So, … More Funny Math of the Heathcare Insurance Variety

We are blessed to have health insurance.  I have no idea what’d we do without.  Crazy scary to be uninsured.  Despite being one of the fortunate ones, I believe our system is broken.  I take no political stance here; only going to give you some examples.

B had his five year routine colonoscopy screening.  Here is the breakdown of the charges:

  • Amount billed
    • Surgical Center = $2100
    • Member rate = $2063
    • Plan pays 100% or $2063
  • Amount billed
    • For Doctor = $575
    • Member rate = $375
    • Plan pays 100% or $375
  • Amount billed
    • For anesthesia (doctor and procedure) = $1190
    • Member rate = $474.50
    • Plan pays 100% or $474.50

Grand spanking total = $3865 with plan paying $2912.50 and $0 out of pocket since screening is a perk of having the insurance.

Am I complaining?  Nope. Well, yes!  And I have to ask, what is the true cost?  Did someone get shorted $952.50?  Or is the true cost $2,912.50?  My guess is neither and there in lies the problem.

We are playing with people’s lives.  Those who can afford testing, medication, etc and those who go without.  Criminal I tell ya!  How’d we begin to pony up $3865 as a no insurance patient?  The answer is sad.  People don’t.  They skip preventive, they cut back on medications, they sacrifice … that’s the word.  Sacrifice.  I said I would not be political but it’s shameful.

One more example before I go. My emergency office visit.  Here I found out I was nearly normal.  

  • Amount billed
    • For doctor = $258
    • Member rate = $98.07
  • Amount billed
    • For CT with contrast = $1084 plus $50 for iodine
    • Member rate = $553.34 plus $12 for iodine (bet I can find iodine on shelves for $1.99)

Stop it Jilly! But no!  I wanna know!!  What’s the real cost?  Is it $1392 or $663.41?

In this case, I had not met my $2700 deductible.  Therefore the plan pays nothing.  I was billed onsite for $607.10.  Had to pay before they’d treat me.  When things came out in the wash, I owed $565.34.  I called again to find out where the difference was and a request to credit my card was made.  I will have a credit in 7 to 10 business days versus the 30 to 45 days if I had allowed the system to reconcile things on its’ own timeline.

I paid the doctor $98.07 out of HSA funds since I did’t understand the whole big red boat thing anyway.  I surely won’t get rich from healthcare tax deferral.  A – I do not put in enough and B – the interest is only a dollar.   Would be years before I use these funds to get my yacht.

Well we’re moving on up, to the east-side, to a deluxe apartment in the skkky iiii  … we finally got a piece of the piiiiieee. 

I’d laugh if it wasn’t pitiful.  And my family and I, we are the fortunate ones.  I had a credit card with no balance to drop the charges on.  I hate like heck that’s what it took but I am grateful I could.  Why should I even care about anyone else?  Oh but I do.  Cue the haters.  I can take it.

As always, more to come.

17 thoughts on “So, … More Funny Math of the Heathcare Insurance Variety

  1. Insurance is the problem. For the doctor to get paid what it cost they have to bill the insurance triple that. Example to visit my doctor would cost 45 bucks BUT for insurance to pay that 45 buck he has to bill 135(so yes if you are uninsured you get to pay the whole 135) I only know this because I had to go to war with the insurance company a year ago over medication. I am 51 years old and only take one medication. Otherwise, they have never paid my doctor anything. If there is a visit they send me a file claim. Here is how it goes. Your doctor billed us 135 for your recent visit. He can only charge you x dollars(it is always different) We will pay NOTHING. You owe your doctor x dollars. The doctor is willing to take only what insurance says they will pay(collected from you of course) because they are allowed to write the difference off of their taxes as a cost of doing business loss. Back to the lecture at hand They didn’t want to pay for the one medication I have to have. So, I appealed it. They tell you that your doctor has to appeal it. That is a lie. They tell you this because they know your doctor does not have the time OR the resources to deal with the 6 MONTHS it will take to jump through all the hoops they will make you jump through. Dealing with the insurance company DAILY, for HOURS a day, proved to me how corrupt, and down right dishonest the insurance companies are. They lied, told me something different every day, they’d tell me to file this paperwork out only to tell me hours later, they didn’t know why I filled that out, they don’t need it. Bounced from department to department to be told something different each time. It is a shameful sham.

