Why are medical costs so ridiculous?
March 7, 2005 5:41 AM Subscribe
Can someone with experience in the medical field break down the incredible costs of an emergency room visit for me?
A few weeks ago my son injured his elbow, we made a trip to the emergency room on a Sunday, waited about three hours before we saw a doctor. He received an x-ray, but the doctor was able to diagnose and fix the problem immediately (something called nursemaids elbow)
I have insurance so the cost to me is only $50, but the breakdown of the bill is as follows: "Radiology charges" $206; "Emergency Room" $819; "Emergency Department Visit" $145.00. Does this mean if I didn't have insurance the bill still would have been $1120? The actual time spent with a doctor was 20 minutes at most. How can people without insurance even begin to deal with this?
A few weeks ago my son injured his elbow, we made a trip to the emergency room on a Sunday, waited about three hours before we saw a doctor. He received an x-ray, but the doctor was able to diagnose and fix the problem immediately (something called nursemaids elbow)
I have insurance so the cost to me is only $50, but the breakdown of the bill is as follows: "Radiology charges" $206; "Emergency Room" $819; "Emergency Department Visit" $145.00. Does this mean if I didn't have insurance the bill still would have been $1120? The actual time spent with a doctor was 20 minutes at most. How can people without insurance even begin to deal with this?
How can people without insurance even begin to deal with this?
As Hankins said, many don't. They tend to die younger.
posted by Jairus at 6:47 AM on March 7, 2005
As Hankins said, many don't. They tend to die younger.
posted by Jairus at 6:47 AM on March 7, 2005
The cost largely depends on where the hospital is and exactly what sorts of services were used; ask your insurance company and they'll tell you that the "Usual, Reasonable and Customary" cost for a given medical service varies from location to location. It's hard to generalize, but hospitals seem to be cheaper in the South.
The charges you mention seem a little bit steep for the actual ER charge (which is for the use of the facility and supplies) -- if you're curious about the source of the expenses, ask for an itemized bill (not the UB92 claim form they filed, which would probably be pretty meaningless to you) and go over it line-by-line. One thing to look out for is charges for supplies: typically, if the hospital has to open a new box of bandages/gauze/whatever for your case, they bill you for the entire box, since it's hard to charge for "6 inches of gauze" or "one wad of cotton".
The physicians' charges seem fairly reasonable; keep in mind that the radiology includes both the charge to perform the test (an x-ray, I assume?) and the charge to read and interpret it. And the charge for the ER physician's visit is most likely a fixed fee; it would have been $145 whether you got 5 minutes or an hour (of course, if it had been an hour there probably would have been other procedures and tests billed on top of that).
As to how people without insurance deal with it, Medicaid often gets the bill for uninsured ER visits, and many hospitals, especially in poorer areas, offer various types of aid and financing to people who get caught in that situation. Plus, people who are insured often get billed more to make up the cost; hospitals are usually fairly shrewd financially and they negotiate deals with insurance companies which help the costs balance out in the long run.
posted by ubernostrum at 6:57 AM on March 7, 2005 [1 favorite]
The charges you mention seem a little bit steep for the actual ER charge (which is for the use of the facility and supplies) -- if you're curious about the source of the expenses, ask for an itemized bill (not the UB92 claim form they filed, which would probably be pretty meaningless to you) and go over it line-by-line. One thing to look out for is charges for supplies: typically, if the hospital has to open a new box of bandages/gauze/whatever for your case, they bill you for the entire box, since it's hard to charge for "6 inches of gauze" or "one wad of cotton".
The physicians' charges seem fairly reasonable; keep in mind that the radiology includes both the charge to perform the test (an x-ray, I assume?) and the charge to read and interpret it. And the charge for the ER physician's visit is most likely a fixed fee; it would have been $145 whether you got 5 minutes or an hour (of course, if it had been an hour there probably would have been other procedures and tests billed on top of that).
