The real problem with health insurance

[rj.phila]

True. I just worry about how this affects people. How many patients put off getting needed medical care because they simply can't figure out what it will end up costing them? And calling the company doesn't generally help because if you call 3 times and ask the same question, there is a good chance that you'll get 3 different answers. Even the people who work for the company don't always know how things work.

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

[MonkeyMama]

I think it's almost better on some level to be uninsured in that then you know what you are paying for.

& NO - I do not recommend being uninsured. BUT, we do not have dental insurance (have not seen any plan worthwhile) and so in that vein we skip this game completely. We may pay more in the long run, but certainly no surprises. (& maybe even this is not true since I know so many people who blindly pay for unnecessary dental work).

Our health insurer (nonprofit, top rated) is also very good. I don't get bills -just about everything is simply covered. We switched to a HDHP a few years back - I only have a thorough understanding of how it all works because we have used the insurance very thoroughly since the switch. But - it is more along the vein of catastrophic insurance, and a little simpler to navigate. If I Was having surgery, I'd know exactly how much it cost before dedutible. After deductible? Haven't a clue. & would be hard to pin down - I have gotten different answers from insurer before, definitely. I know the maximum they can charge me though. Though I do not have a 100% thorough understanding, I have found this plan easier to understand than just about everything else out there (I have private insurance and do shop around). I should say I might pay more for insurance I Can understand. Though I am not 100% sure because I can not understand the other health plans!

Interestingly, with Obamacare, the insurer had to give us 60 days notice of premiums this year, but they failed to tell me what my deductible and out of pocket would be for 2012. Kind of USELESS information? (It is possible they can not change those figures, with the new laws. But I am not sure on that).

Health care reminds me of the tax code. It's about as complicated. I can hardly think of anything that comes near as complicated as these two monsters.

[bjl584]

I think it's almost better on some level to be uninsured in that then you know what you are paying for.

& NO - I do not recommend being uninsured. BUT, we do not have dental insurance (have not seen any plan worthwhile) and so in that vein we skip this game completely. We may pay more in the long run, but certainly no surprises. (& maybe even this is not true since I know so many people who blindly pay for unnecessary dental work).

Our health insurer (nonprofit, top rated) is also very good. I don't get bills -just about everything is simply covered. We switched to a HDHP a few years back - I only have a thorough understanding of how it all works because we have used the insurance very thoroughly since the switch. But - it is more along the vein of catastrophic insurance, and a little simpler to navigate. If I Was having surgery, I'd know exactly how much it cost before dedutible. After deductible? Haven't a clue. & would be hard to pin down - I have gotten different answers from insurer before, definitely. I know the maximum they can charge me though. Though I do not have a 100% thorough understanding, I have found this plan easier to understand than just about everything else out there (I have private insurance and do shop around). I should say I might pay more for insurance I Can understand. Though I am not 100% sure because I can not understand the other health plans!

Interestingly, with Obamacare, the insurer had to give us 60 days notice of premiums this year, but they failed to tell me what my deductible and out of pocket would be for 2012. Kind of USELESS information? (It is possible they can not change those figures, with the new laws. But I am not sure on that).

Health care reminds me of the tax code. It's about as complicated. I can hardly think of anything that comes near as complicated as these two monsters.

There is something to be said for being uninsured AND having the cash available to pay cash for medical procedures. If you are rather wealthy and simply go to the doctor/surgeon and the hospital and offer up cash for a procedure and a hospital stay, it is much simplier than having to puzzle over insurance coverage and copays. But, most of us don't have that ability.

[disneysteve]

Hmmm...I wonder if it is all in the question? If you ask the surgeon's office for how much they might BILL the insurance company for a procedure such as this you might actually get an answer from the billing department. If they could then provide that information to the insurance company prior to the proceedure, the insurance company MIGHT be able to give an estimate on the cost share of the procedure. Maybe.

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.

[creditcardfree]

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.

That makes absolutely no sense to me. I wonder if it needs to go up to a supervisor. There is no way they could not know. It seems they could give a number, but emphasize it is an estimate. I think they just don't want to deal with giving figures until it is a true claim, for liability reasons.

This is really a very good example of what is wrong with healthcare. Too many middle men, specifically insurance. If it was just doctor and patient. There would be not be this kind of problem.

[disneysteve]

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]

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]

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]

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]

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?