Last month, I had to go to the emergency room after midnight for what turned out to be a kidney stone. I was very lucky in that the pain subsided after I finally had to pee that night and the next morning, the stone immediately popped right out when I took a leak.
A few weeks ago, I got the bill. It was over $16,000. However, I only owed $150. The insurance paid over $9,000 and the rest was eliminated by “Other adjustments.”
So what are these other adjustments that saved me over $6,000?
Likely discounts that have been negotiated between your health insurance company and your medical providers.
Why doesn’t the hospital just expect me to cover what the insurance didn’t? Not that I’m complaining.
I just posted about my own bill shenanigans in the generic Pit thread this morning. Wish I had your kind of adjustments.
The regular rate quoted by the hospital is the equivalent to the rack rate in the hotel business - the absolute highest rate that anyone who’s unfortunate enough not to get any sort of discount will have to pay. But usually, health insurers don’t pay that rate; they use their negotiating leverage to get substantial discounts from hospitals. The net result of this scheme is that low-income individuals who don’t have health insurance are actually hurt twice: By having to pay what the health insurance would cover in another case; and by being charged more than what the health insurance would be charged. If that sounds like a rotten system, that’s because it is.
Because your health insurance company has negotiated lower rates for various procedures with that hospital for its policyholders.
For example, the hospital’s “standard rate” for taking an abdominal X-ray might be $1500, but the insurance company has already negotiated that down to, say, $500.
The big number ($16,000) in that statement from the ER is what you would have been on the hook to pay, if you didn’t have insurance, and could not benefit from those negotiated discounts.
Even as an individual consumer, if you are savvy you can usually negotiate down some of these charges if you are paying directly and not contesting major treatments. Those inflated charges are really there to give hospitals and other medical providers ‘leverage’ against insurance companies refusing to pay for procedures that were not ‘approved’ even though they are standard treatment protocols or were ordered by a specialist, and in the uninsured or “pay as you go” consumer just gets screwed. However, this means that you have to become knowledgeable about the “Code List” to figure out what you are even being charged for.
And all of this obscures the cost of medical treatments (good luck getting an estimate even if you know in advance what treatment you are seeking), so even if you are a canny and conscientious consumer you will have no way of estimating the cost of a procedure, even a very standard one such as normal childbirth or basic surgical procedures, not to mention outrageous markups on prescription pharmaceuticals or disposable medical items. So much for consumers making informed cost/benefit decisions regarding their own care.
Why does this system exist? Because it profits the medical industries to obfuscate costs while keeping patients and consumers uninformed and unable to effectively push back, and benefits insurance companies as having the leverage to get these “discounts”, which are still largely inflated while trying to deny benefits to their customers. And they all spend a lot of money on congressional lobbying (albeit, a tiny fraction of a percent of their profits because buying votes is cheap). What a racket.
Stranger
$16,000 is insane for a non-surgical ER visit.
I had my own kidney stone back in January. I spent about 6 hours in the ER, had an IV, pain meds, a CT scan, and sent home with a script for Hydromorphone and Lasix. The two scripts cost me $20 after my work insurance picked up the balance.
I have no idea what the ER visit cost was because we don’t get bills for any of that here. Publicly funded single-payer healthcare for the win!
I had a $930 charge after a brief hospital stay.
I’m well after any deductible charges. Nothing was done of an unusual nature, that maybe it was not covered. I was in my network. My doctors were in my network.
Went to the billing office, placed the paper on the man’s desk and said “No charge”. Walked out.
The next week I got a check in the mail for $144.
Letter said I was overcharged.
These people that work in these places do whatever the heck they want.
Poorly regulated, poor policy, underpaid, overworked employees. It’s a crap shoot.
Don’t pay anything til you talk to your insurance company. Ever.
You would think so, wouldn’t you? But you are paying for a lot more than just services rendered:
Even if you are a hardcore market-is-the-best-solution capitalist, there is a persuasive argument for why hospitals and medical providers should be cost regulated if not single payer with an income- or asset-based cap on patient cost that insures that they won’t be bankrupted by a single medical emergency. Like fire protection, roads and bridges, and education, it is a service that benefits society, and for which individual consumers cannot pre-negotiate or even anticipate costs, which has fostered a system that is essentially legal extortion against the patient’s literal health and well-being.
Stranger
And to answer the specific question, the contract between the hospital and the insurance company prohibits the hospital from billing the patient for this difference.
