Joe Perez

iTrader: (8)

My whole portfolio is filled with stuff like this:



This was a very minor "surgery." Lumbar steroid injections, administered under a flouroscope. Still, done in a proper hospital setting, where at least 8-10 people in total participated in the process.

The hospital billed $2,700. Insurance "denied" $2,294.75 of that, meaning it just completely went away and the bill magically dropped to $405.25. They then paid $324.21 of that, leaving me with a bill of $81.04.

To recap: the hospital recovered a total of $405.25.

But if I didn't have health insurance, I'd have been billed for $2,700, and since I'm not a health insurance company, I don't have the magical power to "deny" 85% of that bill, meaning that I'd be on the hook for the full amount, with no recourse, and the hospitals gross would increase by 650%.


This whole system is fucked up, and annoys me.

DNMakinson

iTrader: (3)

Chances are the insurance company pre-approved coded procedure #1234, but the third party billing company billed code 1235, so it was denied.

My last back surgery took 11 months to get straightened out. And even then, it was corrected because I engaged a 5th party company* that my employer offers to help sort things out. Oh, surgeonn's fee is still up in the air.

* Me, My Company, Dr and Hospital, the "insurance company" that administers for my self-insured company, and then this fifth party that helps sort out the screw-ups.

Also, if you don't have insurance or means, you can negotiate forgiveness, as long as you do so before the bill goes to collection.

Yeah, totally screwed up.

bahurd

iTrader: (8)

Self employed so I pay 100% insurance. My wife routinely negotiates 25-35% bill reduction but will wait for 1 billing cycle before she initiates call to "pay today if you do xx% off".

25% off is a given.

It is pretty screwed up.

18psi

iTrader: (76)

That's not how it works.
I work in this industry, auditing these things. Without wasting too much time, here's a recap:

hospital does a thing for you
it realistically costs 20 bux, and they're contracted with insurance to get reimbursed 20 bux for it when they sign the contract

they find out you have insurance
that 20 bux procedure magically becomes a 3,000,000 dollar procedure

they bill us 4,000,000 just to be safe
we're like "naw, but here's 20bux"

if you had no insurance, they could either take the risky approach and bill you 4,000,000, see if you'll pay, then when you do they get all that money, and if you don't they'll have a "discount card" or some sort of card that will lower that price to 20-25bux, or they'll bill you that from the get-go.

I oversee an audit and oversight department at a very large health insurance company. when I call a place that tried to pull something like that, they get real scurrd

Savington

iTrader: (31)

Billing dept. execs of hospitals that attempt this belong in ******* prison.

18psi

iTrader: (76)

The worst part about this, is that the people that normally get "shafted" the worst are people with normal, commercial/employee insurance. There's a lot less regulation/oversight there.

Medicaid/Medicare, they get audited ALL...THE....TIME, and get punished very severely when caught. With the working man's insurance, way less rules/regulations/laws so it's like the wild west. It's up to the person to navigate all these things, and most are ignorant of it and just pay.

Dann0

I had a case like this recently. I needed a specialized test done, and the testing center tried to charge the insurance company more than $3000. Insurance said, "Nope, not paying any of that." So the testing center sent me a bill for $350. I then applied for insurance reimbursement, and insurance sent me a check for $271. So the real test cost something less than $350, and they tried to bill insurance more than $3000? That's nuts. Should be criminal.

18psi

iTrader: (76)

That's how it usually works.
Sometimes the test actually costs more than that, but all contracted providers/hospitals sign a contract with the insurance, hence "contracted". That contract specifies reimbursement rates and amounts for just about everything. So later on when they try to hike up the price, or even if something legitimately cost more than they agreed on in the contract, insurance goes: NOPE. They then either need to do a prior authorization and prove that what they're doing isn't shady, or eat the cost.

They then try to shaft the end user, because why not? There are, of course many different scenarios and exceptions, I'm just talking about the most common one.

