Do Everything By The Book And Still Get Screwed By Health Insurance

Every time we think that we have health insurance figured out, we are proven that we are and will always be wrong.

You can do it all.  Every step.  Check it off.  Verify it.  Dot every i and cross every t.

Doesn’t matter.

The insurance companies will still manage to get you.

Actually, it’s not always the insurance companies.  It’s more the laws and the medical profession as a whole.

In Network But, Oh, Just Kidding

The latest example I saw that just floored me was in a New York Times article last week where unsuspecting people need immediate medical care.  They do the right thing.  They head to their emergency room that they already know is in network and get the care that they need.

It all sounds fine and good, until the bills come, and they realize that while they went to an in-network emergency room, the physician that treated them may not have been in-network.

Meaning, you’re stuck paying through the nose.

Apparently, many hospitals can’t (or won’t) fill all positions with employed doctors, so they contract out some of the staff that they need.  This is becoming more and more common.  It reduces fixed costs for the hospitals, but it means that you really have no idea what you’re going to end up being billed for.

Sometimes, it’s a crap shoot.  The hospital may have some doctors employed by the hospital, and some brought in as contractors.  The one that you get to see?  You can’t really pick.

Granted, patients can find out if the doctors are in network or not, and if the doctor that comes to see them is not, they could always refuse service or ask for someone else, but honestly, if you’re in a situation where you or a loved one needs emergency care, how often do you think this will happen?   If you’re hurt or having a heart attack, or your child has a broken bone, are you really going to wait around in hopes that a doctor is available that can save you money?

Sadly, that’s what our health system in America is coming to, and you may be asked to make this choice.

The hospitals themselves are covered.  In the sheaf of paperwork that you sign when you first arrive, you’re likely signing something that indicates that there is no guarantee of the network participation of anybody that treats you.

Since most hospital visits incur separate charges for the hospital and the doctor(s), many unsuspecting patients are falling into this trap, and when they call to protest the bill, the hospital can point to the fact that they signed the paperwork.

And, the sad thing, this is all legal.

What’s The Better Way?

The bottom line is that the system is broken.  I’m generally conservative, but I’m not staunch enough to think that Obamacare is an unmitigated disaster.  Many conservative people argue that it should be repealed, and many politicians build their platform on trying to do just that.

I’m not so sure, and the main reason is more of a fear as to what would happen if it was repealed.

Think about that for a second.  There are people out there whose goal in life seems to be to get rid of our current arrangement, and they will talk for hours at end about why it is so awful for our country and our citizens.  If anybody started that conversation to me, I would politely stop them and ask them how they would propose to make it better.  What would they put in it’s place that would stop the stupid nonsense and loopholes that screw the average consumer?

My guess, based on the fact that I’ve never heard one good proposal, is that nobody really knows.

On the flip side, Obamacare has not and will not prove to be a big fix.  We’ve already seen that.  It made a lot of promises, and even lived up to some of those as to problems that it was able to solve.

The main  issue I have is that for every problem it solved, it often created another issue.  You have many paying higher than they used to for insurance.  The second problem is that it did not truly reform the system in that there were way too many problems and loopholes left open that didn’t get addressed.

Like going to the in-network Emergency Room and getting billed thousands for the out-of-network doctor that took care of you.

Sorry, until stuff like that gets fixed, you can slap any label you want on the health care system, but the one I would slap on it would read:

Out of Order

23 thoughts on “Do Everything By The Book And Still Get Screwed By Health Insurance”

  1. Thank you for this timely blog. We have lost our way especially with healthcare and Obamacare just makes it worse. In my home state the answer from Obamacare seems to be to push everyone on to Medicare. But now Docsare refusing to take new Medicare patients. I purchase my own health insurance and it is a full time job making sure that I’m not getting ….taken advantage of…. I went for a wellness visit in January which requires a $10 co-pay which I gladly paid. I then recieved a bill for $17.20 …for labs that weren’t covered…BUT any labs in the visit in the Docs office ARE covered says so in the policy book. Made too many phone calls and sent too many e-mails to straighten this out. Finally talked to someone on the phone at the insurance company who agrees with me that this should be covered and that she is going to “re-submit it” but to give it 30 days…Sure… this is second week of October and the service was provided in January…I got plenty of time…

