You GOTTA have insurance

[boulderjohn]

I was once seriously injured in a bicycle accident that was clearly caused by the person with whom I collided. I ran up quite a hospital bill and had other monetary losses. I only had to pay the deductibles, but I know the total billed was a small fortune. I sued the guy who hit me. The attorney explained to me that if I won, the insurance company would want to be reimbursed out of my award. I asked what the point of my suing would be if the attorney took 1/3 of the award and the insurance company was fully reimbursed for its payments--how would I get anything out of it? He explained that the insurance companies do not actually pay the amount they are billed--they negotiate lower payments. Under law, we are compensated in a lawsuit for the amount that was billed, but the insurance company only gets reimbursed for what it actually paid.

Well, I got a pretty good settlement, and the attorney notified the insurance company so that they could be reimbursed for the amount they had paid. It turned out they had not paid anything! The amount they had actually paid to the hospital was less than I had paid in deductibles! They had not paid a dime, and they had made a profit off of my hospitalization.

Years ago, when my younger son was still on our insurance, he got an eye infection, and he got a prescription for our standard deductible cost of $30. A few months later, he got it again, and we paid another $30 deductible for it. A few months later, we were all in Cozumel together, and he got it again. With no insurance available to us there, he went into a local pharmacy and bought it without a prescription, paying the full retail price of $5. Again, the insurance company was paying nothing and making a profit from the deductible.

It is indeed possible in some cases to do better without insurance. In my local hospital's lab, an uninsured patient will pay $19 for tests for which the insurance company is billed (but doesn't pay) hundreds of dollars. That is not true in most cases, though. In my bicycle accident, if I did not have insurance, I would have been billed the full amount that the insurance company was billed but did not pay, and I would be in debt to this day.

 

[Storker]

In my local hospital's lab, an uninsured patient will pay $19 for tests for which the insurance company is billed (but doesn't pay) hundreds of dollars.

Who pays the difference? Is the insurance company thoroughly fleeced (which I have a hard time believing, given what they can afford to pay their lawyers, and hardly any medical test really costs only 19 USD), or is someone else picking up the bill for the uninsured patients?

 

[boulderjohn]

Who pays the difference? Is the insurance company thoroughly fleeced (which I have a hard time believing, given what they can afford to pay their lawyers, and hardly any medical test really costs only 19 USD), or is someone else picking up the bill for the uninsured patients?

I don't know how it works, but I do not hear of insurance companies going out of business, and I hear continually from insurance companies who want me to choose them in the next enrollment period. They must like the way things are now.

Here is another story people might find interesting.

A friend of my brother's took a job in an insurance company. One day she got a letter from a customer making a large claim for medical treatment received. She saw that it had been misaddressed to her department and should instead have gone to the department right across the hall from her. She delivered it there. She was reprimanded, and her superiors explained to her that in such instances, she was to stamp the letter "Claim Denied" and return it to the customer without explanation. If the customer wanted to find out why the claim was denied and so send it to the proper department, it was up to the customer to take those steps.

It happened to me. I had to be treated out of network, paying out of pocket, and I had to fill out a form with a simply mind-boggling grid of questions in order to be reimbursed. My claim was denied without explanation. It took 6-7 exasperating (and sometimes temper-blowing) phone calls to find out why. I almost quit in frustration. It turns out that the form had 2 different places on the same page for me to put in my social security number. I had missed one of them and left it blank. Once I filled in the blank, they reimbursed me.

 

[lexvil]

Who pays the difference? Is the insurance company thoroughly fleeced (which I have a hard time believing, given what they can afford to pay their lawyers, and hardly any medical test really costs only 19 USD), or is someone else picking up the bill for the uninsured patients?

There is no difference, billing is a sham, until someone truly gets a major injury/sickness, that may cause extended hospitalization the deductible and co-pay will almost always be more than the cost, by over billing and settling for less the claimed loss override the profit for a giant tax write off.

Only Americans who look to TV personalities for guidance on everything from politics to health care (actually the same thing) and paying these costs and through foolish follower syndrome think they are the only ones in the world getting good health care.

