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Over charged by Hospita? Over charged by Hospita?

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Unread 05-12-2003, 11:41 AM
Over charged by Hospita?

I just received a notice of payment from my insurance co. for a CT Scan I had done last month. I don't usually see the bills directly from the provider because they bill the insurance co. Hospital bill $2454.72 but insurance payed $1395.61. Amount I pay 0. What protection is there for people paying cash or an 80/20 plan?

I am just asking because there have been threads in the past regarding the vast differences in billing. If I didn't have insurance I would have had to pay the full amount billed or not receive services again. It just insn't fair!

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Unread 05-12-2003, 12:03 PM
Over charged by Hospita?

Hi (((Terry))) you're right, it's really tough. I have a PPO plan... as long as I use providers who are PPO's with my plan, I end up paying very little (after meeting the annual deductibles, which are getting pretty steep, and assuming I don't exceed the plan maximum, which I've gotten close to a couple of years in a row now).

However, the minute I use a DR or facility which is not a PPO in my plan, I start paying through the nose. With a PPO, your insurance company tells the provider what they're allowed to charge and only pays them that much, and the provider has to eat the balance. When they're not a PPO, you get to pay the difference between the (usually much smaller because you didn't use a PPO) portion of the bill that the insurance company will pay and the total that the provider or facility billed.

For me, the main problem is anesthesia. I've had three surgeries in the past year and each time the anesthesiologist's bill has been around $3000 (because of a family history of malignant hyperthermia which requires special equipment and preparations). While the hospital I use is a PPO, the anesthesiologists (who are selected the day before surgery by the hospital) are not. In fact, there is not an anesthesiologist in our whole county who is a PPO for my plan because of how little they pay! So I have had to pay these whopping anesthesia bills.

Except this time, when I registered at my pre-op at the hospital I complained, and the lady who was processing my paperwork suggested I appeal to the insurance company, nicely, when I receive their statement. She said the insurance people hate it when we get all upset and complain at them, but if we ask them "can't you help me out here, I'm kind of stuck because..." they can be very receptive. So that's what I did... and they ended up taking another $800 off of my portion of the bill. I wish everybody knew you could do this! I'm planning to send that admin. at the hospital flowers for helping me by sharing that little hint with me.

I don't know how people who are uninsured do it. My most recent surgery bills have totalled around $45,000... and I will end up paying about $4,000 when it's all over. It's still $4,000 that I don't have at the moment, but I can't imagine having to pay the $45,000.

Unread 05-12-2003, 02:02 PM
Over charged by Hospita?


You shouldn't have to worry about the bills along with everything else you have to deal with. The only reason we have such good insurance is my dh worked for a major corporation that offered him an early retirement package that included lifetime insurance. So far I haven't had any problems but this hospital did have me call & get preapproval this time as there will be 4 surgeons involved & possibly a longer stay. We don't have a max but where my husband works now or where I used to work is an 80/20 & our share would have been $25,000.00 right now! It is expensive enough to keep me in cathater bags & adult diapers. Now I have a prescription to home health store for them. Home health said cathater bags are definately covered but the diapers they will send in & see about.

I know how tough it is without good insurance because I have family members that have been fighting the system their whole life. I have a 14 year old niece with hearing aides in both ears & learning sign language. She went through most of her young life without being diagnosed because of no insurance. I think that had they treated her earlier she would still have her hearing.

Good Luck,
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Unread 05-12-2003, 02:05 PM
Over charged by Hospita?

PS Linda,

How are you feeling these days. I haven't seen an update from you lately!
Unread 05-12-2003, 02:12 PM
Over charged by Hospita?

(((Terry))) thanks for asking... I'm doing OK... I go for my almost 8 week checkup next week, and I'm pretty sure my DR will tell me I'm doing fabulous... but I don't feel fabulous, at least not yet. Healing from this one is a much bigger deal than I anticipated, I thought it would be just like the hyst . I wish! I do great up and walking around, but sitting up straight is very uncomfortable, sometimes painful, so driving is a problem. And as I started increasing my activity level recently I started having some symptoms of low estrogen so I'm having to tweak stuff there, too. Par for the course I suppose!