As to how people without insurance deal with it, Medicaid often gets the bill for uninsured ER visits, and many hospitals, especially in poorer areas, offer various types of aid and financing to people who get caught in that situation. Plus, people who are insured often get billed more to make up the cost; hospitals are usually fairly shrewd financially and they negotiate deals with insurance companies which help the costs balance out in the long run.
posted by ubernostrum at 6:57 AM on March 7, 2005 [1 favorite]
Somehow I copied and pasted the wrong link for the UB92; this, which is a PDF of the standard UB92 form, is what I meant to link to.
posted by ubernostrum at 7:02 AM on March 7, 2005
posted by ubernostrum at 7:02 AM on March 7, 2005
Also keep in mind that the insurance company may not pay the total amount of the bill you saw. My husband had a serious arm injury a few years ago and was repeatedly billed by a clinic for charges the insurance company had disputed.
Here's how it went: The clinic issues a bill. The insurance company goes over it and concludes: "$800 is too much for that procedure. The customary rate in your area is $400 and that's what we are paying." Then the clinic bills my husband for the extra $400, which was an unjustified charge to begin with, and immediately threatens legal action when he questions the validity of the bill.
This is a criminal racket if you ask me. My husband ended up getting most of the extra charges erased, but it took many hours of work and the fact that he's a lawyer. Imagine how they treat people with fewer resources.
posted by naomi at 7:29 AM on March 7, 2005
Here's how it went: The clinic issues a bill. The insurance company goes over it and concludes: "$800 is too much for that procedure. The customary rate in your area is $400 and that's what we are paying." Then the clinic bills my husband for the extra $400, which was an unjustified charge to begin with, and immediately threatens legal action when he questions the validity of the bill.
This is a criminal racket if you ask me. My husband ended up getting most of the extra charges erased, but it took many hours of work and the fact that he's a lawyer. Imagine how they treat people with fewer resources.
posted by naomi at 7:29 AM on March 7, 2005
Does this mean if I didn't have insurance the bill still would have been $1120?
The bill might say $1120 on it. Odds are they wouldn't expect you to actually pay that.
Bills from doctors are basically wish-lists -- here's the most we'd like to get from you or your insurance, but we expect to get less.
You can see this in action when the hospital bills $1120, the insurance company pays $250, you pay $50 copay, and the hospital happily eats the rest. Or in my life, my bride got her neck MRI'd, the company billed $2000, the insurance company paid something like $150 and we paid something like $50 or $100, and the rest disappeared into accounting never-neverland.
How can people without insurance even begin to deal with this?
Some just don't pay, and the hospital eats it. Fees take this into account; one of the reasons they bill for $1120 is to take care of someone else who doesn't pay at all.
Some are on medicaid, which acts as health insurance.
Some pay less, either directly or after a run-in with their collections department.
Some get screwed.
posted by ROU_Xenophobe at 7:50 AM on March 7, 2005 [1 favorite]
The bill might say $1120 on it. Odds are they wouldn't expect you to actually pay that.
Bills from doctors are basically wish-lists -- here's the most we'd like to get from you or your insurance, but we expect to get less.
You can see this in action when the hospital bills $1120, the insurance company pays $250, you pay $50 copay, and the hospital happily eats the rest. Or in my life, my bride got her neck MRI'd, the company billed $2000, the insurance company paid something like $150 and we paid something like $50 or $100, and the rest disappeared into accounting never-neverland.
How can people without insurance even begin to deal with this?
Some just don't pay, and the hospital eats it. Fees take this into account; one of the reasons they bill for $1120 is to take care of someone else who doesn't pay at all.
Some are on medicaid, which acts as health insurance.
Some pay less, either directly or after a run-in with their collections department.
Some get screwed.
posted by ROU_Xenophobe at 7:50 AM on March 7, 2005 [1 favorite]
As naomi says, be prepared to deal with disputed claims, especially on an ER visit. Many insurance companies will refuse to pay for the entire billed amount, and you will find yourself receiving a past due notice from the hospital itself within a matter of weeks for the unpaid claim. Expect to be on the phone with your insurance provider and the hospital for hours on end and to spend many more days sending appeals and receiving refusals from both.
