và đòi tiền; bệnh nhân nhận được hóa đơn bất ngờ hoặc bị từ chối điều trị cần thiết; chi phí y tế tăng vì quá nhiều thời gian và nguồn lực bị tiêu tốn cho thủ tục hành chính.

Tóm lại, khi công ty bảo hiểm từ chối chi trả, mọi người đều phải trả giá—dù là bằng căng thẳng, điều trị chậm trễ, hay phí bảo hiểm tăng cao.

Mặc dù bảo hiểm y tế được kỳ vọng sẽ mang lại sự yên tâm, nhưng trong thực tế, nó lại giống như một cuộc chiến. Giữa hàng loạt thủ tục, sự trì hoãn có chủ đích, và các điều khoản mơ hồ, các công ty bảo hiểm đã biến việc từ chối bồi thường thành một “nghệ thuật thầm lặng”. Cho đến khi có nhiều minh bạch, kiểm soát và cải cách hơn, cả bác sĩ và bệnh nhân đều cần cảnh giác—ghi chép cẩn thận, đặt câu hỏi, và đừng bao giờ chấp nhận việc bị từ chối mà không phản hồi.

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A CRIMINAL BECOMES A MOLE FOR THE FBI

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Dr. Robert John Joseph II, D.P.M

In July 2022, Dr. Robert John Joseph II, D.P.M., a podiatrist, pleaded guilty to misconduct and malpractice charges. He was convicted of a felony for defrauding government healthcare plans by writing compound drug prescriptions to patients and directing them to accomplice pharmacies in exchange for kickback payments.

The Department of Consumer Affairs investigation into Dr. Joseph’s practices involved detailed examination of medical records, expert testimony, and an assessment of Dr. Joseph’s actions. The core of the allegations included issues such as failure to diagnose, improper treatment methods, and negligence in patient care. The findings of the investigation led to his disciplinary action but in a plea deal, Dr. Joseph agreed to cooperate with federal authorities. As part of this agreement, he has been working undercover for the FBI to expose illicit practices by other doctors and medical facilities. His role has involved attempting to lure other doctors and medical facilities into illegal agreements.

In July 2022, Dr. Robert John Joseph II, D.P.M., a podiatrist, pleaded guilty to misconduct and malpractice charges. He was convicted of a felony for defrauding government healthcare plans by writing compound drug prescriptions to patients and directing them to accomplice pharmacies in exchange for kickback payments.

The Department of Consumer Affairs investigation into Dr. Joseph’s practices involved detailed examination of medical records, expert testimony, and an assessment of Dr. Joseph’s actions. The core of the allegations included issues such as failure to diagnose, improper treatment methods, and negligence in patient care. The findings of the investigation led to his disciplinary action but in a plea deal, Dr. Joseph agreed to cooperate with federal authorities. As part of this agreement, he has been working undercover for the FBI to expose illicit practices by other doctors and medical facilities. His role has involved attempting to lure other doctors and medical facilities into illegal agreements.

Dr. Joseph is currently working undercover in California and has been visiting medical facilities and doctors’ offices to solicit illegal practices to see if any of them would take the bait. A medical facility in Orange County, CA, reported that Dr. Joseph, equipped with a concealed camera, attempted to offer an illegal deal as part of his undercover work. The facility did not take the bait and chose to publicize the incident to alert others about such undercover operations.

This situation underscores the FBI’s method of combating fraudulent activities, which sometimes involves setting traps to uncover wrongdoing. While the goal is to identify genuine malpractice, this approach raises ethical concerns about creating scenarios that may not have existed otherwise. It highlights the need for vigilance within the medical community to avoid being caught in such undercover operations. Essentially, this tactic risks turning tempted individuals into criminals by creating opportunities for misconduct.

https://www2.mbc.ca.gov/pdl/document.aspx?path=%5cDIDOCS%5c20231208%5cDMRAAAJD1%5c&did=AAAJD231208220712717.DID&licenseType=E&licenseNumber=4013%20#page=1

https://www.justice.gov/file/1076086/download

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CAN HEALTH INSURANCE COVER A NOSE JOB (RHINOPLASTY)?

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Rhinoplasty, commonly known as a nose job, is a popular cosmetic procedure that alters the shape or structure of the nose. Many people seek rhinoplasty for aesthetic reasons, desiring a more symmetrical or balanced appearance. However, there are cases where rhinoplasty is performed for medical reasons, such as to improve breathing or correct a structural abnormality. In these instances, health insurance may provide coverage for the procedure.

The key factor in determining whether health insurance will cover rhinoplasty is the purpose of the surgery. Health insurance generally does not cover purely cosmetic procedures, meaning those that are done solely for appearance. However, rhinoplasty that is considered medically necessary—such as for functional or reconstructive reasons—may be covered.

Rhinoplasty may be deemed medically necessary in several situations, including:

Septoplasty: A common reason for insurance coverage, septoplasty involves the correction of a deviated septum, which can cause difficulty breathing. A deviated septum is a condition where the cartilage and bone dividing the nasal passages are off-center, leading to obstruction and difficulty with airflow.

Chronic Sinus Issues: If a person has chronic sinusitis or recurring infections due to nasal passage obstruction caused by a structural issue with the nose, rhinoplasty to correct the obstruction might be covered by insurance.

Nasal Fractures or Trauma: If the nose has been broken or damaged in an accident or injury, reconstructive rhinoplasty may be necessary to restore both function (breathing) and appearance. This type of surgery is often covered by insurance, especially if there is ongoing functional impairment.

Breathing Difficulties: If a person is experiencing breathing difficulties due to structural abnormalities, such as a collapsed nasal valve or congenital deformities, insurance may cover surgery to improve nasal airflow.

If rhinoplasty is performed purely for cosmetic reasons, it is generally considered elective surgery and is not covered by health insurance. However, there are cases when a patient who has sustained an injury or has a congenital defect that affects the function of the nose, in addition to its appearance, may be able to make a case for insurance coverage if they can demonstrate that the procedure will improve both function and form.

If you believe your rhinoplasty is medically necessary, the first step is to check with your health insurance provider. It’s essential to also consult with an experienced ENT (ear, nose, and throat) specialist or a board-certified plastic surgeon who can evaluate your condition and provide the necessary documentation for insurance approval.

Document Symptoms and Issues: Keep a detailed record of your symptoms, such as difficulty breathing, frequent sinus infections, or any other related issues that may support your case for medical necessity.

Appeal Denied Claims: If your insurance company initially denies coverage for rhinoplasty, don’t be discouraged. Many patients successfully appeal denied claims by submitting additional medical documentation or a letter from their doctor outlining the functional necessity of the procedure.

While rhinoplasty for purely cosmetic reasons is not typically covered by health insurance, it may be possible to get coverage if the surgery is deemed medically necessary. Suppose you’re considering rhinoplasty for functional reasons, such as to improve breathing or correct a medical issue. In that case, it’s important to consult with your insurance provider and a skilled surgeon to understand your options. Always thoroughly review the details of your insurance policy and any associated costs before proceeding with surgery.

To speak to a specialist or for more information, call Coast Surgery Center toll-free at (855) 263-9968 or (714) 375-3600.

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