A personal commentary on the state of health care and insurance in this country

First, I used to work in medical billing (5 years), so I do have some background in this area.

I am going to use a personal story to highlight the flaws in the current health care billing system that I do not think are going to be addressed.

My spouse and I have insurance through an employer. We pay $600/month in preimums and are responsible for 20% of every medical bill up until we hit $4000 out of pocker per year.

My spouse underwent an endoscopy. This procedure is one in which they stick a tube down his throat to look for problems.

The procedure itself lasts probably 15 minutes, but he was at the facility (not a hospital) for about 3 hours.

We got the following bills:

$600 for the Gastro MD
$600 for the Anesthesia MD
$150 for the Pathology Lab
$1400 for the facility.

For each of these I had to pay 20% of the allowable price negotiated between the insurance carrier and the provider and in total we will pay about $600 out of pocket for this procedure. We are lucky that we have the extra cash to pay for this.

Now I don't want to sound like I don't respect medical doctors, I do. They are professionals they go to school for a long time and they deserve compensation. However this procedure doesn't take that long and my husband only occupied a space for 3 hours. It wasn't like he got intensive nursing or care. He was sedated, they stuck a tube down his throat and they took a small tissue sample. He woke up and went home with me.

Not one of these bills came with any itemization that I would find acceptable. Three of the four actually had diagnosis codes and procedure codes but they were only one line item.

Perhaps it is callous for me to say this but I don't think any doctor's time is really worth $600 for 15 minutes and I don't even know if that $600 covered anything else. The Gastro doc spent less than 2 minutes at my husband's bed to say, "looks good see you next year". Wow, what great customer service that was.

The largest of the bills was $1400 and it had absolutely no itemization and when my husband called the hospital that runs that facility to get an itemization they balked! Now if they want me to fork out more than $200 for my portion of that bill, they had better give me the itemization. When my spouse asked, "what amounted to $1400?" They started to say, well the Gastro doctor, etc. My husband said, "whoa nelly, i got a separate bill for him so how could you be charging me twice?" The billing clerk got all huffy and said, well he used supplies! Until I see a line by line itemization I don't trust these bills.

You see I worked with this kind of stuff when I did consulting in the medical billing industry. The amount they charge is set high to try and negotiate higher allowables with the insurance companies. It is a game they play. Knowing this, I don't really know that aside from labor costs that anyone truly knows the real costs associated with any procedure, except accountants, because everything is heavily padded for this dance providers do with insurance companies. It is this padding ritual that causes folks without insurance to get screwed because they are too poor to pay for insurance premiums so that they can be let into the "allowable" club.

Every insurance company has varying allowables and for that reason the ones who are more stingy are accepted at less providers. So you might buy ACME Insurance and it is cheap, but that insurance card might not be accepted at many private hospitals or doctor's offices because they are also stingy on the allowables. So where does that leave you?

Now this is how it works and it isn't going to change unless you turn the entire system on its ear.

So mandating that people buy insurance doesn't do anything to address issues like I am talking about.

Forcing insurance companies to accept pre-existing conditions is only going to allow them to gouge more.

It would be better to nationalize the system and remove the middle man (Insurance) who helps to create the bill padding, then fix the rates for every and all procedures. No matter where in the country, or what provider provides the service. Every two years they can apply to increase rates but that's it. We can be fair to the providers of services so that they earn a respectable living under such a system.

So what happens to the insurance companies? They can get contracts to manage this national system by region just like Medicare works today.

With the system nationalized we basically have some control through our vote on what improvements we make from there.

:wow:

seems like a LOT through an employer based plan.

I work for a large multi-national company too.

I can't blame them though because health care costs are hurting their bottom line too. I can't help but think that many folks who got laid off were cast aside as they tried to trim costs elswhere so to a degree there are a lot of folks who lose their jobs because health care premium rate hikes force employers to make those types of decisions.

:(

but I will say that the system has gotten far more bloated in the 20 years I have been working in industry overall.

I remember the old days when health insurance was a "benefit" and you didn't pay a dime into it. Most companies today are trying to figure out how to get out of paying for any part of it at all because the rate increases are so ridiculous from year to year and even they can't budget for 30% increases in premiums.

And forces people to buy into a very crappy system that allows a company to make money by NOT providing the services its customers pay for.

Congress will close a few loopholes and the insurance corporations will find a few more. In 2 years, insurance corporations will be back to denying claims and dropping fully paid customers just like they do now. But in 2 years, they will be making even bigger profits thanks to the mandate.

It's a win win for insurance corporations.

1) I assume these are the first bills. Don't they have to go through the insurance company's allowable system? IOW, might they be revised lower by the insurance company?

2) I'm wondering if a requirment that insurance companies spend 85% of premiums on actual claims might make the system better by either lowering your monthy premium or decreasing your portion of the payment. Dumb question 2b might be -- is that provision still in any of the health care bills?

All that being said, you're main points stand...

1. Yes, they did go through the process, however I can log into the insurance company's system to view my bill. No Itemization viewable by me, the consumer.

They billed $1400, the Insurance allowable must have been around $1000 because they paid $800 of it and stuck me with a bit over $200. However given the other bills from the other providers of services (gastro, etc) I am not sure what that bill represents and the phone call that my spouse had with them indicates that perhaps they padded it and could be double billing both me and the provider.

This leads me to believe that this was automatically paid because they used the right combo of codes with the insurance carrier and didn't get caught up in any audit. It just takes putting the wrong combo of code together to trigger an audit of every line item.

2. I understand your question but I don't think so. Sadly, the profit motive makes it hard to believe they will pass any cost savings on to you or me. I don't know if that provision still stands but I bet they fight tooth and nail to take it it out and how could anyone prove they actually do it without complex auditing of those insurance carriers and who will do that?

It is completely unaccountable because of the "system" they created to hide the enormity of the graft.

The $1400 "facility charge" has nothing to do with what was done or what was used in your procedure, it is simply a charge that can be made because the code will be approved for $1400. Same with the other charges, unless the doctor is a partner (s)he didn't get much of the $540 your insurance company paid.

The only solution to our health care issue is to remove all profit from paying bills, however we want to define the system.