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An Interesting Look at Medical Insurance

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Posted 8/1/2010 4:31 PM (GMT 0)
So I am just sitting around today trying to catch up on some loose ends. I decided to reconcile my medical payments and the report I get from the Health Insurance Carrier every time a new claim is submitted. Thankfully I have reached my total out of pocket for the year and won't pay anything else for anything medically related.

I downloaded a year to date summary of all claims into a spread sheet and then totaled each of the categories.

Now it shouldn't be a surprise but two of the totals kind of jumped off the page. Makes one say Hmmmm!

Total of all submitted claims for my family, Me, Lynn and Son, $162,022.00. And the total paid to the billing entity by contract with the carrier, including my portion, $46,438.00.

Now if I had been a poor sap with no insurance, I would have been expected to pay the full amount.

I know that this is not uncommon, but it is the first time I have looked at it on my own personal expenses. I don't even want to go back to 2006 and look at the disparity of billed versus accepted in the year of Lynn's stem cell transplant, major chemo, radiation, and 45 day isolation stay in the hospital, just to name a small portion. And oh yeah, there was one of the drugs she was on that the supplier was billing at $9,600 per month and our co-pay was $45.

Just an observation and put forth for conversation,

Sonny
Posted 8/1/2010 6:11 PM (GMT 0)
Sonny,

As one who is well aware of the cost of medical treatment when one is uninsured your observation reinforces my perception and experience. When I was going through the testing to confirm the PCa (CT and Bone Scan) I was in a bigger battle with the hospitals over the charges. My daughter works for a well know insurer and gave me some typical reimbursements. The hospital was charging me three to four times the insurance amount. They also tried to tell me that the patient had to make up the difference even if insured. I knew this was BS as I had previously been insured and if the provider was in network there were no extra charges to the patient. I was finally able to secure a meager 10% discount by paying cash upfront. The financial director at one institution told me the reason for the higher charge was there was a higher risk of recieving payment. Huh?! I reminded him that I was the one taking the risk as he was holding my check for the full amount in his hand and I had received no treatment as of yet.

My experience with my urologist and radiation oncologist was better. They gave me a 30% discount and billed me once a month. I always paid in full. My lupron was well below the cost I had been quoted by the pharmacy and was most likely at the urologist's cost. So, there are some compassionate souls in the medical business.

One of the hopitals that agreed to the discount later sent my account to a collection agency for the 10%! After a few choice words with their accounting department this was quickly corrected. Insult to the injury. Even more galling was a request for a donation to the hospital a year later. This was so they could offer the less fortunate in the community medical care at a reduced cost as they were a "non profit" organization.  Reduced to whom?

My second opinon required me to pay cash up front as well. The check was $3000 just to get in the door. They took thier time with the refund of the balance but still made off with $2200 for a three hour meeting with the doctor. By the way, they first sent in a PA to discuss the findings. It was only after I complained that I was expecting to see a urologist or an oncologist that I finally saw the doctor. He seemed a bit miffed that I would not accept the PA as the sole arbiter of my condition. It took some doing but I finally got a decent evaluation and report from this institution.

Be thankful for the insurance company that can deal with the providers on your behalf.

Apologies if this comes off as a rant. Not my intent.

Best Regards,

Don

Posted 8/1/2010 6:13 PM (GMT 0)
Sonny it is very interesting when you look at what amount is billed and what the contracted amount that is paid out. I was happy to see my surgeon get far less than what he billed. But yes when you look at someone who doesnt have the power of insurance it can mean having to sell the farm to pay the medical bills. I have also caught errors by going on line to keep track of billing and payments. Caught one for 4,700.00 that was billed to me and I wasnt even at the Dr.'s office on that day. That had billed my account for service done on someone else. Whe I called the Dr.'s office the billing person said they would put in a disputed claim for me. I said there is no dispute as I wasnt even there that day, never saw that Dr, before and I told her I would let the insurance company know asap. Never did get a dispute form, but it was taken off my account.

Michael

Posted 8/1/2010 6:35 PM (GMT 0)
Just as a note. Look at the things that are not covered on our policy. Ex. the rec. pills. Look what the paramacy gets from incurance for the pills v/s what we have to pay. Something is wrong with all of this.

Cajun Jeff
Posted 8/1/2010 7:19 PM (GMT 0)
Ok, rest easy, I'm from the government and I'm here to help.