    • This is way too common. The problem is that the labwork is done by a different provider so they bill separate. If the codes don’t match up to align the work between the two providers, the insurance company won’t see that it’s related to the preventative visit. I’ve had this happen on multiple occasions, but I’ve never had to wait more than a month to get it corrected.

  2. Wow, that’s a loophole one would hope would be fixed….it just shouldn’t be so hard to determine whether or not you’re “in network.” Even if you could choose your ER doc to ensure he/she was in network, who’s going to do that when it’s a life/death situation? And if there IS someone in network on staff, but they’re busy…do you wait??? It’s the difference between living and dying, and potentially thousands and thousands of dollars. I agree – OUT OF ORDER!

    • I’m not sure that it really can be fixed. Short of telling doctors that they won’t allow them to contract unless their insurance plans match perfectly, which would never work, there’s just no way around it as long as contractors are used. Maybe that’s a way, but can you force hospitals to direct hire yet still expect them to run lean? Lots of gray area.

  3. I sometimes think that the insurance companies keep things complicated just so you never really know what to do and they maintain control. I have excellent insurance and they make minor changes which ends up costing me a lot. For example, I pay more for certain drugs than others although they are branded drugs. It as though the co-pay is a moving target.

    • Yes, it’s always entertaining to see the difference in price going to the same pharmacy, getting the same thing, and yet ending up paying a (hopefully) slightly different amount each time.

  4. In the interest of full disclosure, I’ll start by saying that I have spent most of my career in healthcare, including 8 years with a managed care organization.
    Let me start by saying that I am a major beneficiary of the Affordable Care Act. When my pre-paid COBRA’d insurance ran out, I had three options this year, whereas in the past I only would have had two.
    Option 1 would have been to continue my COBRA plan, paying it myself. The cost? Over $1,100/month- pretty much the same amount as my mortgage. Considering that the reason I needed the insurance was that I was unemployed, that cost was prohibitive.
    That means that in another year, I would have been stuck with option 2- go without insurance. We would pay out of pocket for my thyroid meds and C’s migraine meds. It wouldn’t have been cheap, but it would have been cheaper than $1,100/month. Of course, that also would have left us uninsured, making my thyroid condition and C’s migraines pre-existing conditions the next time we went to get insurance, even though both were diagnosed while we had coverage.
    Luckily, the Affordable Care Act not only abolished the “pre-existing condition” loopholes, but they instituted the exchanges. I was able to go online and find us coverage for under $130/month. We didn’t have to go without coverage, and we didn’t have to break the bank to afford coverage.

    But the question of how do we fix healthcare? I can think of two solutions, neither of which is incredibly popular with certain segments of our society.
    1) Universal coverage with a true single payer system. Basically, we all have Medicare. Everyone is automatically covered, and there is no other insurance company is out there.
    2) Force all healthcare organizations to be not-for-profit. In my state, the law states that all health insurance companies must be not-for-profits. However, healthcare providers (individual doctors, clinic systems, and hospitals) are all allowed to be for-profit. Pharmaceutical companies are also for profit (and notoriously so). If we instead said that healthcare could not be for profit, for anyone, I think we’d see a lot less of the ridiculous bills, of in-network vs out-of-network pricing, etc.

    • Thanks for the detailed post. I sort of think that there really isn’t a solution in sight, at least not in my lifetime (and I’m only 40). The history in place will simply not allow for scrapping the whole thing and starting over, so we’re always going to be working on trying to fix/change a fundamentally broken system.

