The real problem with health insurance

[disneysteve]

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]

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]

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]

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]

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]

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]

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.