The real problem with health insurance

[disneysteve]

Originally Posted by creditcardfree

I think they just don't want to deal with giving figures until it is a true claim, for liability reasons.

That's my assumption. They don't want to tell her it will cost one amount and then have it end up costing a different amount because the claim wasn't exactly what she called about.

Still, the bottom line remains that nobody can tell the patient how much her procedure is going to cost. Since she has to pay her deductible and then a certain percentage of the balance after that, she'd really like to know what that will mean in dollars and cents so she can prepare for it.

[elessar78]

It strikes me as a type of complex negotiation. Either side doesn't want to give their number first because they can be held to it down the road. Each side is trying to extract as much money out of the situation as possible and they don't want to give away their leverage too early.


Let me see if I understand how this all works:
Either way, the surgeon gets his fee through a combination of deductible + what insurance will pay.

What the insurance company will pay depends on various factors like how it is coded and the Insurance company's policy on those codes and procedures? Which seems to be the closely guarded secret. In any negotiation, information is power-- keeping one side in the dark about how things are determined certainly tilts things in favor of one side.

[Mozaik]

I wonder how long Americans will continue to accept a medical insurance system that so poorly serves those who are fortunate enough to have coverage. While you deride your northern neighbors whose system does have flaws, how would it feel to have all permanent residents with full coverage, no longer paying premiums [either employer or individual], eliminate co pays [except drugs], confident you will not end up with a bill for all but elective surgery?

The downside here is we pay 40 cents tax per gallon gas and depending on province a few cents sales tax for doctor, surgeon and hospital costs. [only a few private hospitals primarily for elective procedures] We have waits for non urgent surgeries but anyone in serious condition flies to the top of the list. With pre-approval, we can have procedures in other countries.

DH had a procedure called Lithotripsy to smash kidney stones. Out of pocket cost for overnight emergency rm @ hospital, family physician visit/referral, pre surgical visit urinologist, hospital day surgery and post op visit were all zero. Due to an incredibly painful kidney stone attack DH moved up the line quickly. We understood he would be bumped for cancer and accident patients etc. since kidney stones are not 'life threatening.'

I've been told that American insurance companies have staff whose function is to find reasons to deny claims since people who are ill don't focus on insurance details or look for errors on billing. Most patients don't have access to charge codes to efficiently review charges/bills. The paperwork involved will fill a file!

What bothers me as well is the fact that people can't change employment because pre existing medical conditons within the family will prevent them from having medical benefits from another carrier.

These super low interest rates are having a negative effect on all insurers and they are under enormous pressure to create dividends for their stock holders.

[LivingAlmostLarge]

When the income disparity between the rich and poor grows larger and more people fall into HDHP and insurance companies start figuring out how to pay less and less. Then people will realize that the american system needs serious revamping.

[photo]

My mother (in her late 60s) was recently hospitalized, and I was going over her itemized bill. When I found a charge for a pregnancy test, I asked her if there was something she wasn't telling me!

When I phoned the hospital billing department, I was told it was common to test females for pregnancy before undergoing a procedure that my mother had.

I was somewhat aghast that even though the rep knew my mother's age, the rep still argued with me. When I said I would write the hospital administrator about the situation, the rep decided to "drop" the charge.

Absurdity rules.

[disneysteve]

Originally Posted by photo

My mother (in her late 60s) was recently hospitalized, and I was going over her itemized bill. When I found a charge for a pregnancy test, I asked her if there was something she wasn't telling me!

When I phoned the hospital billing department, I was told it was common to test females for pregnancy before undergoing a procedure that my mother had.

You raise a critically important point. Any time you, or a loved one, is hospitalized, get a copy of the complete itemized bill before paying any claims. Reports have shown as many as 90% of hospital bills contain errors.

One of the last times my wife had surgery, I found an error of just over $1,000 on her bill. By getting that corrected, it reduced our out of pocket cost by that amount since the insurance had already paid by the time I got the bill straightened out. Had I not reviewed the bill, we would have been out $1,000 more than necessary.