  5. Thanks for the post; it can be crazy to work with insurance companies. One job I had while a college student was submitting claims for a doctor’s office. The hoops you have to jump through can be frustrating.

    I read that article last week too and was blown by how crazy the bills can get. So much was wrong, but my biggest concern is why hasn’t hospitals look at who they get contractors. That specialist that billed outrageous amounts appeared to have a horrible track record of unessential service.

  6. Too right the system is broken, but what doesn’t make any sense to me is that the entire country isn’t outraged enough to do something about it. I have never understood the US health system and the way a civilised, first-world, 21st century nation — arguably the envy of the world in so many respects — has so little regard for its citizens that healthcare is considered a privilege, not a right.

  7. I think the insurance system will have its faults in each kind of care plan or company. Everyone wants something different and each plan isn’t going to fit everyone’s needs how they want it to.

  8. Wow that sounds really messed up and should get fixed. So glad that we don’t have to deal with this kind of stuff here in Canada.

  9. Beagle –
    I tend to agree with you that the healthcare system is broken, but it’s not all bad. It is confusing with doctors billing differently than the hospitals they work at and such (leading to the in/out of network problems you mentioned) but my experience with health insurance this year has been stellar (and if you feel like they always “get you” in the end, pull up a chair)

    My daughter was born 3 months early, got taken by the flight for life 90 miles to the nearest big city with a NICU that could care for her, and stayed in the NICU for 3 months. At the time, I was paying $120/mo for health care for my family. Out of pocket max was ~3k, which as you can guess was eaten up in about 15 minutes. Total costs from birth to her going home were north of 750k , and we are still seeing therapists to make sure that she’s progressing like normal babies should (she is).

    The best part is that since she weighed sooo low (2.5lbs) at birth, she was enrolled in medicaid from day 1, and was also collecting money from social security. The money wasnt much ($800) but medicaid ended up taking care of most of our deductible. so for about 600 in premiums for the year (I switched jobs right after all this) we ended up getting almost 1m out of them. If you always feel like you lose, have some of mine 🙂

    • That’s an instance where it worked out like it should. I just think that should be the norm, and that the cases like the example I gave should not be as common as they seem to be, not to mention the growing trend.

  10. I’m of the same perspective as you; generally conservative but I do see where the ACA has done some good. I also see a lot of holes and gaps where it seemed not to have been properly implemented to make it a fully functional system but the many political compromises or outright opposition on both sides has me fairly certain we’ll never get to scrap everything that doesn’t work and start fresh because everyone involved in any decision making has some stake in a particular, contradictory outcome. It’s incredibly frustrating.
    I read the same article and came away feeling awfully relieved that I’ve stayed with an HMO all these years; they’ve actually improved services in the past eight years and even though I may not be able to hand pick the best of the best specialists for everything, I also don’t run the risk of being slapped with an unexpected contractor bill.
    I reviewed our coverage for prenatal stuff, it said everything was covered, and everything has been, except for paid parking at one of the visits in the city: exams, lab work, vaccines, ultrasounds. That’s pretty good in comparison.

  11. Out of order is a good way to put it. There are too many inconsistencies that make this an overall system that can use some major improvements. I could go on and on about this, believe me.

  12. I am fortunate enough to have decent healthcare insurance however, the continued increases in premiums and out of pocket costs is ridiculous. With a system that is based upon a for profit model, it will be next to impossible to maintain the current system indefinitely. I’m not sure what the answer is but the healthcare industry will need to figure out how to deliver healthcare at a much lower cost than it currently is.

    • I’ve always had pretty good insurance too but the difference in pricing, deductibles and contribution levels is continually rising. Employers think that a couple of percent per year is no big deal but it adds up especially when their raises on the take-home side are not in line.

  13. Great article! This raises various concerns about the healthcare industry and insurance. It’s always a good idea to double check what facilities your insurance is accepted at. Thanks so much for sharing!

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