As for why it's so expensive - part of the reason is that about 1/4 of all Americans are uninsured, and a vast majority of them only use health systems in the case of an emergency. When they default on the bills they receive, as is almost always inevitable (1/2 of all bankruptcies are related to medical expenses) the extra costs get added to your bill, in the hospital's effort to ensure it turns a profit and keep shareholders happy.
This is one of the main arguments for a national healthcare system - if everyone is insured, the costs go down for everyone, partly because there are no longer any defaults on emergency procedures, and partly because preventative medicine becomes more widely available. That way the ER isn't a person's first choice in diagnosing a problem, oftentimes allowing something to still be done about it before it becomes an emergency.
posted by dogmatic at 7:51 AM on March 7, 2005
As for why it's so expensive - part of the reason is that about 1/4 of all Americans are uninsured, and a vast majority of them only use health systems in the case of an emergency. When they default on the bills they receive, as is almost always inevitable (1/2 of all bankruptcies are related to medical expenses) the extra costs get added to your bill, in the hospital's effort to ensure it turns a profit and keep shareholders happy.
This is one of the main arguments for a national healthcare system - if everyone is insured, the costs go down for everyone, partly because there are no longer any defaults on emergency procedures, and partly because preventative medicine becomes more widely available. That way the ER isn't a person's first choice in diagnosing a problem, oftentimes allowing something to still be done about it before it becomes an emergency.
posted by dogmatic at 7:51 AM on March 7, 2005
Just another local anecdote/perspective. We just approved our ambulance budget for the town that I live in at last week's town meeting. The ambulance receives about $60K from our town and then bills patients' insurance for services. There are many elderly and poor in my area who have Medicaid. Medicaid does what Naomi mentions but has very rigid limits of what they will reimburse. So, for example, if an ambulance ride costs $200, Medicaid might pay $140 of that.
According to the ambulance company, which was asking for increased funding from the town this year, Medicaid usually pays about 60-70% of the ambulance fees, probably because we are in a rural area and cost of delivering ambulance services is more expensive in rural areas. So, the ambulance company has to eat the difference, or bill the person receiving the service. If the person can't pay [as with many Medicaid recipients] the cost is borne by the ambulance company. The ambulance company is a non-profit company so it's not like there's R&D overhead going into their services, which is what many people say about drug companies and what dogmatic alludes to above. Their costs are fixed, it's not like they could reduce their profit margin and save the town money.
So, in our case the "accounting neverland" that the missing money goes to is our town budget which has to cover the roughly 30% of the ambulance fees that are not covered by Medicaid, in addition to the budget we give them for specific line items like staffing, maintenance and supplies.
posted by jessamyn at 8:18 AM on March 7, 2005
According to the ambulance company, which was asking for increased funding from the town this year, Medicaid usually pays about 60-70% of the ambulance fees, probably because we are in a rural area and cost of delivering ambulance services is more expensive in rural areas. So, the ambulance company has to eat the difference, or bill the person receiving the service. If the person can't pay [as with many Medicaid recipients] the cost is borne by the ambulance company. The ambulance company is a non-profit company so it's not like there's R&D overhead going into their services, which is what many people say about drug companies and what dogmatic alludes to above. Their costs are fixed, it's not like they could reduce their profit margin and save the town money.
So, in our case the "accounting neverland" that the missing money goes to is our town budget which has to cover the roughly 30% of the ambulance fees that are not covered by Medicaid, in addition to the budget we give them for specific line items like staffing, maintenance and supplies.
posted by jessamyn at 8:18 AM on March 7, 2005
Very interesting that 1/2 of bankruptcies are related to medical expenses, thanks for that dogmatic. Here's a Forbes/AP cite for those who are also curious.
posted by quiet at 8:22 AM on March 7, 2005
posted by quiet at 8:22 AM on March 7, 2005
Many insurance companies will refuse to pay for the entire billed amount, and you will find yourself receiving a past due notice from the hospital itself within a matter of weeks for the unpaid claim. Expect to be on the phone with your insurance provider and the hospital for hours on end and to spend many more days sending appeals and receiving refusals from both.
