Insurance Games

I work at a large company that provides a health insurance benefit for part time employees who have worked there over 1000 hours, or about a year. We’re drawing toward the end of the second year of that.

There are two plans. Let’s say that one costs $10 a month and has pathetic coverage, a catastrophic plan that is marginal until you have been personally responsible for $5250, after which it pays everything that it covers. That’s over 1/3 of my gross income there, and could easily be half of someone’s income, depending on location and seniority. That’s equivalent to an out of pocket maximum closer to $25,000 on the income I’d need in order to be out the other side of the donut hole. I am up over $3000 of that so far this year. That’s a lot of years of making sure the providers get at least $10 a month to avoid having it sent to collections.

The other plan, which I was on last year, costs five times as much, and covers much more. That year, I only saw a doctor a few times, and for whatever reason I never saw a bill. I’m pretty sure I should have seen bills for a portion of each office visit. I was supposed to have been on the same plan, but the company defaults your choice to the bottom plan, and in a tricksy accident I was not allowed to select the one I wanted. You know that’s a guarantee I’d actually need the coverage for that year. In six more days, I will get to select again, which is a relief.

I am also covered, into the beginning of next year, by the part of RomneyCare called Health Safety Net, which is backstop coverage for people who are poor, but not so poor, and have crappy insurance that they can’t actually afford to use but that satisfies the mandate. I had thought that covered all the things, and that was why I never saw one bill from the doctor last year. However, it covers stuff at hospitals and “community health centers” (what are those? where? who designates them? couldn’t tell you!), but not at regular practices. That would encourage one to hit the ER for something relatively mundane, which makes no sense, given the alleged overuse of ERs by poor people was the driving force behind RomneyCare. I have never done that in my life, and it would never occur to me, unless I had an emergency. The practice I use has after-hours urgent care that’s pretty easy to get into, and they have people on-call for emergency visits. Usually seeing a nurse practitioner, but no need for more for most things. Heck, when middle child broke her arm, we went there, not ER. NP saw her and then our family doctor, who is her boss, stepped in to help put on a cast. We didn’t even have to see the orthopedic people.

As an aside, the wife is on separate insurance, through her employer, and the kids are fully covered by RomneyCare, but we pay a monthly premium for that. Not sure how we’d do it if kids were on an employer plan for probably more additional premium than the state charges, but were not as well covered. I know! We’d magically up our income tens of thousands of dollars to get to the other side of the donut hole. Can I digress like a fiend, or what?

Where was I? The point of this was to discuss my EOB (explanation of benefits) for the 34 hours I spent at the hospital, getting a cardiac catheterization that resulted in two stents, followed by time in a room for observation – otherwise I’d have been home same day.

The cath and stent procedure was free as part of a large study I agreed to participate in for the privilege of it being free, and not having to be transferred to another hospital if they found blockage that could be treated with stents. (Bypass would have required transfer, since there is not a full cardiac unit there – thus the study showing the efficacy of hospitals being able to do stents without full cardiac units.) I thought that was cool, and a worthy goal. Cost didn’t matter so much, since RomneyCare would backstop the hospital charges.

On the EOB, there is no indication that anything about the event was “free.” It may be that there is some tiny portion of the charges that is what they actually meant that is not noticeable in its absence. The hospital billed over $60,000 for the 34 hour stay, plus another $2500 for the hospitalist in charge of me for most of that time. Great guy. Chatted with him twice, briefly. He even gave me his cell number in case I needed anything after I got home and couldn’t reach anyone. Even in the middle of the night… call. Except… his number was nowhere on any of the paperwork. Oops.

About $40,000 of the total on the main bill was “physician” charges. Since the hospitalist was covered elsewhere (and the insurance actually covered all but around $400, after discounting it to about $1600 they’d actually cover), that was all for the excellent cardiologist who did the “free” procedure and presumably the anesthesiologist. I expected the retail on the procedure not to be cheap. Specialized room, team of people, special prep and recovery area, special skills and equipment… but, yeah, don’t think so, especially “free.” The room overnight, amazing nurses, meals, whatever… those were apparently around $4000-5000 of the total charges.

Anyway, insurance denied most of it, either not covered or separately billed items already included elsewhere not being allowed. I maybe should have called this “hospital games,” since the culprit here appears to be the hospital, but I suspect this is what they have been trained to do by the government and insurers, as self-defense. If my old business could only have collected 30% of what we billed our clients, our prices would have gone up accordingly, and every scrap of any billable time or expense would have been included. Like when I’d go to four people to solve minor problems in 15 minutes, that was our minimum increment of .25 hours (which was too low), it could instead have been four minimum charges for four incidents, making it 1 hour.

The part they didn’t deny, but discounted deeply, was the physician charges, implying that those are so large because they already incorporate all the supplies, labs, etc. Net result is almost as low an insurance payment for the 60k as for the 2.5k. The other thing they paid is a tiny indigent care surcharge the state collects.

I was pretty amused by the whole thing. I’d never be able to pay my share of it regardless, so as well for them it’s backstopped. But it makes me wonder what they bill RomneyCare now, and what that coverage allows them to get paid for. Is the 60k thing a ploy to get a ton of state money? Or will the state pay only what the insurer left me for a balance? No idea. What should happen is I will either never see a bill from the hospital, or I will remind them of HSN if I do, and will never see anything else about it.

I was opposed to RomneyCare, and can’t believe I am supporting Mitt for President, not that there’s a choice, but with actual enthusiasm. It has been good to us, though. Not that times should have been this rough. I call myself “pragmatic libertarian, because I’d love to see that pure society, but we have to get there from here. You can’t just snap fingers and make it so. You have to backtrack through the bramble maze. People can’t be left in the lurch as if there is and has always been a free market economy. It’s an interesting question, then, how you backtrack to FDR, undo the effects of wage controls that made health insurance a free perk of employment that could differentiate employers, undo the effects of insurance being for maintenance, not “insurance,” and undo the effects of later adding Medicare/caid in part because of the effects of FDR on the market, making matters vastly worse. You can’t just press Ctrl-Z on entrenched policies and their aftermaths. I hope we can make a start, though, before it gets out of hand.

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