An experiment... How much will my insurance cover...

[rodi]

So - as I've mentioned here - my son had a rapidly growing mass on his jaw - the dentist discovered it and referred us to an oral surgeon.. We had no idea of the scale - assumed it was dental in nature, so not covered under health insurance. The oral surgeon (outside our kaiser insurance) did some scans and suggested surgery sooner than later. I quickly suggested we get a referral into the Kaiser Permanente system. His office was very helpful and arranged for us to bypass the primary and get straight into the maxillofacial surgical department.

OOP - $232. Money well spent on out of network doctor and panoramic xrays.

Once at Kaiser we had our office copay (with balance billing still to come) - $55 for the doctor, $30 for xrays.

Surgery was schedule and happened the next week. Today we got the first statement (no money due yet) on that surgery.

Lab - Pathology/Histology : $1187
Operating room : $10,022
Anesthesia : $182
Pharmacy - drugs requiring special coding : $108.25
Pharmacy - drugs self administered : $6.85

Note - this is before the adjustments for insurance. Those showed as "pending".

Note - this does not include any professional services. There were 2 surgeons.

Since the surgery we had one post op visit. We have another today.

We have a HDHP. $4500 deductible/person, $6500 max OOP/person. It's clear we'll be hitting the max OOP.

Oh... and this was an out patient surgery. No overnight.

 

[Texas Proud]

If your insurance is like what we had a few years ago then I bet your hospital will end up less than $2,000...


Heck, you might not hit max OOP....


Let us know what the final numbers are...

 

[rodi]

That's the experiment. I'll post numbers as they come in.

We just got back from the 2nd post op and my son is healing well. So glad the mass was discovered and removed in time to avoid jaw reconstruction.

My personal guess is the "pre" negotiated rates, once the surgeons (2) and anesthesiologist are in, the hospital/professional portion of the adventure will be at least 18k... maybe even $20k or more.

Our cap should be $6500 total... so I'm not worried.

And as a bonus - both son and I got our flu shots (free - preventative) while we were there.

 

[pb4uski]

Keep in mind... around here anyway... if you call the billing department and offered to pay right then and there by credit card it's not uncommon to get a discount of as much as 20% for a big bill like that! In my experience, sometimes it works... sometimes it doesn't.

 

[rodi]

Keep in mind... around here anyway... if you call the billing department and offered to pay right then and there by credit card it's not uncommon to get a discount of as much as 20% for a big bill like that! In my experience, sometimes it works... sometimes it doesn't.

Why would I do that before they apply their insurance discounts. Those discounts will likely cut the bill in half (or more).

And my exposure is limited to 6500 Max OOP for my son.

I just find it interesting to see what the "rack rate" is - and am curious what the "real rate" will be. Hence the experiment.

 

[sengsational]

I bet that the rack rate will be three or four times what the in-network negotiated rates will be.

But there might be some out of network "gothcas", so you could be in for more than your max oop.

 

[pb4uski]

Why would I do that before they apply their insurance discounts. Those discounts will likely cut the bill in half (or more).

And my exposure is limited to 6500 Max OOP for my son.

I just find it interesting to see what the "rack rate" is - and am curious what the "real rate" will be. Hence the experiment.

What I am talking about is AFTER they have applied their discounts... IOW an additional discount off of the negotiated rates that the medical provider bills you.... for immediate payment... plus if you us a rewards credit card then you get another 2%!

 

[Katsmeow]

A couple of years ago my daughter went to the ER with abdominal pain. We started at Urgent Care (this was on a weekend) and they did a flu test and determined it wasn't flu. They recommended going to the ER because it could be appendicitis, etc.

Went to the ER, they did a CT and some blood work. We hung around for several hours and, ultimately, the ER decided it was....the flu (they said the flu test is often inaccurate).

She never saw a physician (she did see a nurse practitioner).

This was an in network hospital and bill (not including for the physicians who read everything) was about $21k! The discounted amount paid the hospital was, if I recall, something under $3k.