Art

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farpolemiddle

All with the threat of damaging your credit hanging over your head.

concealer404

iTrader: (3)

Nothing was denied in this case. Bad terminology, likely triggered by some pretty stupid terminology in the screenshot.

slowcarfast

I recently had a minor surgery at a university associated hospital. It was an unplanned thing and I had just started a new job and while I was covered by insurance, the bureaucracy hadn't caught up yet so I had to self pay (I was later reimbursed). Their stated policy was that all self pay patients received a 40% discount off what negotiated rates with the insurer, which seemed interesting. Also, even when a procedure is covered by insurance, if it's a significant bill, we'll usually put the portion for which we are responsible on an interest free payment plan with the healthcare provider and they'll usually offer to settle at a 20-30% discount before too long. My wife has a lot of health issues (she has the strange luck of being a very healthy sick person) so I've dealt with a lot more medical bills then I care to think about!

JasonC SBB

There are multiple root issues:
- Joe is not the customer of the insurance co. His employer is. The former care about the latter and not Joe.
- The coupling of employment with insurance happened during WW2. Gov't wage increase freezes so the gov't wouldn't suffer a brain drain of people who worked on the war effort, made companies get creative and offered benefits like health insurance to attract employees. Because it was an "expense", they got to write it off. So of course now, the tax break is why employers buying health insurance is cheaper than employees buying it. Really, people should be able to write off health insurance premiums and insurance should follow them when they change employers, just like with car insurance.
- Today's "health insurance" is also a *maintenance plan*. How much would car insurance cost if it included brake pad and oil changes? Imagine the paperwork too. The reason for this is in the 70s Nixon gave a tax break to the up and coming (Kaiser) HMO business model, as a means of relieving pressure from the political left to adopt a UK-NHS like model. The result is that actual *insurance* (catastrophic coverage), became far less common, as the HMO business model became the cheapest way to get routine health services.
- Insurance should be treated as a financial product - to prevent financial catastrophe, to cover unlikely but financially ruinous events (like your house catching fire). Health maintenance/subscriptions can be a separate product. The two should not be intertwined via the perverse incentives the law creates.
- Hospitals are like a cartel via "certificate of need" laws. If Joe and Brain want to open up an emergency clinic, they have to file a "certificate of need" to "prove" the market needs it, reviewed by... their competitors. Imagine if you needed to convince taco truck owners in the area to open a competing taco truck.
- many more... the above scratches the surface.

Basically a huge part of it is laws and regulations that stifle market competition.

mgeoffriau

iTrader: (7)

Here's a fun one from when my son was born 2 years ago.

My employer-managed BCBS plan does not cover hearing care (only the very first hearing screen after birth is covered). He failed his first screening, so 2 weeks later we took him back for a second hearing screening.

In the same timeframe, we were following up with various specialists, as we had a difficult pregnancy (hydrops) and there were a lot of things that needed checking out to make sure he was healthy and normal. As it happened, one day after his followup hearing screening, we were back in the hospital for some appointments with a cardiologist, a nephrologist, and some additional labwork.

When we received our next BCBS statement, I was surprised to find that not only was the followup hearing screening denied (as I expected), but everything that was done the next day was denied as well -- roughly $2600 in services from cardiology, nephrology, and the lab.

I called BCBS and asked why this was so. They stated that the hospital had filed all of those services under the same claim, and therefore were denied as uncovered hearing care. So I called the hospital billing department, and they informed me that it was BCBS who required the hospital to file all services within a 48 hour period under the same claim, and if that if the hospital attempted to separate them out into different claims, BCBS would deny the entire thing, so the hospital complies with this ridiculous policy as they have no other choice.

After 14 months of going back and forth between BCBS and the hospital billing department, I finally made contact with a billing supervisor at the hospital who was immediately familiar with the BCBS 48 hour policy and had dealt with it with other patients. She contacted the BCBS account manager for the hospital to personally request refiling the claims separately. The BCBS account manager told her that this would have been possible but as 12 months had elapsed since the date of service, BCBS would not accept a refiled claim. As a result, the hospital billing department supervisor agreed to waive all of the charges from that 48 hour period, both the covered charges from cardiology, nephrology, and the lab as well as the charges for the hearing screening that we would have been responsible for.

All it took was 14 months, 40 phone calls, 50 emails, and finally finding the one person with the brains to understand my dilemma and the power to do something about it.