[cptacek]

Originally Posted by rj.phila

i am in the 33% tax bracket and only carry a catastrophic ins plan cause of this. its amazing how inefficient our health care system is here, and how we rank LAST in the developed world in terms of care(inf mortality rates), and HIGHEST in cost per capita. its totally insane.

how does it affect people? well, we dont visit doctors very often

I think we measure infant morality differently than other countries do. I hardly ever quote Wikipedia, but here you go:
Infant mortality - Wikipedia, the free encyclopedia

The World Health Organization (WHO) defines a live birth as any born human being who demonstrates independent signs of life, including breathing, voluntary muscle movement, or heartbeat. Many countries, however, including certain European states and Japan, only count as live births cases where an infant breathes at birth, which makes their reported IMR numbers somewhat lower and raises their rates of perinatal mortality.[5]

Something to think about, anyway...

[Frugal]

I agree it can be impossible to know in advance. I get a different answer on how much a procedure costs or whether something or someone (physician) is covered each time I call my ridiculous health insurance! Even this past week, I could not get a definite answer as to whether my flu shot would be reimbursed at a certain pharmacy. They said I had to basically just submit the charges and take my chances. HA

Our dental insurance is even worse. They are utterly horrible, and have tried to deny claims for what their contract states they MUST cover. I won one appeal already for basic cleaning required for my husband, but it took 90 days and way too many phone calls and frustrations and letters.

[disneysteve]

Originally Posted by Frugal

Even this past week, I could not get a definite answer as to whether my flu shot would be reimbursed.

Perfect example. Really, how tough of a question is that? Is it covered or not? Sounds pretty basic to me. As I said earlier, can you imagine any other business operating this way and getting away with it?

[muexm]

Originally Posted by disneysteve

Nope. That's exactly what she tried. She has the procedure billing codes that will be submitted to the insurance company. We needed those to issue the referral for surgery. So there is no question of what will be done.

She called the surgeon's billing department and was told by them to call the insurance company with the codes to find out how much they would pay. The insurance company, given that information, told her they don't know how much they'll pay until after they get the claim.

I am also a Healthcare Administrator with a Master's Degree in Healthcare Administration. Healthcare Transparency is only one of several issues with our Healthcare system. Knowing ahead of time what a procedure costs gives consumers power and the incentive to shop around for health care. Some health plans allow plan members to go online and get an "idea" of what the plan will pay for a specific service at an "in-network" facility (United does a great job of this). Besides the fact that a simple surgical procedure can turn complex while a patient on the operating table from and healthcare costs vary greatly from region to region (Ultrasound in New York $200 vs same ultrasound in North Carolina $80), why would an insurance company or regional health system want to give consumers a choice if they don't have to?

[disneysteve]

Originally Posted by muexm

Some health plans allow plan members to go online and get an "idea" of what the plan will pay for a specific service at an "in-network" facility (United does a great job of this). Besides the fact that a simple surgical procedure can turn complex while a patient on the operating table from and healthcare costs vary greatly from region to region (Ultrasound in New York $200 vs same ultrasound in North Carolina $80), why would an insurance company or regional health system want to give consumers a choice if they don't have to?

Being able to go online and see prices would be great.

Certainly, I realize that with surgery, the end result could be more than anticipated depending on what is found at the time of the operation, but at least tell what the basic surgery would cost.

Regional variations are perfectly understandable. That's true of most any product or service. Cost of living varies. Incomes vary. Cost of goods and services vary.

[LivingAlmostLarge]

But health insurance companies make big money by denying coverage or fighting not to pay for what consumers are paying to be covered for. If that makes sense. They are the worse at paying out claims.

[Like2Plan]

I had my gallbladder removed about 8 weeks ago. It was an outpatient procedure with an in network provider. I spent 45mins in the OR and 2.5 in recovery.