Yes, it’s called “balance billing” and is prohibited in some circumstance, but allowed in others.
It is generally allowed if you seek non-emergency care at an out of network facility. Your insurance may cover some of that cost, and you will be responsible for the rest.
If you go to an in-network facility, but receive out-of-network care; or in the event of an emergency, you cannot be billed for the balance. Your insurance will pay the contracted rate (at an in-network place) or a “reasonable and customary” rate at an out-of-network emergency room, and you cannot be billed for the difference.
One of the exceptions in which balance-billing is still allowed for emergency care is [ground] ambulance services (as opposed to air ambulance services like LifeStar helicopters).
The reason for this carve-out is reportedly because many municipalities own their own ambulance services and they all whined they would have to raise taxes otherwise. Of course the privately-owned ambulances benefit as well. Lawmakers eventually decided to fight that battle another day, so ambulance services, which apparently are out-of-network for virtually all insurance companies, can balance bill to their heart’s content.
And what’s even more aggravating is that many municipalities have contracted out their billing and collection services to private companies like COMSTAR, who aggressively market their services to the municipally-owned ambulance services. So the first bill you get is from COMSTAR, and if you don’t pay the full amount beyond what your insurance pays, they are the collection agency as well and will promptly initiate collection efforts.
I ran into this shitshow last year when I took the first ambulance ride of my life after a serious skiing injury. Because I got three medications by IV (two doses of pain medication and an anti-nausea medication), my trip was billed as the highest level of care, Advanced Life Support (ALS) Level 2. I got a bill for $3,500 for a 20-minute ambulance ride, of which my very good (Blue Cross Blue Shield) insurance paid the maximum in-network rate of just about half that amount.
However, the ambulance service is out-of-network (as is typical for ambulance services), so COMSTAR then proceeded to hound me for the difference. They absolutely refused to negotiate or give me any discounts. After 9 months of trying to get my insurance company to pay more, or for them to accept a lower amount, the best I could get out of them was a monthly payment plan for the remaining $1,700. I’m still paying this off.
As I said to my insurance company and the ambulance service, “Was I supposed to look for an in-network ambulance? I didn’t even call for the ambulance in the first place!”
It’s quite a rigged system, and I wish it would be addressed by lawmakers.
And that’s how you end up with incidents like this:
That made me think of this installment of Something Positive
Yeah - and a MAJOR frustration. Hospital bills are pure and utter fiction. They don’t expect to get more than a fraction of “rack rate”.
My gallbladder surgery carried a bill of something like 50K. I think the hospital got a tenth of that. My own copay was a grand or so.
My copy of the Ontario OHIP Schedule of Benefits dates from 1987, but I might be able to give you an idea, adjusted for inflation.
More to the point though, I’m old enough to remember Ontario before OHIP (Ontario Health Insurance Plan, which is the provincial health insurer). Because my father worked for an insurance company, our family had the solid-platinum, gold-plated health insurance plan, and everything was “free.” Until it wasn’t. We got a bill from my doctor for something. Might have been a doctor’s note for school or something like that, certainly a minor thing not covered by our insurance, and costing very little. But Mom argued on the phone with the insurance company about it for a few days.
And that’s not only because of “adjustments” such as those in the OP’s case. In many cases, where patients can’t pay, the hospital will sell the debt to a commercial collection agency at a hefty discount, and that agency will then try to get as much out of the patient as they can.
Agreed. Fortunately I’ve not had to do this myself, but I’ve heard of several instances where the hospital agreed to charging the discounted insurance cost for a non-insured patient when the patient agreed to pay in full immediately. Granted anyone in such a situation is less likely to have that sort of cash on-hand, but it’s helpful to know for strategizing.
I remember reading of another issue - some doctors have binding agreements with insurance companies that assures them they will be charged the doctor’s lowest rate. That means the doctor cannot give a break to an uninsured person, because then that becomes their “lowest rate” which the insurance company is entitled to as well.
Yes, even in Canada ambulances are not covered, and it is common for less injured people to beg bystanders not to call the ambulance, or to refuse the ride if one arrives. (Inter-hospital transfers are free, IIRC) I recall someone complaining that a 20-mile ride from a ski hill cost an exorbitant $350, but that was two decades ago.
I recall reading about situations in the USA especially where injured parties were told they could not refuse the ride. I’m not sure what your rights are.