This is just appalling. How common is this kind of thing? Does it matter whether your on an HMO or some other plan?
posted by Mitheral at 9:55 AM on March 7, 2005
This is just appalling. How common is this kind of thing? Does it matter whether your on an HMO or some other plan?
posted by Mitheral at 9:55 AM on March 7, 2005
Many insurance companies will refuse to pay for the entire billed amount...
Happened to me with emergency orthopedic surgery. The difference between what the surgeon billed and what my insurace (regular major-medical) would allow as its "standard rate" was thousands of dollars. How the insurer could even have a "standard rate" for the procedure I underwent, which can't be very commonplace, is beyond me.
My surgeon tried repeatedly to justify the charge to the insurer; they wouldn't budge. He wound up eating most--but not all--of the difference; I wound up paying about $600.
This also happened to my mother with non-emergency surgery. Her doctor practically wrote a medical treatise explaining why the expense was justified, and her insurer did pony up the full amount--but this was about 20 years ago.
posted by adamrice at 10:26 AM on March 7, 2005
Happened to me with emergency orthopedic surgery. The difference between what the surgeon billed and what my insurace (regular major-medical) would allow as its "standard rate" was thousands of dollars. How the insurer could even have a "standard rate" for the procedure I underwent, which can't be very commonplace, is beyond me.
My surgeon tried repeatedly to justify the charge to the insurer; they wouldn't budge. He wound up eating most--but not all--of the difference; I wound up paying about $600.
This also happened to my mother with non-emergency surgery. Her doctor practically wrote a medical treatise explaining why the expense was justified, and her insurer did pony up the full amount--but this was about 20 years ago.
posted by adamrice at 10:26 AM on March 7, 2005
Mitheral: what's happened is they've exceeded the Reasonable and Customary amount for the procedure(s). Here's how it works:
When you go to a doctor or hospital in your network, there's a contractual agreement in place which sets the rates for different services (called a "fee schedule"). For most common services there's simply a flat rate specified, but for some procedures the fee schedule actually just specifies a certain percentage of the doctor's or hospital's bill which will be discounted. But that only works in your network.
When you go out of network, some plans won't pay anything at all (typically HMO plans are like this). Those which do (typically PPO) will switch from paying based on fee schedules to paying based on the "Reasonable and Customary" amount; this amount is basically an average of the fees being charged for that procedure in that area of the country. The R&C amount is not determined by the insurance company; there is a specialized industry of data-gatherers and statisticians who calculate R&C tables for various regions and sell the information to insurance companies. Many plans don't pay up to the full R&C amount; commonly they allow 90% or 95% of that amount and base their payment on that. The bad part for the patient is this: when they're in network, any amount that's billed above the fee schedule amount must be written off according to the doctor's or hospital's contract. But when they're out of network no such contract exists, and so when the insurance company pays based on R&C, the amount which went over R&C is passed on to the patient.
Amounts which are egregiously over the R&C (your insurance company can tell you what the calculated R&C amount was) can be fought in a variety of ways; my general recommendation is to contact your local insurance commissioner for advice on how best to proceed, because it varies from state to state. Also, in some cases your insurance company will help you fight an extreme R&C overage, because it helps them to control costs (also, some plans have "hold harmless" clauses which allow the insurance company to litigate on your behalf in extreme cases); sometimes a hospital will be out-of-network but will have a contract with a third-party review system (such as Moody or Plan Vista) which is allowed to determine the amount the hospital is allowed to bill; again, this is something to talk to the insurance company about, because they are very aware of which hospitals have those contracts.