 

[Texas Proud]

I bet that the rack rate will be three or four times what the in-network negotiated rates will be.

But there might be some out of network "gothcas", so you could be in for more than your max oop.

Can we go over/under

I take over... I think it might reach 5X or more... at least on some of the charges...

 

[ivinsfan]

So on your comments about doctors billing for the surgery. When my DH had a mitral valve repair the the bill came as one huge operating room charge. I expected additional charges from the surgeons. Charges were billed for anesthesia but not the surgeons, it was apparently all rolled into the operating room charge which was around 75K if I remember correctly. There were charges like going on bypass, mitral valve, etc which most likely went to the surgeons. A very opaque way of billing as you had no idea what the surgeons actually got paid.

 

[ExFlyBoy5]

Surgery was schedule and happened the next week. Today we got the first statement (no money due yet) on that surgery.

Lab - Pathology/Histology : $1187
Operating room : $10,022
Anesthesia : $182
Pharmacy - drugs requiring special coding : $108.25
Pharmacy - drugs self administered : $6.85

Note - this is before the adjustments for insurance. Those showed as "pending".

I know you mentioned this was BEFORE adjustments and I *think* that there is some adjustment there...those prices are VERY, VERY CHEAP. As a comparison, here are the "rack rates" that were charged for gall bladder removal back in February:

OR: $3208
Anesthesia: $3208
Lab: $3056
Pharmacy (during surgery): $2243
Recovery Room: $2243

In all (not including billing from the surgeon which was separate) the total bill was $24,194. Insurance paid a total of $3774 and I paid very , VERY little (I have Tricare Prime which is about as great as an insurance plan you can have).

Edit: Glad to hear the follow up went well and everything is great, all things considered!

 

[GTFan]

What I am talking about is AFTER they have applied their discounts... IOW an additional discount off of the negotiated rates that the medical provider bills you.... for immediate payment... plus if you us a rewards credit card then you get another 2%!

We tried that with a Humana in-network hospital after my wife's broken leg surgery last year and they said if it's an insurance rate w/deductible there is no cash discount for the balance. I was not surprised to hear that because the bill had already gone from $80k to $50k (we paid full $6300 deductible), but YMMV.

 

[pb4uski]

Yes, in my experience some providers will and some refuse. But if you don't ask then you won't get a discount.

 

[kgtest]

I love how the drug dealer (anesthesiologist) gets like a couple hundred bucks. Its like always the cheapest part about a surgery, but who would go without?

It cost me more money to get a strep test than that anesthesiologist .

 

[kgtest]

In all (not including billing from the surgeon which was separate) the total bill was $24,194. Insurance paid a total of $3774 and I paid very , VERY little (I have Tricare Prime which is about as great as an insurance plan you can have).

Edit: Glad to hear the follow up went well and everything is great, all things considered!

buddy had his removed at Kaiser about 6months ago for around 30k. He didn't have insurance but the hospital worked with him and it dropped his responsibility to about 1/3 the total.

 

[ivinsfan]

I love how the drug dealer (anesthesiologist) gets like a couple hundred bucks. Its like always the cheapest part about a surgery, but who would go without?

It cost me more money to get a strep test than that anesthesiologist .

In my experience there will be another bill coming for the anesthesiologist....that's the way it seems to work around here.

 

[rodi]

New bill - for professional services prior to the surgery and the surgeon's fees. This one has the adjustments.

initial surgical consult
- base charge - $335
- insurance reduction - ($195)
- less payment at time of service - ($55)
Balance due: $85

Orthopantogram (panoramic xrays)
- base charge - $48
- insurance adjustment - ($31)
- paid at time of service - ($17)
Balance due: $0

Orthpantogram (2nd view)
base charge - $53
insurance reduction - ($33)
paid at time of service - ($13)
Balance due - $7

Surgeon (one of two - but the first to show up on a bill)
Base charge - $1815
Insurance Reduction - ($1130)
Balance Due - $685


This bill clearly shows the value of just having insurance to reduce the charges... I'm also surprised by how low the surgical charge is... I suspect there is more coming. The initial bill was reduced by more than half - just for being insured (but still in the deductible phase.)

