spouse of scouse

3k for an outpatient procedure despite paying through the nose for insurance. That's obscene, as is the $150,000 billed to (presumably) your insurance company. That's one hell of a sick health system

Lion in Winter

It's set up as a business - for hospitals, doctors and above all insurance companies. The hospital charges were by far the largest part of that 150,000k, and he wasn't even admitted, it was outpatient. The patient is a minor cog in the whole thing really. There is help if you are destitute, but little help until you are destitute. If we were very low income, we could get a cheaper (and worse) plan on the ACA (formerly Obamacare) but with any kind of professional wage you are going to pay full price.

durham_lad

I always maintained a spreadsheet for keeping track of all the costs of each treatment mainly because it is so complicated that the health providers rarely get it right and every year I had to go demand repayment of the money they owed me because you pay up front for treatment based on what they think your insurance will pay and they always underestimate but after the insurance company pays more they never refund the extra back to you. On one occasion my wife had a hospital stay and I had to pay $5,800 to take her home even after I had my exceeded my annual OOP expenses and should have paid nothing. Many weeks later I had to call the hospital and demand it back. The year before we left the USA (2015) I had paid $6,600 too much to the heart clinic I was being treated at as an outpatient and after the insurance company finally paid out the claims, I went in for my next appointment and when the receptionist told me that would be $30 for the copay I told her to check my account and she confirmed that I was in credit to the tune of $6,600 and asked if I had wanted the $30 taken out of that. When I told her that I wanted all the money refunded to me she called accounts and said "no problem, they'll refund it". But I've been there many times and while health care places happily take your money via credit or debit card they only issue refunds via paper check. I told her that I needed the check today as tomorrow we were going on our delayed 7 month road trip and the check would be expired by the time we got back. I had to wait a couple of hours after my appointment but did walk out with the check in hand.

In 2010 my wife and I retired and went onto retiree benefits from the company I worked for. Good insurance except after a couple of years they started removing the company subsidy on the premiums so that by 2016 the premiums were up to $8,654/year. I still continued to receive the paperwork to sign up each year and by 2019 it was over $12k/year, but fortunately I didn't need it after 2016 as we moved back to England.

Our out of pocket costs including premiums for our first years of retirement from 2010 through to 2016 were $49,662. (That is 7 years in total, no overnight hospital stays but one visit to an ER in 2015 with an irregular heartbeat - turned out to be Atrial Fibrillation)

Glasgow Girl

The time for self pay is quicker because the doctors in my area use their own private facilities for out patient surgery, but they don’t accept the ACA marketplace insurance at those facilities. To use that they have to use one of the hospitals that do accept it and that is where the delay (and additional cost) is. I guess the ACA plans do not pay as much as insurance through employers because I am now finding that many doctors and facilities no longer accept it.

Yes, I go private pay if I am pretty sure I will not reach my very high deductible. That of course is a calculated gamble, but it has always worked out for me so far. If it does not I likely will have bigger problems to worry about.

Doctors focus on the medical procedures not the financial side of things, you have to ask their office staff about self pay. You have to press them because they always say that insurance will be best until they run the numbers and then they are frequently very surprised. You have to be your own advocate.

Private pay does not count towards your in network deductible, but does count for your out of network deductible so long as you have the doctors office run it through the insurance first (to get it denied before you pay!)

Steerpike

I presume your current plan is an ACA-compliant plan? To have 'only' $3,000 'max out of pocket' is extremely 'good'!; my max OOP is $8,550 (I just looked it up - I thought it was much higher!). So I presume your plan is a silver or gold ACA plan with that 'low' level of OOP (mine is 'bronze'). My premium is circa $800/mo; premiums are age-adjusted, and I'm getting close to the worst-possible age for such plans (over 60). If you are considerably younger than me, your premium would go down a lot, but they your premium would go up because of the silver/gold choice, and ... if you are covering hubby then that increases it further.

My $800/mo premium is currently subsidized, assuming I make less than $50k/year, to around $350/mo. If I end up making more than $50k, I'll have to pay back the subsidy, and if I make considerably LESS than $50k, I may get more subsidy retroactively.