But the moral of the story is that when you're on a plan that has a network, stay in-network; as long as you do, you'll be subject to your network's fee schedules and you will not be held responsible for overages (and if you're worried about the doctor who sees you at the hospital, note that many plans make exceptions for out-of-network doctors practicing at network hospitals; they will often pay those doctors as if they were in-network).
posted by ubernostrum at 10:50 AM on March 7, 2005 [2 favorites]
When you go to a doctor or hospital in your network, there's a contractual agreement in place which sets the rates for different services (called a "fee schedule"). For most common services there's simply a flat rate specified, but for some procedures the fee schedule actually just specifies a certain percentage of the doctor's or hospital's bill which will be discounted. But that only works in your network.
When you go out of network, some plans won't pay anything at all (typically HMO plans are like this). Those which do (typically PPO) will switch from paying based on fee schedules to paying based on the "Reasonable and Customary" amount; this amount is basically an average of the fees being charged for that procedure in that area of the country. The R&C amount is not determined by the insurance company; there is a specialized industry of data-gatherers and statisticians who calculate R&C tables for various regions and sell the information to insurance companies. Many plans don't pay up to the full R&C amount; commonly they allow 90% or 95% of that amount and base their payment on that. The bad part for the patient is this: when they're in network, any amount that's billed above the fee schedule amount must be written off according to the doctor's or hospital's contract. But when they're out of network no such contract exists, and so when the insurance company pays based on R&C, the amount which went over R&C is passed on to the patient.
Amounts which are egregiously over the R&C (your insurance company can tell you what the calculated R&C amount was) can be fought in a variety of ways; my general recommendation is to contact your local insurance commissioner for advice on how best to proceed, because it varies from state to state. Also, in some cases your insurance company will help you fight an extreme R&C overage, because it helps them to control costs (also, some plans have "hold harmless" clauses which allow the insurance company to litigate on your behalf in extreme cases); sometimes a hospital will be out-of-network but will have a contract with a third-party review system (such as Moody or Plan Vista) which is allowed to determine the amount the hospital is allowed to bill; again, this is something to talk to the insurance company about, because they are very aware of which hospitals have those contracts.
But the moral of the story is that when you're on a plan that has a network, stay in-network; as long as you do, you'll be subject to your network's fee schedules and you will not be held responsible for overages (and if you're worried about the doctor who sees you at the hospital, note that many plans make exceptions for out-of-network doctors practicing at network hospitals; they will often pay those doctors as if they were in-network).
posted by ubernostrum at 10:50 AM on March 7, 2005 [2 favorites]
this amount is basically an average of the fees being charged for that procedure in that area of the country.
Doesn't this imply that half of all bills will be contested? More than half actually because they are only paying 90-95%.
Thanks for the explanation ubernostrum. It's not quite as outrageo^H^H^H^H^H^H^H arbitrary as it first seemed. Are networks generally nation wide? If not do Americans purchase some kind of travel insurance when venturing out of their network area?
I've encountered a similar thing here with my dental insurance. My dentist charges more (about 5-10%) for a few select procedures than the book rate and my insurance company wont pay the overage. It's the application to routine emergency medicine that shocked me.
posted by Mitheral at 11:19 AM on March 7, 2005
Doesn't this imply that half of all bills will be contested? More than half actually because they are only paying 90-95%.
Thanks for the explanation ubernostrum. It's not quite as outrageo^H^H^H^H^H^H^H arbitrary as it first seemed. Are networks generally nation wide? If not do Americans purchase some kind of travel insurance when venturing out of their network area?
I've encountered a similar thing here with my dental insurance. My dentist charges more (about 5-10%) for a few select procedures than the book rate and my insurance company wont pay the overage. It's the application to routine emergency medicine that shocked me.
posted by Mitheral at 11:19 AM on March 7, 2005
Your bill was actually lower than many I've seen. Crazy, huh?
This is one of the main arguments for a national healthcare system - if everyone is insured, the costs go down for everyone.
If only the problem was anywhere near as simplistic as you put it.
posted by justgary at 11:20 AM on March 7, 2005
This is one of the main arguments for a national healthcare system - if everyone is insured, the costs go down for everyone.
