Pretty soon you're talking about real money
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That was the verbal story I was given at the time. Along with a warning from the surgery center Administrator to call her if I had any trouble from my insurance company. Which sank my heart a bit. I worried that she knew she was going to be trying something they might not like. Then there was the wording on the estimate, the first line of which warns that the bill sent to the insurance company will be large but that I shouldn't worry because these things get negotiated down. But behold, no negotiation, just retail, right there on my insurance company's website that collates all my current medical bills. And when I called the insurance company, they are uninterested in doing anything about it. They just want me to call the surgery center. And I can't get in touch with the surgery center Admin because she's on vacation this week.
It's a little odd that the surgery center is "out of network" since they work exclusively with surgeons who are "in network" for my insurance. I think they intentionally are "out of network" so they can send these sorts of bills and leave the patient with the choice of paying the cash immediately to make it go away, or letting them suffer under the massive debt.
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You're either pre-approved, or you aren't. If you were pre-approved, the surgery center screwed up the filing. It needs to be refiled. If you were lied to, and you weren't told you were not pre-approved...Might be time to get very serious
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I don't know from pre-approved. The estimate I was given before the surgery indicated uncertainty but a specific number was quoted that I would be expected to pay within 15 days of receiving the statement. Which I have never received, for some reason. There was a number to call, on this estimate. I called it and a recording told me to email them because they're not in the office because COVID. The email address is "collections@<blah>.com". Collections, of all things. I guess they want you to know they're not messing around. I emailed them last night and received this in response this morning:
Good Morning,
Because we are out of network, as a courtesy to the Provider and the patient we are accepting the carrier payment, you are only responsible for $1,444.23, as per the agreement this needed to be paid 15 days after the procedure.
Kindly call me to make your payment.
So this person doubles down on the "out of network" aspect. Of which I was never apprised prior to surgery, and which would seem to preclude any pre-approval from my insurance company.
Note also that the email says I needed to pay within 15 days of the procedure, while the written estimate indicated 15 days from when I receive the statement. Which I have never received.
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The US has a weird system.
The insurers are the customer, patients just a necessary input.
My understanding is that often the physicians and practitioners have no idea what the procedures they do ending up costing. There’s no mechanism in the system to understand the cost / benefit of treatment A vs treatment B.
As in treatment A maybe be 10x more expensive than treatment B, but only slightly more effective in trials. (Or even essentially the same level of effectiveness)
The system is set up that way though. An analogy I heard on an econtalk podcast was that it’s like going to dinner and splitting the bill. You know everyone else might order steak, so you order surf and turf too. Everyone does. We all split the bill and insurance pays. So everyone gets the absolute best that money will buy, at all times.
There’s few market mechanisms in place to keep the cost down. The hospital often doesn’t even know its cost for procedures.
It’s not a market system. It’s a system where we have unlimited private money going in to a system without cost controls.
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That podcast was excellent. If depressing.
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I've told the story before about my FIL having a back problem when he was visiting us, and the hospital recommended a scan. He asked the doctor the price, and was told 'about $1000', so he went ahead. They sent him a bill for over $10,000. We weren't at all sure the insurance would cover it since it was a pre-existing condition, thankfully they did.
I'd probably get fired if I was so clueless about what we charge for services.
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No kidding, @Doctor-Phibes !
Not the same at all, but when my first daughter was born two years ago, she was 7 weeks early. I can tell you, maybe out of pure ignorance, but both during the labor as well as the 3 weeks in the NICU afterwards, not once did I think about the cost. I presumed our insurance covered it all. Luckily it did, but again...I didn’t think about it, nor would I understand how it works if someone told me.
Later I found that the NICU stay was like $90,000 pre-insurance.
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@xenon said in Pretty soon you're talking about real money:
The US has a weird system.
The insurers are the customer, patients just a necessary input.
My understanding is that often the physicians and practitioners have no idea what the procedures they do ending up costing. There’s no mechanism in the system to understand the cost / benefit of treatment A vs treatment B.
As in treatment A maybe be 10x more expensive than treatment B, but only slightly more effective in trials. (Or even essentially the same level of effectiveness)
The system is set up that way though. An analogy I heard on an econtalk podcast was that it’s like going to dinner and splitting the bill. You know everyone else might order steak, so you order surf and turf too. Everyone does. We all split the bill and insurance pays. So everyone gets the absolute best that money will buy, at all times.
There’s few market mechanisms in place to keep the cost down. The hospital often doesn’t even know its cost for procedures.
It’s not a market system. It’s a system where we have unlimited private money going in to a system without cost controls.
Where do you come up with this stuff?
Almost none of what you say is true.
Maybe you have one or two anecdotes.
But of course there are cost controls, and audits and accounting rules.
There is lots of competition in insurance and services and medicine.
Your post is not anywhere near reality.
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@Jolly said in Pretty soon you're talking about real money:
They just need to refile. Errors like this are common.
Yep. I'm dealing with one now for my cataract surgery last fall. Likely coded wrong or incorrectly denied. It helps that I have a background in both healthcare billing and insurance.
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I assume the insurance guy would have been able to tell me that this place was in network and that it was a simple mistake that it was billed as out of network. Also the email I posted above affirms the "out of network" billing. The guy at the insurance company wanted to be included in the conversation when I called the surgery center. He apparently expects this to be a negotiation rather than a simple fix of a clerical error.
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@Copper Is there cost competition on standard of care?
I thought there would be tiered healthcare in the U.S. when I moved here (as in better stuff for people who had more money and better insurance). But if you're insured, everyone seems to get the "gold standard of care". Your insurance just tells you how much out of pocket you're going to pay.
And the U.S. definitely has the best of the best in terms of equipment, drugs and services. (doesn't always equate into best healthcare outcomes though)
A lot of this perspective is from listening to a recent talk by Vivian Lee
The interesting insight for me is that on standard of care - typically physicians aren't looking at cost effectiveness, they're looking at efficacy.
We have physicians here - I'd love to hear from @George-K if he ever thought about treatments and made decisions on the dimension of how much they would cost?
There's competition in the system - but not necessarily in the places that are driving the cost increases.
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I think most of what Xenon said is defensible. At least if you allow for some exaggeration (e.g. there are some cost controls, not none, they're just very weak).
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I just paid the $1400. The place is indeed out of network, while literally all the surgeons they work with are in network. They have a strict 15 day policy from the date they mail the first statement, which I am unaware of ever receiving but which they say they mailed on June 29. They bill the insurance company as out of network. Their business model is apparently to get the tiny fraction that the insurance company pays out of network providers, and a little bit more from the patient. It is unclear to me whether my insurance company would have covered 100% of this had they been in-network - I think they would have, since my deductible is covered. The surgery center gave me a story the morning of the surgery that they would be charging 15k to insurance, who would cover 90% and I was responsible for 10%. That story was completely fabricated as far as I can tell.
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@xenon said in Pretty soon you're talking about real money:
@Copper Is there cost competition on standard of care?
There's competition in the system - but not necessarily in the places that are driving the cost increases.
Of course there is competition.
And of course the better doctors cost more.
Here is a program I used up until last year.
It was not covered by insurance, I paid for it myself so I could have access to the doctor I wanted. Believe me, this was a cost increase.
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@Copper The most expensive thing we've done in the U.S. is have kids.
In SF our OB gyn's resume was ridiculous (Harvard, Standard med school, head of OB at UCSF... lots of other prestigious positions).
In Seattle our OB was fantastic - but a bit more "normal" on the qualifications and earlier in her career (we actually loved her, since she had more time to spend with us).
Don't know what they cost - wasn't any different for us.