I really expect it to get worse. Probably the big discounts will start to evaporate because the insurance will be forced to pay out more in claims, and we may be forced to make up the difference. And insurance rates, deductibles, and co-pays will go up.

But, I suppose I am pessimistic. It's a tough thought process to go between employer, insured, and taxpayer. I have different view points from each different vantage point.

As an insured, I am very thankful for good insurance. My total PC process, with second and third opinions, surgery, and follow up probably cost me less tha $200 out of pocket.
Posted 8/1/2010 7:33 PM (GMT 0)
I think Obama wanted to change all this, I really think that's what he wanted to do..But the Medical Lobby descended on Congress with all their might, the Republicans linked arms to block any real change in the system, and the status quo has been pretty much maintained.

I suspect a very large percentage of the OVERALL medical care being provided in the U.S. is being paid for by Medicare, Medicaid or the V.A.

Instead of doing everything possible to control costs, the Medical Industry seems to do just the opposite..The sad thing is, for this money spent, we don't live any longer than people in countries that spend just a FRACTION of what we do on medical services..It's just a huge transfer of wealth...
Posted 8/1/2010 8:56 PM (GMT 0)
Is there anyone who doesn't think the system is broken now? (Sorry. Guys like Cleve Killingsworth, chairman and chief executive of Blue Cross and Blue Shield of Massachusetts, who received 3.5 million and 4.8 for 2008 and 2009 can't reply. We know they think everything is fine. ) Remember there are CEOs for every state and some states like NY get multiples - lucky us. Also there are the VPs, the Asst VPs, the CFOs, their cousins ... Heck, even fired execs like Mike Unhjem, N Dakota, collect $2.2 million. How many billions per year is that? And not one nickel of it goes to actual health care.
We've tried this system for so many years and look how it morphed into a get rich scheme for a few very powerful individuals. Isn't it time to at least look at something different?

Another thing that bothers me is the varying price for the exact same work done in the same lab depending upon the insurer. We are not in Korea or Italy where it is expected that everything is negotiable. There should be set prices.

Just sayin'...
J

By the way, just for fun, .check out the top dog's salary in your own state. Unless he's your son, the numbers will make you sick.

Post Edited (Worried Guy) : 8/3/2010 1:38:23 AM (GMT-6)

Posted 8/1/2010 9:46 PM (GMT 0)
From the point of view of the patient (us), the best system is Medicare. They set the price. Most hospitals and doctors chose to take what they pay ("take Medicare assignment")--it's too big a part of the health insurance pie for them not to. Medicare pays for most medical care with little need for "gatekeepers". The administrative costs are far far less than commercial insurance. The cost of Medicare funded health care, per item, is substantially less that that funded by commercial insurance. My health insurance is from my state, so it has some, but not all, of the good features of Medicare. I'm counting on getting Medicare in a few years.

If we had Medicare for all (AKA "single payor"), hospitals, doctors, pharmaceutical companies would all take some financial hit. The insurance industry industry would go bankrupt, out of business, gone. That's why there was fierce lobbying against any expansion of Medicare to cover more people, and that's why the health care reform bill was so imperfect--it was either an imperfect bill or no bill. However, as the US budget deficit grows, we'll be faced with a choice of doing single payor, or raising taxes substantially.
Posted 8/3/2010 4:55 AM (GMT 0)
My GP does not accept Medicare, so all things remaining the same, I would have to find a new doctor at age 66. Wonderful.
Posted 8/3/2010 11:51 AM (GMT 0)
That $100k diff that the Dr and facility was shortchanged on is guess what ,,,a tax write off

Now imagine how large the write-off is when most patients generate more write-off than what the Dr was actually paid

I used to wonder why they bothered billing so high when they knew they would only get less, well the taxman says its better for their business to claim they lost on the surgery
Posted 8/3/2010 1:14 PM (GMT 0)
So we simply end up paying one way or the other -some to the hospital, some to the doctor, some to taxes, and some to the insurance companies. The only one of the four that I can ever hope to reduce or eliminate are the insurance companies.
Sure they tout that they might be more efficient than the government but when I see that the wages of the top dog and his minions are 10x the wages of the president of the US. Something is out of whack. Why must there be multiple TDs in so many states? Because they can. There should only be a single top dog, an STD if you will. And his pay should be less than the president's pay. Don't worry about the myth of attracting and retaining top talent. The only talent they show is the ability to grab funds and benefits for themselves. If it takes more than that to keep them, then good riddance.