If only the problem was anywhere near as simplistic as you put it.
posted by justgary at 11:20 AM on March 7, 2005
Just to add on, the ER must admit anybody and do whatever is necessary to save their life. This can include post-ER treatments such as cancer. As such, you can imagine that with all these people who can't afford to pay their bills, the hospital must buck the bill (normally, as already stated, they don't really expect you to pay the full bill. A lot will work a deal out so you don't have to sell your house just to pay you bills). Also, medicare/medicaid do not pay anywhere close to the full value assessed by the hospital. I forget what the values are, but I remember it is shockingly low, as in ~10% for one of them. Combine all of that and you have a lot cutting into a hospital's bottom line so in order to fix it, the next logical step is to get the insurance co's to pay a lot, which they of course try to avoid. One big vicious cycle, really.
posted by jmd82 at 11:30 AM on March 7, 2005
posted by jmd82 at 11:30 AM on March 7, 2005
A few months ago I experienced a stress fracture in one of my metatarsals. I was at the hospital for over 4 hours and left only with two Ace Bandages and a pair of crutches that I didn't want/was unable to use. I also had 3 x-rays taken and talked to a doctor for a total of 10 minutes (if that). It cost over $1300, $200 of which came out of my pocket, & insurance kind of* took care of the rest.
As I understand it, they employ some VERY CREATIVE ACCOUNTING. I received three sepearte bills from three "seperate" entities; 1) a physicians fee bill -- this is what it cost for me to talk to the doctor and for him to look at the x-rays. It was noted on the bill that the doctor was an independent contractor and not affiliated with the hospital (wtf?). 2) A facilities charge for walking into the hospital and later having one of its nurses wrap the Ace Bandages around my foot ... and 3) A bill for the x-rays and crutches (which were billed at about 10X the going market price). In bills #1 and #2 I was charged for emergency room visits, even though I checked in at only the "urgent care" level.
*Yesterday I got a notice from a creditor for an unpaid amount of $16 on one of the three bills.
posted by fourstar at 11:45 AM on March 7, 2005
As I understand it, they employ some VERY CREATIVE ACCOUNTING. I received three sepearte bills from three "seperate" entities; 1) a physicians fee bill -- this is what it cost for me to talk to the doctor and for him to look at the x-rays. It was noted on the bill that the doctor was an independent contractor and not affiliated with the hospital (wtf?). 2) A facilities charge for walking into the hospital and later having one of its nurses wrap the Ace Bandages around my foot ... and 3) A bill for the x-rays and crutches (which were billed at about 10X the going market price). In bills #1 and #2 I was charged for emergency room visits, even though I checked in at only the "urgent care" level.
*Yesterday I got a notice from a creditor for an unpaid amount of $16 on one of the three bills.
posted by fourstar at 11:45 AM on March 7, 2005
I am not a toady for the insurance industry, but as a way of making things go smoother, it's always a good idea to call your primary care physician before going to the emergency room (unless blood's spurting out of your neck or something). Often if you do this, they'll tell you to go the emergency room, anyway, but you'll only be on the hook for your office visit co-pay. Your mileage may vary on this depending on what type of plan you have.
Are networks generally nation wide? If not do Americans purchase some kind of travel insurance when venturing out of their network area?
It varies depending on what provider/plan you have. They run the gamut from small staff-model HMOs that may only provide in-network coverage inside your county all the way up to big nationwide networks (these are your CIGNAs, Aetnas, Uniteds, PHCS, etc.). You're almost universally covered for emergency care when you go outside of your service area, but it can get tricky if you're in a small regional HMO and your child goes to college across the country, etc.
The billing discussion above is a good one. I think people don't realize what's going on behind the scenes. As someone who has been working in the insurance industry for years, it still shocks me what the differences are between the initial bills and the charges once they've been repriced by the carriers. It can be shocking -- I've seen the discounts be 60-70%. I try not to imagine an uninsured person getting that un-discounted bill. It's probably how a lot of people end up in the emergency room.
posted by MarkAnd at 12:43 PM on March 7, 2005
Are networks generally nation wide? If not do Americans purchase some kind of travel insurance when venturing out of their network area?
