Tag Archives: health insurance

Two Hours… And Counting


Oh man! I may need treatment to recover from working out my health care expenses. For several years now, my shoulder has hurt. I have had it looked at by a doctor and I went through physical therapy until I had used up all that I was allowed to use, and treatment didn’t really work. My shoulder still hurt a lot. I then got sidetracked by all kinds of other things going on in my life and so I pretty much lived with the pain (eased a bit by massage, ibuprofen and Salonpas). Finally, I decided that enough was enough and that life should not be lived in pain, so I went to see the doctor who helped me out when I fractured my knee. I love his guy. He is absolutely awesome. And it is a great and special thing when you establish and relationship where you are treated like an adult with a brain and all your questions are answered and things are good. You feel great, until you start to talk money. Then you feel all kinds of unwell again.

I am a person with health insurance and I believe it is pretty good insurance because it is pretty widely accepted and my co-payments are decent. I understand that choosing an out of network doctor is bound to be very pricey. However, several years ago, I had some pretty terrible experiences when I went with in-network doctors that were recommended to me by my insurance website and not by a fellow medical profession. Now, when I find someone who treats me with respect and seems to have a vested interest in my being healthy and fully recovered, I tend to stick with that person. I understand that this can come with a premium; I just wanted to know what this premium might be. So, there I was, discussing a treatment plan and then payment plans. The treatment plan ended up being the easier part of things to understand. Let me tell my tale…

Looking at a schedule of my health insurance benefits is like solving a complex math problem, where suddenly I need my calculator and a whole lot of patience. I have to factor in a deductible and then calculate the split between what insurance will then cover and what I have as an out-of-pocket expense. I sat down with the office manager at my doctor’s office and he went through the various costs of my treatment and then he pulled up the Fair Health Consumer website. The office manager then explained to me that, because my doctor was out of network, we should go over what the treatment could, potentially, cost me. He explained to me that even though my insurance would cover a percentage of my “eligible expenses”, what that meant could make a huge difference to my wallet. I found out, this week, that things can get very complicated and expensive.

First of all, the health insurance company will determine the reasonable and customary cost of a procedure. This is the average fee charged in a particular geographic area. Then, for out of network providers, regardless of what the provider charges, the health insurance company will cover costs based on the reasonable and customary cost. However, a health insurance plan may determine what they will cover, based on a published rate allowed by Medicare. This rate has nothing to do with the average cost of a procedure in the part of the country where your treatment occurs. This rate can be wildly different from the reasonable and customary rate and this can result in a big difference in how your wallet looks at the end of the day. For example, you could have a procedure that has a reasonable and customary cost of $10,000. If your health insurance covers 60% of this rate, your out-of-pocket expense will be $4,000 or 40% (I am, for the sake of simplicity, assuming that there is no deductible). Now, if your health insurance uses the Medicare based rate, they could reimburse you only about $300 (this is a comparison that I actually did on the Fair Health Consumer website, and not something that I made up, as extreme as the difference is). That means here, your out-of-pocket expense will be $9,700. That is a significant difference. So it is very important to have an idea of what you are going to pay beforehand, Otherwise the doctor’s bill may give you a heart attack, in addition to all your other issues. The health insurance companies say that they have switched to the Medicare rate in order to push out of network doctors to become in network doctors in order to get better reimbursement rates from them, but what I have read of how this rate came about does not appear to support that claim. However, it seems to me that the patients are the ones who are suffering, being that they are the ones who then get the gigantic bills from the provider that they have chosen to use. And this could be because they have looked at their explanation of benefits and calculated their out-of-pocket based a reasonable cost. Imagine that.

With this in mind, the office manager gave me a list of information, including the codes for the treatment and suggested that, beyond visiting my insurer’s website and reading their explanation of benefits, I actually call and have conversations about what exactly the explanations mean. So began my adventures in telephone conversations regarding my health insurance benefits. I made my first call, thinking I would be on the phone for a few minutes but I didn’t hang up until over an hour later and I was still clueless. The man I spoke to was very friendly and polite and he took my information but then as we got into what I should expect my out-of-pocket expense to be, things became very murky and confusing. It appeared that he could not access out of network information for what my cost would be and, he was not clear on what rate my out-of-pocket expenses would be based. After an hour of us hanging out on the phone, trying to figure things out, he found a form that I could submit in order to get a quote from the health insurer but he seemed to not know how to get it to me. So he said he would call me back or email me before the end of the day. He did neither.

The next morning I called again and, even though this particular insurance company representative seemed to have access to a little more information, she too was very vague and kept telling me that she could not tell me how much things might cost me or what would be reimbursed. That is a bit scary since I was calling to make sure that I would have as few surprises as possible. About an hour into a very frustrating and circular conversation, I mentioned that the day before, the representative had mentioned a form and a client advocate. She claimed she had never heard of such a thing but she put me on hold as she went to investigate. She came back on the line and said she had found this form but she could only either fax it to me or send it via snail mail (I could go into a whole rant about why, in 2016, people can’t email you something and, instead, you have to figure out how to get your hands on a fax machine).

So, now I am at a point where I have sent information in to the insurance company and I am now waiting (for 2-3 business days, per the form) for a response on the eligible expense for my treatment – the first step in calculating out-of-pocket expenses. I am hoping that my future does not hold more protracted conversations where things end up even more confusing than they were going in. I would feel dumb, but the health insurance representatives seemed to know about as much as I did about what my insurance policy does and does not cover. I hope that I can get to a point where I can make an informed decision about what to do next. And my lesson, almost, learnt that I am sharing here – don’t take the website blurb at face value; don’t take the information booklet at face value; don’t assume you know what is going on. Keep asking questions, even if you get so frustrated that you want to throw your phone across the room. If what you are being told about your insurance doesn’t make sense, ask to speak to someone else. I could tell you what I think about all of this, but I am going to stick with telling you to ask the questions until you get clarity (even if it is very expensive clarity). Insurance is a very murky space and those dark spots could turn out to be a lot of money coming out of your pocket.


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