Glad to have Health Insurance

[KingB]

Earlier this month, I had a mild chest pain and I went to ER. I was not having a heart attack but I was admitted to the hospital for observation and further test. My total stay in the hospital was 16 hours.

Now, the explanation of benefits (EOB) from the insurance carrier started coming in. And I was shocked at the bills! The hospital bill alone comes to almost $30K. Of this, the negotiated price brought it down to $28K. I only have to pay almost $900 after what the insurance picks up.

The hospital bill and other doctors' bill easily used up my $1500 deductible and are now using up some of my OOP limit.

I can't imagine people paying these bills without health insurance. The "negotiated price" really brings down what someone would have to pay.

 

[Midpack]

Glad you're happy to have health insurance and the predictability is obviously wonderful, but who do you think is paying the rest of those costs?

 

[KingB]

Glad you're happy to have health insurance and the predictability is obviously wonderful, but who do you think is paying the rest of those costs?

I want an answer too.
And why do the medical providers agree to accept an insurance payment much lower than their original bill. Could it be that the bills were inflated in the first place?

 

[eytonxav]

I am happy to have insurance, but am flabbergasted at how far out wack these charges are from what the real actual costs should be.

 

[Midpack]

I want an answer too.
And why do the medical providers agree to accept an insurance payment much lower than their original bill. Could it be that the bills were inflated in the first place?

However the costs finally shake out, the cost of health care in the US was $8,233 per person in 2010 (give or take).

Though you may indeed pay more or less than that, you pay far more than the co-pays and out-of-pocket costs you see directly. Health insurance premiums are costly, those you don't pay directly, you pay as part of the cost of all the products & services you buy.

YOU and all of us ARE paying all those costs, you just don't "see" most of it directly. If people could actually see how much it costs them, we'd all be a lot more interested in the health care debate, instead of thinking health insurance is a bargain...

 

[bUU]

I want an answer too.
And why do the medical providers agree to accept an insurance payment much lower than their original bill. Could it be that the bills were inflated in the first place?

AARP members pay less to visit Luray Caverns than the general public.

That's pretty much what health insurers do for their subscribers: They negotiate lower rates with providers, capitalizing on their buying power. If everyone paid the negotiated rate, rest assured that providers would earn less. As long as the provider is paying people more than minimum wage there is some lee-way for reducing costs and passing that cost reduction along to you. So yes - it is true that you can always say that every bill, for everything, is "inflated", on that basis. However, it looks a whole lot different when you're at the other end of cost reduction.

With regard to whether the people at the other end of the cost reduction are over-compensated - that's over the line into a political discussion, which is something not permitted here. There are separate forums for that elsewhere on this website.

 

[Live And Learn]

I'm actually surprised that the difference between the billed and negotiated price is only 7%. Most the EOBs I get have a difference of 30 - 60% - which really makes the whole thing look crazy.

 

[KingB]

I'm actually surprised that the difference between the billed and negotiated price is only 7%. Most the EOBs I get have a difference of 30 - 60% - which really makes the whole thing look crazy.

I am sorry. Thanks for pointing it out.
My original post says: "Of this, the negotiated price brought it down to $28K." What I mean to say is: "Of this, the negotiated price brought it down by $28K". The actual discount is 92.4%.

 

[MichaelB]

I am sorry. Thanks for pointing it out.
My original post says: "Of this, the negotiated price brought it down to $28K." What I mean to say is: "Of this, the negotiated price brought it down by $28K". The actual discount is 92.4%.

Thanks for the clarification. This makes more sense, and looks like the pricing I have seen as well. Not sure I'd call it a discount, though. More like a price dysfunction. Pity the person stuck with no insurance and a bit of money in the bank.

 

[fh2000]

Thanks for the clarification. This makes more sense, and looks like the pricing I have seen as well. Not sure I'd call it a discount, though. More like a price dysfunction. Pity the person stuck with no insurance and a bit of money in the bank.

I have insurance and I have not experienced hospital stay in the last 20 years, though I need to be ready as I age.

So, for those who do not have insurance, do they simply walk away without paying? What would happen then?

 

[bUU]

I suppose there are various levels... patient refuses to identify themselves; patient refuses to provide contact information; patient contact information not real; etc. -- all of which leads to a write-down of the costs incurred as noncollectable. Then, there are are the patients who don't have insurance but the hospital can still send a bill to. That's what they do. Then they refer it to collections, and from there to collection agencies, and collection agencies do what they normally do. Then the bill either gets paid or it gets written-down as noncollectable.

 

[easysurfer]

This talk kind of makes me want to get a policy with no lifetime limits .

The policy I have now is only a measly $5 Million limit.

 

[utrecht]

I have insurance and I have not experienced hospital stay in the last 20 years, though I need to be ready as I age.

So, for those who do not have insurance, do they simply walk away without paying? What would happen then?

In Dallas they go to the County Hospital who can't turn anyone away and the rest of us pay for them thru Hospital District taxes on our property tax bill.

 

[Meadbh]

Or they simply don't access the health care.....

 

[MichaelB]

I have insurance and I have not experienced hospital stay in the last 20 years, though I need to be ready as I age.

So, for those who do not have insurance, do they simply walk away without paying? What would happen then?