It varies depending on what provider/plan you have. They run the gamut from small staff-model HMOs that may only provide in-network coverage inside your county all the way up to big nationwide networks (these are your CIGNAs, Aetnas, Uniteds, PHCS, etc.). You're almost universally covered for emergency care when you go outside of your service area, but it can get tricky if you're in a small regional HMO and your child goes to college across the country, etc.
The billing discussion above is a good one. I think people don't realize what's going on behind the scenes. As someone who has been working in the insurance industry for years, it still shocks me what the differences are between the initial bills and the charges once they've been repriced by the carriers. It can be shocking -- I've seen the discounts be 60-70%. I try not to imagine an uninsured person getting that un-discounted bill. It's probably how a lot of people end up in the emergency room.
posted by MarkAnd at 12:43 PM on March 7, 2005
I had surgery when I was about 12, on my hands, and the insurance company claimed that they weren't going to pay for the anethesia. So, no, there are no limits to the asshattery in which insurance companies will engage. (My mother brow-beat them into reasonability.) Depending on the hospital, they make more or less of an effort to get your insurance company to pay. My best friend worked in medical billing at a particular hospital, and they really went after insurance companies first. I guess other hospitals take a different route.
posted by Medieval Maven at 1:46 PM on March 7, 2005
posted by Medieval Maven at 1:46 PM on March 7, 2005
jeremias- you may have only had to pay $50 at the time, but don't be suprised if you get another bill in the mail in a few weeks for a few hundred bucks. Just a warning about how it usually works. If you do get this bill it should break it down for you, and even if you don't get a bill, you should get a statement from your insurance company showing you how nice they are by paying your bill.
posted by pwb503 at 6:06 PM on March 7, 2005
posted by pwb503 at 6:06 PM on March 7, 2005
"Reasonable & Customary" is bullshit. I lived in a remote area where I had 1 hospital closer than an hour's drive. Of course the bill was higher than the R&C. The other hospital an hour away probably would have been no different, and the next closest was 2 hours away. Do I have attitude? You betcha! I was paying full price for my insurance, as I didn't belong to a "group".
Add to this the absurdity of a doctor in the same area charging 18% interest on unpaid bills. Oh yea, this guy moonlighted as a fundy preacher. I nixed his crap by calling a state authority and accusing the doc of usury. Keep in mind, this area was extremely depressed and has been so since the 60's.
posted by Goofyy at 9:53 PM on March 7, 2005
Add to this the absurdity of a doctor in the same area charging 18% interest on unpaid bills. Oh yea, this guy moonlighted as a fundy preacher. I nixed his crap by calling a state authority and accusing the doc of usury. Keep in mind, this area was extremely depressed and has been so since the 60's.
posted by Goofyy at 9:53 PM on March 7, 2005
Doesn't this imply that half of all bills will be contested? More than half actually because they are only paying 90-95%.
I don't know if the "average" used in R&C calculations is median, mode, etc., so it'd be hard to say. But in general, going over R&C doesn't make the bill "contested", it just means that the amount which went over is passed on to the patient (who then usually throws a fit over it).
Are networks generally nation wide?
Some are, and some aren't. The insurance company I used to work for administered a variety of plans, and our general solution was to have plans with a "fallback" network for cases where you're out of area. For example, there's a network called Medical Mutual of Ohio which, obviously, only contracts doctors and hospitals in Ohio. For the plans we administered which used that network, we'd also sign on another, national network as a fallback; as long as they were in Ohio, patients had to go to an MMO doctor or hospital, but if they were traveling out-of-state they could use the national network (I think we usually had PHCS for that) without penalty.