Still I am very, very thankful I am alive and able to eat and use the bathroom normally now... it's the small things like that we take for granted that can be so HUGE, can't they? I am hoping that once you get done with this surgery you will be in the same position I am... just cranky because it takes so long to feel 100% again but basically everything in working order! Keeping fingers and toes crossed for you!
Unread 05-12-2003, 02:40 PM
Over charged by Hospita?

Just got a call from the hospital saying I was approved but letting me know that I do have a limit. A million & a half dollars lifetime! That sounds like a long way to go but after this next surgery I will be a quarter of the way there with 20 more years before I am eligible for medicare. I am uninsurable at this point to pick up a supplemental.

Guess I won't worry about things I can't change! Glad your feeling better Linda, little by little. Actually I don't feel all that bad just more tired then usual. I think I was running on adrenalin & it just gave out! I am even too tired to worry about my next surgery!

See you later,
Unread 05-13-2003, 04:45 AM
Over charged by Hospita?

HI Ladies,

(((hugs))) Linda- glad you are feeling better sweetie- you most surely deserve it!!!

(((hugs))) Terry- glad you are getting along well and will be fixed real soon.!!

I am doing great and just wanted to chime in on the insurance issue. I could not be admitted for fistula surgery until I paid my $500 co-payment for admission. nice huh?? What if I didn't have the money- which I didn't and stole from my rainy day fund. We have been self-insured from my DH former business for the past 3 years and last year between Insurance premiums and co-pays I spent $14,000 - which is unbelievable!! Now we are changing to my DH new company plan which will still cost $250 a month- it is staggering..and you are right- I would have had to pay the entire amount like Linda said if had no insurance..there had to be a better way!!

Well enough said and hope everyone is having a better time of it!!
Sending warm s to all!!
Unread 05-13-2003, 06:36 AM
Over charged by Hospita?

To my knowledge there is no such protection. We are fortunate to have very good insurance that allows us to go to any doctor or facility of our choice w/o referral, etc.

However, part of the payoff for that privilege is that we must pay our own office calls. And THAT can be hefty! As much as $220 for an inititial office call w/a new specialist.

Now I am on Medicare w/our previous insurance as a secondary, which means I have to pay the difference between what Medicare pays for an office call and what the actual charge is.

My son, on the other hand, is disabled and on Medicare w/the same secondary insurance. His doctor, knowing his circumstances, is agreeable to accepting only what Medicare pays and doesn't charge him the balance. When my son is referrred to a specialist tho, he has to pay that difference and it can be HEFTY! So he is primarily treated by his GP and seldom sees a specialist.

Basically, what is happening is that those of us with known income but no insurance or insured but who have to pay their own office call are subsidizing those on Medicare or with no insurance and no ability to pay at all.

Medicare and the HMOs and PPOs pay well under the actual cost of an office call. A doctor could not survive and stay in practice on the little they are paid by these "insurances". I can remember years ago, when my old family doctor did very well in a one man office with one nurse/receptionist. But now w/so many insurances, etc. my current doctor, also in a one man office, needs to employ 5-6 nurses & office staff just to keep up w/insurance and regulatory paperwork. Which also means he has to carry a MUCH heavier patient case load than my old doctor did so many years ago. Which means less time per patient and less time to get to know each patient.

Hospitals that received government grant money to build, etc. are required to provide pro bono medical care to the uninsured needy and indigent. They have to make up some of those losses somehow.

What bothers me most is in our local area the hospitals are screaming poverty and budget problems, cutting staffing and staffing pay and benefits yet they are constantly building additions, remodeling, building outpatient clinics, outlying area doctor offices and labs, etc. And I can't help but wonder about the salary, benefits and perks the upper echelon such as the "CEOs", etc. are making.
Unread 05-13-2003, 08:16 AM
Over charged by Hospita?

I do understand the dr's & hospitals side as well. Understaffing is a big problem in our area. Nurses work 12 hour shifts & are staffed due to patient census. When I have been hospitalized & my MIL hospitalized we had very good care at the same hospital but it was my dh that helped us bathe, rubbed lotion, massaged, walked us & made sure we didn't need anything that wasn't medical like water, dry linens, trips to the bathroom. He even learned to tube feed his mother & catherize her. Difficult thing for a man to do but he did it out of love.