So far, I have received bills from (I rounded all the numbers up):
The hospital billed $7,631...the network allowable amount was $6,410...ins paid $5448..bal $962
The surgeon billed 3,600... the network amount was $800... ins paid $680...bal $120
The pathology dept billed $135...the network amount was $135...ins paid $88 ...bal 48.
I think the only bill missing is the anesthesiologist.

The bills go on to my secondary ins, so we'll see what is left after that.

The shocker to me is the surgeon's bill. Would a person without ins have to pay the full amount? On the other hand, can the surgeon meet his overhead with the amount my ins paid?

I didn't ask cost beforehand. I did seek a 2nd opinion, but my choice was mostly based on whether the providers were in network and the amount of this type of procedure done by the Dr.
The surgery was something that needed to be done (and I feel like a million bucks since )

[disneysteve]

Originally Posted by Like2Plan

The surgeon billed 3,600... the network amount was $800... ins paid $680...bal $120

The shocker to me is the surgeon's bill. Would a person without ins have to pay the full amount? On the other hand, can the surgeon meet his overhead with the amount my ins paid?

To answer your second question, no, the surgeon probably couldn't meet his overhead if that's all he got routinely for the surgeries he performs.

As for your first question, probably not. In most cases, the doctor would work out some discount for a cash patient, though it would most likely end up being more than what he's getting in your case. Even if he gave a 50% discount, that would still be $1,800 vs. the $800 he's getting from you.

Make sure you get a complete itemized copy of the hospital bill before you pay any out of pocket costs. If you really care, do it even if you have no out of pocket costs because there's no reason your insurance should have to pay for mistakes either.

[maat55]

Originally Posted by disneysteve

Still, the bottom line remains that nobody can tell the patient how much her procedure is going to cost. Since she has to pay her deductible and then a certain percentage of the balance after that, she'd really like to know what that will mean in dollars and cents so she can prepare for it.

Is it possible that procedures and recoveries for the same issue may involve different levels of time and resources?

In the custom furniture business, I could have a set price for a sofa. But, this could change if the clients wants extras(this could be unforseen issues) not included in the base price. Is it possible that doctors and hospitals cannot guess the outcome of a surgery and hospital stay?

[muexm]

My step dad is a small business owner who does not have health insurance in Upstate New York. He was recently diagnosed with Inguinal Hernia. And he called around New York to at least 10 different Hospitals and none of them would give him a quote because he did not have health insurance. He is a very frugal man with a paid off house and money in the bank to pay for cash the surgery but the Hospitals refused to even consult with him unless he had health insurance. Long story short, I helped him locate a highly certified, educated, and credentialed physician in Las Vegas who performed the surgery for a flat rate.

So, there is a small revolution of providers who care about patients and understand that most uninsured individuals are not lazy bums depending on government aid. Most uninsured individuals are hard working Americans who were recently laid off or simply cannot afford $600-$800 a month in health insurance premiums. These physicians are doing a noble thing by offering medical transparency and options to patients without health insurance.

Youtube link: No Insurance Surgery - YouTube

[Like2Plan]

Originally Posted by maat55

Is it possible that procedures and recoveries for the same issue may involve different levels of time and resources?

I wonder about that, too. In my case it didn't take the surgeon very long--but the two cases before me took longer than they scheduled for the surgery (my time slot was pushed back a couple hours later as a result). Would the surgeon get the same amount for a case with complications and more time in the OR--would it be a different code?

The Dr. had said if I had complications, it could require an overnight stay which would have added to the cost.

[maat55]

Originally Posted by muexm

My step dad is a small business owner who does not have health insurance in Upstate New York. He was recently diagnosed with Inguinal Hernia. And he called around New York to at least 10 different Hospitals and none of them would give him a quote because he did not have health insurance. He is a very frugal man with a paid off house and money in the bank to pay for cash the surgery but the Hospitals refused to even consult with him unless he had health insurance. Long story short, I helped him locate a highly certified, educated, and credentialed physician in Las Vegas who performed the surgery for a flat rate.