I received three sepearte bills from three "seperate" entities
fourstar: as wrong as it may seem to you, they typically are all independent entities. What often happens is that there will be a group of, say, radiologists in a given area, and they'll cycle through the local hospitals, doing a day or two at each. They don't work for the hospital and they don't bill through the hospital; instead the group they belong to does their billing. ER doctors are usually the same story -- they'll form an "emergency physicians group" in an area and make circuits of the local hospitals.
I was charged for emergency room visits, even though I checked in at only the "urgent care" level.
If you visit the ER, you're going to get charged an ER visit. "Urgent care" and "emergency medicine" are distinct medical disciplines (the difference is mostly that emergency medicine is broader and can handle much more serious issues -- hence they take you to the ER after a car accident, not an urgent-care facility) and most ER doctors are doctors of emergency medicine.
MarkAnd: When I started working in insurance I was astonished by the discounts we were allowed to take, especially on "per-case" things like maternity; after I'd been there about six months, though, I started to see how the costs balance out; yeah, you get a $20k bill knocked down to $2500 by the fee schedule, but we paid $2500 per case no matter what, even when the claim was for less than that (and it usually was). So I figure it all evens out in the long run.
posted by ubernostrum at 4:11 AM on March 8, 2005
I don't know if the "average" used in R&C calculations is median, mode, etc., so it'd be hard to say. But in general, going over R&C doesn't make the bill "contested", it just means that the amount which went over is passed on to the patient (who then usually throws a fit over it).
Are networks generally nation wide?
Some are, and some aren't. The insurance company I used to work for administered a variety of plans, and our general solution was to have plans with a "fallback" network for cases where you're out of area. For example, there's a network called Medical Mutual of Ohio which, obviously, only contracts doctors and hospitals in Ohio. For the plans we administered which used that network, we'd also sign on another, national network as a fallback; as long as they were in Ohio, patients had to go to an MMO doctor or hospital, but if they were traveling out-of-state they could use the national network (I think we usually had PHCS for that) without penalty.
I received three sepearte bills from three "seperate" entities
fourstar: as wrong as it may seem to you, they typically are all independent entities. What often happens is that there will be a group of, say, radiologists in a given area, and they'll cycle through the local hospitals, doing a day or two at each. They don't work for the hospital and they don't bill through the hospital; instead the group they belong to does their billing. ER doctors are usually the same story -- they'll form an "emergency physicians group" in an area and make circuits of the local hospitals.
I was charged for emergency room visits, even though I checked in at only the "urgent care" level.
If you visit the ER, you're going to get charged an ER visit. "Urgent care" and "emergency medicine" are distinct medical disciplines (the difference is mostly that emergency medicine is broader and can handle much more serious issues -- hence they take you to the ER after a car accident, not an urgent-care facility) and most ER doctors are doctors of emergency medicine.
MarkAnd: When I started working in insurance I was astonished by the discounts we were allowed to take, especially on "per-case" things like maternity; after I'd been there about six months, though, I started to see how the costs balance out; yeah, you get a $20k bill knocked down to $2500 by the fee schedule, but we paid $2500 per case no matter what, even when the claim was for less than that (and it usually was). So I figure it all evens out in the long run.
posted by ubernostrum at 4:11 AM on March 8, 2005
pwb503: Actually, on many plans the $50 is all he'll pay; most carriers are going to a flat copayment for in-network ER visits. And regardless, he's going to get a statement from his insurance company of what they paid (called an "Explanation of Benefits"): for most types of plans they're required by law to issue one to him and to the provider of service within 30 days of receiving the claim, or to provide notice of why it's taking them longer than 30 days to process.
posted by ubernostrum at 4:14 AM on March 8, 2005
posted by ubernostrum at 4:14 AM on March 8, 2005
This thread is closed to new comments.
Many don't. A lot of people use the emergency room as their primary care (coming in at 3AM for back pain) and don't have insurance, nor any real intent to pay their bills. From a business sense, the company operating the emergency room has a knack for diagnosing which patients will pay their bills (not to suggest that they provide less than adequate care.)
posted by Hankins at 6:44 AM on March 7, 2005