Well, the inability to pay medical expenses is the leading cause of personal bankrupcy in the US. A little under half of all personal bankruptcies are medical related, and those break down into 1) can't pay 2) lost job for health reason, lost insurance, can't pay and 3) lost job for health reason, can't pay.

Any health care service provider is better off financially with an upfront cash payment vs insurance reimbursement. The fact that the insurance payment gets a much lower price only highlights the dysfunction.

 

[bUU]

In Dallas they go to the County Hospital who can't turn anyone away ...

It should be noted that practically every hospital in the nation is prohibited from turning anyone away and required to provide emergency care to anyone who walks in the door. For more information, see 42 U.S.C. § 1395dd.

 

[gerrym51]

It should be noted that practically every hospital in the nation is prohibited from turning anyone away and required to provide emergency care to anyone who walks in the door. For more information, see 42 U.S.C. § 1395dd.

but they do send you a bill

 

[explanade]

That's pretty much what health insurers do for their subscribers: They negotiate lower rates with providers, capitalizing on their buying power.

Now imagine if we pooled the buying power across the whole nation instead of individual insurance companies ...

 

[ERD50]

In Dallas they go to the County Hospital who can't turn anyone away and the rest of us pay for them thru Hospital District taxes on our property tax bill.

As other's have said - they will bill you. But if you can't pay, it will get dismissed. I know a number of people who have gotten some extensive, free care, and only one was an emergency.

But if you can pay, they will try to hit you with those inflated charges. It is a crazy situation.

Well, the inability to pay medical expenses is the leading cause of personal bankrupcy in the US. ...

I'm quite sure that has been debunked. IIRC, the 'study' simply asked the bankruptee (is that a word?) if they had any outstanding medical bills. That somehow got turned into the 'cause' of the bankruptcy.

-ERD50

 

[MichaelB]

I'm quite sure that has been debunked. IIRC, the 'study' simply asked the bankruptee (is that a word?) if they had any outstanding medical bills. That somehow got turned into the 'cause' of the bankruptcy.

-ERD50

Fact checking reaffirms this but does separate "medical bankrupcy" into three categories, as I described above. Harvard University is the source of the most cited studies.

People with no money or resources can get emergency treatment at a hospital even if they can't pay, but that is not health care, and they are cannot get any other type of medical care without first showing proof of payment.

 

[KingB]

People with no money or resources can get emergency treatment at a hospital even if they can't pay, but that is not health care, and they are cannot get any other type of medical care without first showing proof of payment.

When I was checking in at the ER, I offered my HI card but the ER people said: "Not now, we will do that later after we check you out", which affirms your statement.

When they found out that I am not having a heart attack, they admitted me for further tests. I wonder if they would have discharged me if I did not have any means of paying.

 

[bUU]

Heart attacks are not the only thing considered emergency care. The provisions for this were signed into law by President Reagan in 1986. The law is referred to as EMTALA, and it requires emergency rooms to provide "medical screening examination" whenever "a request is made on the individual's behalf for examination or treatment for a medical condition" which is defined as "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain)". The conditions for discharge include a requirement that the condition, whatever it is, does not preclude the patient from caring for himself or herself, including the ability to walk around on your own, wash yourself, etc. So even a sprained ankle is covered by EMTALA.

 

[rbmrtn]

They are only required to give a screening exam to determine if an emergency condition exists, and only have to stabilize the individual. You can't just walk in and get long term treatment for chronic diseases like hi BP, diabetes etc. Not going to get cancer treatments. FAQ on EMTALA

I was in an ER once after an accident, they didn't even look at me for six hours. Laid on a gurney in the hallway. They couldn't initially verify the insurance, once they did it was game on, meter was running, they ran every test and exam they think of.

 

[bUU]

They are only required to give a screening exam to determine if an emergency condition exists, and only have to stabilize the individual.

The key is what "stabilize" means in the EMTALA context - it isn't just making sure the person isn't about to die. There are explicit requirements that if the condition, even if it is determined not to be life-threatening itself, impedes mobility or other basic things, then the patient cannot be discharged.

Furthermore, EMTALA does not indemnify service providers who follow the letter of the law. By this I mean that if a hospital insists on discharging a patient without treatment, after determining that their condition is not eligible for treatment under EMTALA, and then that person suffers harm as a result, EMTALA doesn't shield the hospital from civil lawsuits (and the general public generally sympathizes with the little guy, not the hospital) on the basis that they didn't want to take the patient's verbal promise that they would find a way to pay.

So effectively EMTALA has a secondary effect which cannot be ignored - it forces hospitals to open the door, and then that effectively obligates the hospital to provide treatment for non-chronic conditions, with no real guarantee of payment.

You can't just walk in and get long term treatment for chronic diseases like hi BP, diabetes etc. Not going to get cancer treatments.

Precisely so... treatment for chronic conditions are readily side-stepped, though treatment for any critical incidents that occur as a result of inadequate treatment for chronic conditions would fall under EMTALA.

 

[frank]

my wife gets prescriptions every month for her problems. one in particular makes me wonder. the initial cost on the statement was 24.98 and after the insurance discount it was 2.98. it certainly makes you wonder about the actual cost of the product. and do people actually pay the full price or if you are paying cash do they charge you the discounted price?