So, there is a small revolution of providers who care about patients and understand that most uninsured individuals are not lazy bums depending on government aid. Most uninsured individuals are hard working Americans who were recently laid off or simply cannot afford $600-$800 a month in health insurance premiums. These physicians are doing a noble thing by offering medical transparency and options to patients without health insurance.

Youtube link: No Insurance Surgery - YouTube

I would love to see the healthcare industry go back to being mainly between the patient and provider. IMO, employer group plans, excessive government regulation and medicare are largely to blame for unreasonable costs of healthcare.

I would like to see employers only fund HSA's as apposed to cookie cutter plans. This would have the individual shop for catastrophic insurance and out of pocket procedures forcing providers to be transparent.

[kv968]

Originally Posted by disneysteve

Nope. That's exactly what she tried. She has the procedure billing codes that will be submitted to the insurance company. We needed those to issue the referral for surgery. So there is no question of what will be done.

She called the surgeon's billing department and was told by them to call the insurance company with the codes to find out how much they would pay. The insurance company, given that information, told her they don't know how much they'll pay until after they get the claim.

As you said before Steve, I think that's just the insurance company not wanting to commit to a price and in a way it makes sense unfortunately. You're giving them the codes you think will be submitted but the insurance company doesn't know if that's exactly what they'll receive. As an example...

I went in to get an epidural steroid shot in my back. The pain management doctor who did it had me go to a surgery center that didn't accept my HMO. After asking my doctor why he would send me to a place like that and talking to the surgery center, they said don't worry about it since they do it as a "favor" to the doctor for all the volume he gives them and they'll accept whatever the HMO would pay and my normal co-pay. Sounded kinda strange but I went with it and it was fine. Paid my co-pay and never received a bill.

I had to get a second shot later on and was asked if I wanted a twilight anesthesia this time. Since the first one wasn't all that comfortable I agreed. I asked if it was covered and they said that my provider typically covers it 95% of the time. Same scenario as before however I must have fell within that 5% that isn't covered because this time I received a $400 bill from the anesthesiologist. I called the insurance company about it and they said since it was billed separately (the anesthesiologist didn't work for the surgery center but was a "contractor") and not included in the cost of the procedure itself, it was deemed not medically necessary and they wouldn't pay it. I told my doctor this and he wrote them a letter saying it WAS medically necessary and it supposedly went through a review at the insurance company but they still denied it.

What I'm getting at is the insurance company probably doesn't want to commit on any sort of price because although you're sure about what's getting done, and even are providing them the codes for the procedures, they don't have it in front of them and if they God for bid receive a different code or it's billed incorrectly they might or might not have to pay it. Screwy system indeed.

[cschin4]

Originally Posted by muexm

I am also a Healthcare Administrator with a Master's Degree in Healthcare Administration. Healthcare Transparency is only one of several issues with our Healthcare system. Knowing ahead of time what a procedure costs gives consumers power and the incentive to shop around for health care. Some health plans allow plan members to go online and get an "idea" of what the plan will pay for a specific service at an "in-network" facility (United does a great job of this). Besides the fact that a simple surgical procedure can turn complex while a patient on the operating table from and healthcare costs vary greatly from region to region (Ultrasound in New York $200 vs same ultrasound in North Carolina $80), why would an insurance company or regional health system want to give consumers a choice if they don't have to?

Good points. And, insurance companies should be compelled to provide patients with estimated payments and so forth. Most of the medical care we all receive is non emergent. So, there is simply NO REASON why patients, doctors, hospitals and insurers should not be able to inform the patient up front as to what is covered, the amount that will be billed, and the amount the patient will pay out of pocket and so forth. This is where we should have started in reform. But, in reality, i don't think anything is really going to change.