The nurses always started out telling you how understaffed they are but please ring for anything you need. If it wasn't medical I could expect to wait such as leaking & getting my pad changed. The patient care person would bring in our towels & gowns & know that when my dh arrived everything would be done.

Without our wonderful insurance we would be spending our golden years paying off all of these bills. One way our insurance co is fighting back is a wellness program. Every quarter we set a goal healthwise. When we achieve our goal we get points. Points are then transferred to a card similiar to American Express & we can make purchases. Since I am having complications my goal is to take my blood pressure twice a week & record it in my book. My dh is diabetic so first they wanted his goal to send the results of his glucose test by phone daily. He told them he does that anyway so he decided to lose 10 lbs. Everytime we achieve a goal we have to choose another. I hope it works to keep us healthy. They have sent us recipes, excersize equipment, medical equipment such as blood pressure machines, new gucovance machines & so on. I just wish everyone had the same advantage we have. We do have to help my step daughter with her families medical bills at times because she has 3 children & inadequate insurance.

Unread 05-13-2003, 11:20 AM
Over charged by Hospita?

We pay well over $600/month for a family of 4 for our PPO, with a $500 deductible per person/year and a $20 - $40 co-pay for prescriptions. In fact, one of the reasons I've not gone back to investigate some lingering, nagging issues is because I still haven't paid off the hyst -- between being out of work for the two months and the reduced hours I work, there is nothing left for any medical bills except my DDs. My stepson's mom takes him to the doctor for a variety of things, and by the time we pay our half of HIS bills, we just have nothing left for ourselves.

I can relate, (((Linda))) to your difficulty with the anesthesiologist. My surgeon's first assistant last year was a senior fellow from UC Irvine, assigned to the GYN-oncology practice for six months. However, his billing came from the UC Irvine practice, NOT members (of course) of the PPO plan. And I was not given any choice (I loved him dearly, and he was worth every penny) in the matter, so I'm still fighting that out with Blue Cross.

We used to have Kaiser, and there are many things about Kaiser that I really miss. For example, when I had an ectopic pregnancy 8 years ago, a friend also had one, a bit less complicated. She had the PPO; I had Kaiser. I walked out not owing a penny -- she, OTOH, had to pay $3000 in addition to losing her baby . And when my DD was born, she spent two months in the NICU (probably a good $300,000 in bills, as near as we can tell) and I spent three weeks including some "quality" ICU time myself. Again, when we took her home, we didn't owe a thing. On our current plan, she already would have been over half-way to her lifetime cap of $500K -- just in the first two months .

About reimbursement: Medicare pays about half what the hospital's "price" is...most prices are "pegged" to that Medicare reimbursement. However, that just meets costs in some cases; others it doesn't even come close. And all other insurers set their reimbursement rates to a complex structure whose heart is the Medicare prices. In practice, this is what that means: when we do an echocardiogram, for example, there are two components -- the technical and the reading fee. Most echocardiograms take the doctor about 20 minutes, start to finish, to read. The Blue Cross reimbursement in our community for a cardiologist to read an echo is approximately $25. However, most physicians do charge more. They have to stay in business, and most medical practices (especially the solo ones -- I work in a solo practice as well) have a great deal of difficulty making ends meet. Fewer and fewer practices are willing to join those PPO networks, as they know they will not be reimbursed fairly for their time and effort. And now, the new HIPAA privacy laws are costing even more in terms of worker hours to ensure compliance.

As far as building goes...many states require changes periodically. For example, in California, all hospitals have to meet a particular earthquake code by 2004. Many hospitals cannot just remodel to meet these requirements, so they are re-building instead. Much of the funding comes from private fund-raising and federal or state money (not enough of it, I would add!). That funding does NOT come from so-called "operating expenses" such as salaries or insurance reimbursements.

I've worked in the healthcare industry for over 30 years, and what I see is so much money spent on paperwork, authorizations, regulatory compliance, etc. If we could turn that around and actually spend it on care , just think of what could be accomplished!

Just my -- stepping off my soapbox now...


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