    I am blessed. BUT this year I had to have 2 emergency procedures(within the last 2 weeks, as a matter of fact. I am still recovering) Insurance wont’ pay for one of the emergency procedures it needed a prior authorization, because you always know when you’ll have an emergency, right? The other procedure they will pay for BUT NOT the anesthesia. Huh?

    Yep you read that right, they wont pay for the anesthesia. So it was either give me some whiskey and a leather strap to bite down on, or pay for the anesthesia myself. The doctors couldn’t help they had to cut me open. It was an emergency. The doctors can’t help that to operate they had to put me to sleep. Sooooo one would think that if the insurance will pay for a procedure that REQUIRES anesthesia, then they would pay for the anesthesia. NOPE.

    To answer your question about what does it cost, did someone get messed out of money. No here is how it works, according to the doctors office, and the hospital(again from my appeal, I contacted several medical offices, and the hospital) The doctor or hospital bills the insurance company. They(and by extension, you) are now at the mercy of the insurance company to decide what they will pay, if anything, and how much they will pay. The insurance says we will only pay x amount. The difference between what is billed and x amount insurance pays is a loss for the doctor, and they get to write if off at the end of the year on their taxes. In reality it is a win win for the docs and the insurance because the doctor inflated the bill in the first place to cover their cost, knowing insurance won’t pay the full amount anyway., the difference is written of as a cost of doing business. The insurance keeps getting your premiums while paying pennies on the dollar for procedures, if they pay at all.

    The customer/patient/one paying all the bills for all of the above gets the short end of the stick 🙂 Sorry for the looooooong comment.

    Liked by 1 person

    1. First of all I hope you are doing well now. One emergency is more than enough but two! Oh my. Sorry that you had to deal with such a mess from the insurance carrier on top of what is already stressful. To outright deny is criminal. And on the one they do pay, makes no sense to me that they’d refuse the anesthesia part of the procedure.

      I have done same with medication when fighting for name brand vs. a witch to generic after 12 years of taking something I will need the remainder of my life. Took me multiple tries and combinations of medication to get results and the insurance company wanted me to go back to square one with a generic which in theory I am not opposed to but I had been there done that and tried everything – three years worth before landing on what I take now. All this reminds me I will be gearing up t battle them again. I split my pills by 4 but will run out eventually. The splitting alone should show I am not trying to screw over anyone. I want to keep taking what works.

      I wish just one party to this crazy train would say enough already! Doctor’s should bill what it costs and get paid that amount. Simple right? All the shady mathematical gymnastics are not required or appreciated.

      Liked by 1 person

      1. We traveled the same road my friend. What I have to take there is no generic. There are other medicines that treat what I have, and over 16 years ago my doctor went through all of them with horrible side effects. BUT they all the sudden didn’t want to pay for the name brand any more. Even though it is covered under my policy. It’s not like i was asking for something that isn’t covered 🙂 They put me on the phone with their “pharmacist” who suggested all these drugs that we had already tried. I asked her when she graduated from med school. She said she isn’t a doctor but a pharmacist. I said isn’t it illegal to prescribe medicines if you aren’t a doctor. She said she wasn’t prescribing but making suggestions. When I told her we already tried all of them but 2(because they are new but were in families we had tried that all almost killed me) She said well bodies change, they might not effect you that way now. My reply was, well maybe if they killed me then you wouldn’t have to pay anything or maybe that is your goal. Anything to not have to pay for something that IS covered by my policy. After the “maybe killing me is the answer” the pharmacist excused herself from the call, and the “manager” who had conferenced her into the call took back over 🙂 They are criminal to say the least. Any other business would be out of business.

        The doctors are held hostage too because if they complain or stand up, then they are booted out of the network, AND investigated by the medical board. The doctors, and dentist around here are starting to NOT take insurance AT ALL. They will kindly bill the insurance for you, as a courtesy BUT what insurance won’t pay, you are responsible for. The dentists started it, and the doctors are following. Miraculously the bills are going down as a result.

        I have had the same doctor since I was 10 years old. I am sensitive to everything. Insurance as well as other doctors don’t get it but mine does because he has seen the life threatening “reactions” I have. I have to stick with him or else I could literally die or worse be damaged. The dying is fine, heaven here I come, God willing. It is the “damaged” part I worry about.