 

[Jcp2]

The billed rate and the subsequent contractual write off is a fictional entity that would have no real impact until relatively recently, when patient cost sharing became more prominent. In the past, if you had insurance you would not have seen this at all. If you had no insurance the hospital and/or doctor would write it off individually but cost shift profits from insured patients to cover the cost, because it’s part of being a hospital. If hospitals only provided profitable services, then there would be no pediatrics, no neurology, no psychiatry, much less obstetrics, and no geriatrics.

 

[boulderjohn]

Years ago I needed a surgery for which I could choose the date. I waited until November, when I had reached my out-of-pocket maximum and would not have to pay the considerable co-pay for the surgery. The hospital contacted my insurance provider ahead of time and got pre-authorization for payment. I had the surgery, and everything went as planned. As planned, I spent the night for observation and was released the next day.

Well, a few weeks later I got a bill from the hospital for more than $144,000. It turned out that when the secretary in the hospital had gotten pre-authorization, she had accidentally keyed in the code for out-patient surgery. Since I had spent the night (which is always done with that surgery), the surgery I had was not what was pre-authorized, and the insurance company was refusing to pay. The hospital was demanding that I therefore pay the full amount.

As you might guess, I protested, and after many phone calls, the company agreed to let my payment await further discussions with the insurance company. (It was not until much later that I learned that under the law, when the hospital makes a mistake like that, it has to eat the full cost of the surgery. They were trying to trick me into paying something I did not owe.) Two years later I was notified that the insurance company had decided to pay the bill, and it was resubmitted. Of course, they waited until the beginning of the year to do this, so I was billed for the full co-pay. I protested that the billing should be based on the surgery date, when I would not have had a co-pay, but I eventually lost that argument. I am sure the hospital and insurance company agreed to settle case this way, knowing that forcing me to pay the co-pay would essentially be forcing me to pay the actual cost of the surgery. Everybody won but me.

 

[Darnold9999]

My partner fell off a ladder and broke her arm just below the shoulder. Required an overnight stay at the hospital, emergency surgery and pins and a plate to put it all back together. Total cost to her $0. Total cost for annual medical insurance $0. Yes I know it comes out of taxes, but so do roads, our military and other things we use as a community. While it is certainly not perfect I can't imagine living in a user pay system for medical care??

I am related to someone that had a daughter with a one in ten million disease that required months in children's hospital and surgery by a Swiss doctor to mitigate. That same someone suffered a spinal stroke some years later and is now paraplegic. They are a regular working class family - in Canada they had significant expenses related to all of this, but the medical bills were all $0. I imagine bankruptcy or even death would have been the likely outcome for them in a private insurance jurisdiction.

 

[johndiver999]

Family member was recently involved in a motor vehicle accident where the Air bags deployed. EMS ride to emergency room. Treatment was band aids, ice and I think tylenol. Total time in ER: under 3.5 hours.

Diagnostics performed (that I know of):
Examination by ER doc
X-ray
Cat scan
Probably blood tests of some sort,

Result: found no discernable injuries other than bruising, skin abrasion, prescribed pain killers. Immediately sent home.

Hospital bill alone was over 30 k!! EMS is extra.

It is beyond insane.

Other driver was at fault and their insurance will presumably pay. Does not negate the fact that the current situation with health care is insane in this country.

 

[boulderjohn]

A friend of ours living in Canada was diagnosed a number of years ago with stage 4 cancer. She got immediate treatment and is doing fine now. She has so far paid exactly $0.00.

 

[agilis]

My recent open heart surgery bills totaled close to $200,000. I paid a $15 co-pay to the surgeon, and $75 for the local hospital's emergency room visit that was my first stop. That's it. I was able to select both the surgeon and the hospital, as well as choose the date for the surgery. I pay nothing for my health insurance, something NJ gives to certain retired employees with at least 25 years of service. I think I'm extremely fortunate in more ways than one. Other than the nicely healed scar that ruins my plans for modeling men's beach attire for women's magazines, I feel pretty good. A lot better than I did before the surgery in many respects. Things I had attributed to getting older were actually caused by restricted blood flow to the heart. Turns out I did not have a heart attack, just pain, so zero heart damage.