Giantaxe

For 2021 and 2022 the "subsidy cliff" is gone thanks to the Covid Relief bill:

https://www.kff.org/health-reform/is...lace-premiums/

Steerpike

That's great info - thanks! Interesting that you still have to run it through insurance to get it to 'count'; you initially negotiated a price based on 'not using insurance', but they still didn't mind running it 'through' insurance so you accumulated the deductible.

I'm about to get my THIRD colonoscopy ("oh lucky me" ). Last two, I had to fight tooth-and-nail to get them to waive the charges, since it is considered 'preventive'. I'm fully anticipating the same battle this time. Colonoscopies are classic problems under the ACA. The ACA deems it a 'preventive' procedure, and therefore covered fully under your insurance (without deductible), but - in a high percentage of cases - while 'exploring' your innards as part of the procedure, they may find minor issues and - since they are 'already in the neighborhood', they take advantage of that fact and 'snip' the offending issue. But once they do that 'snip', the procedure has gone from a preventive exploration to an active corrective procedure, and it changes the 'coding' of the procedure, and switches it from 'free' to 'paid for'. I argued the point with the insurance company in both cases, and in both cases they EVENTUALLY waived the charge, but it was more 'we are giving up arguing with you' than 'you are right'!

Giantaxe

Tell me about it... last colonoscopy I had my insurance pulled the same stunt because a biopsy (fortunately negative) was taken. They claimed that it wasn't preventive but diagnostic. A long fight later, they did eventually pay for it. Honestly, I think they do this because they know some people will give up the fight. Now I'm on Medicare, so who knows what will happen the next time I have one.

sid nv

Same issue here. Our Medicare Advantage Plan not only offers free colonoscopies, they have monetary promotions to go get colonoscopied. So the wife was volunteered for a colonoscopy (I did not partake, agreeing to getting a probe up the jacksie is obviously not going to happen if I can help it). After wife completed this mission, we received a bill with the "diagnostic" coding. I had a prolonged argument with the billing people, but they were adamant and would not change their billing code. Eventually I caved in and paid the bill.

Steerpike

How much was the bill?

Also - my (limited) experience with 'negotiating' billing issues like this is to simply not pay after all verbal efforts fail. You don't argue with them until they say 'OK, you win' - you argue with them every time they ask for payment until they finally remove the billing. 'Victory' in this situation isn't an acknowledgement that you were right, it's the removal of the amount from your bill . Very difficult for a 'decent Brit' to go this route, but it seems to be the only way to 'win'.

Regarding "(I did not partake, agreeing to getting a probe up the jacksie is obviously not going to happen if I can help it)" - it's better to get a 'probe up the jacksie' than it is to get prostate cancer; do keep that in mind! The 'probe' is not even something you are aware of; you go to sleep before it starts and you wake up thinking ... 'was that it?' and go home. The 24 hour fasting and purging ahead of the probe is by far the worst part, but it is but one day every 5 years ...

Giantaxe

When I'm met by health insurance obstinacy, I go full on "aggressive" mode, attempting to make _them_ prove the billing is correct.

In this case, sid_nv has a different way of resolving this, namely getting the provider to recode the procedure as preventive as opposed to diagnostic.

I think you mean colon cancer.

robin1234

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Yes I’m afraid that’s been my weak spot in this situation. I tend to react .. “I’m shocked! These Americans are simply contemptible! I will not sink to their level! I’ll pay, and move on.”

My wife on the other hand always refuses to pay medical bills and always wins.

TexanScot

One of the most interesting things for me about experiencing US healthcare was having to adjust my mindset from being a passive recipient of healthcare to being an active consumer.

Like you say, I don't think self-advocacy and being pushy with billing departments comes naturally to many of us - it's bad enough trying to muster the courage to complain about a bad meal, let alone a medical bill.

civilservant

Excellent article here by Axios on Medicare Advantage enrollment and costs:

https://www.axios.com/medicare-advan...c5af097d5.html

and here's the key lines for me...

Giantaxe

I chose "traditional" Medicare because the only Advantage plans in my area (San Francisco) were HMO plans that didn't cover both some of my existing doctors and UCSF Medical School doctors as well. So I got a high deductible supplemental plan to cover me against catastrophic costs. I have no idea whether I made the "right" decision, but it is what seemed the most plausible approach.