        His nurses, he and the pharmacy still tell me they can’t believe I “beat” the insurance company. They said no one ever wins except the insurance companies. My doc said he hates to stop taking insurance but he can’t in good conscience try to treat people BUT have to check with someone from the insurance who has NEVER been to medical school much less practicing medicine for over 36 years telling him what to give patients. They’d lock you or me up for practicing medicine but the insurance does it every day. I feel if my doctor tells me this is the remedy for my illness I believe him. When the insurance says we know your doctor says you need this but we don’t think you do, try again. I always say, when did you graduate from medical school. Their answer will be they didn’t go to medical school. Yeah I trust the one who did go to med school.

        The shady mathematical gymnastics are required to keep you chasing your tail until you get dizzy and give up 🙂 It’s quite ingenious but still criminal 🙂

        As far as not paying for the anesthesia, and the “not getting prior authorization” for an emergency. I will do what I tell people to do…appeal, appeal, appeal every single bill. I don’t care if it is a yearly check up(which is usually all I have, and that is to get my prescription refilled) APPEAL IT! You will have to appeal it 3 times, call them every day but I feel if enough people quit giving up, and giving in it will be more cost effective for them to pay than to keep wasting resources on the appeals. it is all about the bottom line. It costs less, and makes them more when they deny, and we just try another remedy. When the appeals start costing them more of their bottom line they will start approving what the doctor recommends.

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      2. We are indeed kindred spirits.

        The generic for my medicine just became available in 2018. I fought my fight and won in 2017 and because I split my pills by 4, I have some time before I will battle them again. I worry about taking “expired” medicine but the use by date per my doctor is suggested and my blood work still looks good.

        This next time will be more of a fight because I cannot use the no generic available argument which tipped the scales in my favor last time. But I will still appeal because my insurance does cover it, in a higher tier with more co-pay but still covered. Oh and last time the pharmacist intervened and found me a discount from the manufacturer.

        Liked by 1 person

      3. I have a friend who is retired from pharmaceutical sales. He was in charge of eastern United States, and pretty high up there. He said 10 years is the active ingredient shelf life 🙂

        The pharmacist was nice and clicked every discount they could find when I was going through mine to get me the cheapest too. They were very helpful and sympathetic because they can see what is in my file and know I am highly sensitive BUT they still kept saying, the insurance will never approve this. I told them, just like I told the insurance company. Either they will do the right thing, or God will provide the money for me to pay for it.

        I take halves just because I am so sensitive, and it is working BUT you shouldn’t have to take a half or a 4th just because they are engaged in (my opinion) criminal activity. You don’t pay a quarter of your premiums, do you?

        Be sure when you get it approved that you get it for the life time that you will need the medicine. You might already be approved for life. You can call and ask them. I didn’t even think about that until after the whole thing was over, they approved it, and said they were sending me a refund for the prescriptions I had paid for myself. I called them. They said, no you will more than likely have to get it approved again but let me check. She came back and said it was for life. I said for life? She said yes, for life or until December 31, 2099. I said 2019? She said no 2099. So, they can do it for a lifetime. I guess it just depends on how much of a pain in their rear you are. How much of their resources you suck up. That is money they are losing 🙂 🙂

        Jill, maybe we should start a business doing insurance appeals for people 🙂

        Liked by 1 person

  2. There are so many sad examples. Before Medicare we were paying in excess of $3000 a month for the premium alone. The deductible was $6000 a year. We tried not to go to the doctor for anything routine. It was truly our safety net for a possible catastrophic event.

    My brother’s MIL was just taken out of a nursing home. Her 100 days that Medicare will pay is up. If she had tried to use Medicaid, they can seize assets in order to offset the care. This means she would lose her house, her car, her financial assets. So, if she were to recover, she would have no home to return to.

    It is all pretty messed up.

    Liked by 1 person

    1. Oh my, that is awful. No wonder people are giving away assets to family members. B’s great aunt gets to live in her house which is technically owned by her son until she passes. I never asked why they transferred ownership a few years back. Might have been in a similar situation.

      Liked by 1 person

  3. I have good insurance but i still avoid going for anything but my physical to get renewals of meds. Why? Because of extras that are OOP. Forex, mammograms that need “extra views” just to see that nothing is there for no reason. That’s beyond the routine visit and non HMO patients will get whacked with a bill of $400 or so afterwards. It’s happened to me before. I assume the same thing is true for a colonoscopy, so I haven’t done that either. “Hey groggy patient can we do this extra thing?” Uhhhh? Okay, I would probably say. Bam! Big bill in the mail. 😛 Yes, our system sucks. True cost? Who even know. Whatever the doctor needs to buy an upgraded Tesla…

    Liked by 1 person

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