I see that on June 10 "Vermont regulators ordered Blue Cross and Blue Shield of Vermont to refund $3 million to its subscribers following an investigation into a $7 million retirement package given to former CEO William Milnes.
Paulette Thabault, commissioner of the state Department of Banking, Insurance, Securities and Health Care Administration, says Blue Cross has agreed to make the premium refunds to end the state's probe into excessive compensation given to Milnes.
Milnes retired in 2008.
Officials eventually determined that Milnes had been paid substantially more than he should have been, given the size of the company."

Note they did not take the money from him. They took it from BCBS and taxpayers who will no doubt make up the difference. Shameful.

"Off with their heads!" said "Leakspierre" Jeff
OK I'll stop my rant now. (No more caffeine for me!)
Posted 8/3/2010 1:59 PM (GMT 0)
Today's local newspaper had an interesting article that fits right into this discussion.

A local lady had orders from her doctor for some blood work. Having no insurance she called around to find out the costs. Having something called a "Partner Card" from her doctor's hospital she called them and was told the blood work would be $800, but since she had the partner card her cost would be $400.

She called an independent lab across the street from the hospital and was told the battery of tests would cost $257.

Along the same lines. My doctor gave me a 1 year script for 5mg Cialis for rehab purposes to be taken 1 per day. Of course we all know that the insurance carriers will only approve 5 or 6 pills per month. At the time my co-pay would have been $60.

So I asked the Pharmacist what the cost would be if I filled the script without insurance. She told me a one month (30 pill supply) would cost me $118.00.

There is just no figuring anything in the world of medical and insurance billing.

Sonny
Posted 8/4/2010 3:26 PM (GMT 0)
 

One thing really stood out to me on this thread and that is that doctors and hospitals know they are billing more than they will get paid --- and they do that so they can take a loss on their income tax!!!!  So, do they pay tax at all? 

Post Edited (donnathewife) : 8/4/2010 10:02:20 AM (GMT-6)

Posted 8/4/2010 8:26 PM (GMT 0)
Good question Donna.
Hospitals and many health insurance providers claim they are Non-profit entities. That does not prevent them from paying their upper echelon those outrageous salaries. In many cases the company prepares and pays the income taxes the top dogs owe. Poor things. I also like the low or no interest loans offered by some. Yep, it's broken.

Jeff
Posted 8/4/2010 9:37 PM (GMT 0)
yep, it is a FOR profit business, another reason I am glad we left the country and had HIFU !!  How can you trust them on health when it's clear that so many of them just care about $$$, I am sure some are good, but how do we know who??
Posted 8/4/2010 10:02 PM (GMT 0)
donna,

and you don't think your out of the country treatment wasn't for profit? the way that most, not all, american health insurance providers negotiate with the hospitals/doctors/treatments in recent years, has actually worked in favor for the patient. ask around here, most american men here have had to pay very little out of pocket for their PC treatments, myself included. i believe that our canadian and british brothers under their systems, also pay little to nothing out of pocket. a good medical practice, i.e., urological services, still has to be ran like a tight business, and like all business, absolutely doesn't want to pay more income taxes than any other business out there, that's the american way, lol. that part, is just business, but has nothing to do with the quality of the doctors or their services.

i think HIFU like your husband had, has very good possibilities for men with low grade PC, and meeting the criteria for safe treatment. He is braver than me, I know it will be ultimately approved by our FDA, but until it is, I wouldn't have the nerve to i leave the country and undertake a primary treatment like that, that hasn't been approved yet by the FDA. Its not a right or wrong thing, in my opinion, its a preference, and all treatments have risks associated with them.

the few men here at HW that underwent HIFU, I believe, if memory serves right, have all done well. One day, of course, the number of people doing it will increase once its approval is cleared for mainstream use in the US.

i hope he continues to do well, and that it zapped the living fool out of his cancer. my best to the both of you.

david in sc
Posted 8/8/2010 6:16 PM (GMT 0)

For those currently without insurance.....................

As a result of healthcare reform, each state has a designated insurance fund provided to those who cannot get health insurance because of pre-existing conditions. In PA, the cost of this insurance is roughly $250/month with a $1,000 deductible and it covers everything including drugs. The special fund is effective through 12/31/2013, at which point no insurance company can turn you down. In order to qualify for your state's special insurance fund, you just need to be uninsured for the preceding six months.

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