 

[ivinsfan]

It's funny how different billing systems are, as I mentioned above we never got a separate bill from any surgeon. I suspect they were employees of the hospital and the bill got rolled into the one huge charge.

 

[sengsational]

Do you think that "base charge" is what someone without insurance would see?

 

[rodi]

Do you think that "base charge" is what someone without insurance would see?

Yes.

 

[ExFlyBoy5]

New bill - for professional services prior to the surgery and the surgeon's fees. This one has the adjustments.

initial surgical consult
- base charge - $335
- insurance reduction - ($195)
- less payment at time of service - ($55)
Balance due: $85

Orthopantogram (panoramic xrays)
- base charge - $48
- insurance adjustment - ($31)
- paid at time of service - ($17)
Balance due: $0

Orthpantogram (2nd view)
base charge - $53
insurance reduction - ($33)
paid at time of service - ($13)
Balance due - $7

Surgeon (one of two - but the first to show up on a bill)
Base charge - $1815
Insurance Reduction - ($1130)
Balance Due - $685


This bill clearly shows the value of just having insurance to reduce the charges... I'm also surprised by how low the surgical charge is... I suspect there is more coming. The initial bill was reduced by more than half - just for being insured (but still in the deductible phase.)

These "base charges" still seem very, VERY cheap to me. If you look at my earlier posting, you will see the "base charges" on my bill and they were significantly higher than what you are seeing. My DW's spinal surgery (at another hospital) had numbers similar to mine (but much, MUCH higher for the duration of services).

 

[GrayHare]

These "base charges" still seem very, VERY cheap to me. If you look at my earlier posting, you will see the "base charges" on my bill and they were significantly higher than what you are seeing. My DW's spinal surgery (at another hospital) had numbers similar to mine (but much, MUCH higher for the duration of services).

+1 I'm used to seeing base charges 10x the amount eventually paid. I also see insurance statements that put the entire amount in "doctor writeoff" column which is either absurd or meant to even out those who do pay the entire inflated base amount.

 

[FUEGO]

These base charges seem pretty reasonable to me. I mean once you accept that base charges often have no basis in reality or relation to what was actually done, it makes perfect sense that some people see rates 10x what insurance pays and some see rates 2-3x what insurance pays.

I think you're right, Rodi, that this clearly shows how valuable insurance is to reduce your bills to a reasonable rate. I wouldn't be surprised if you end up somewhere between the deductible and OOP max since those hospital charges (OR and labs) will get cut in a bigly way. For labs and pathology at the hospital I've seen 80-90% reductions and I bet the OR will be cut to a few thousand from the $10k billed.

Insurance = protection money from the racket that is modern health care billing.

 

[Winemaker]

Some of those "insurance reductions" are monies that may have already been paid in another previous payments. My former employer made 'beginning of the year' payments to various health care providers in our rural area to provide contracted services. For example, $200,000 for 10 babies delivered, 5 tonsillectomies, 5 broken femurs, 6 heart attacks, etc. and each year the contract is renegotiated.

 

[rodi]

Surgery was schedule and happened the next week. Today we got the first statement (no money due yet) on that surgery.

Lab - Pathology/Histology : $1187
Operating room : $10,022
Anesthesia : $182
Pharmacy - drugs requiring special coding : $108.25
Pharmacy - drugs self administered : $6.85

Note - this is before the adjustments for insurance. Those showed as "pending".

Ok - the above charges are out of pending and now billed as follows:

Total for hospital account: 11,508.10 (above charges)
Paid by insurance/adjustments/discount: -5907.69
Paid by you (me): -1113.00

Amount you owe: $4487.41

We're over the deductible, but below the max OOP of $6500 by about $120...

I don't know what other bills might be coming in... But the most we'll owe is that balance on the max OOP... so I'm not too worried.