Ouch!

Insurance? Ha!

If you think you have pretty good health insurance, you probably haven't had to use it.

Earlier this summer, I had some diagnostic procedures — a CT scan and a biopsy — to check out some symptoms that I'd been having off and on for some time. The bills are still coming in, and I've found that my health insurance company's first response to claims is to break the bill up into little pieces to make it more complicated; their second response is to say that I had gone to an "out of network" provider, even when I hadn't; and their third response is to say that most of it is part of my "deductibles" ($1200 max) or "out of pocket" ($3000 max). Since both "deductibles" and "out of pocket" come out of my pocket, it's not at all clear what the difference is. Lastly, the same claims may re-appear several times in your monthly statements, once for each time the insurance company does something with the bill.

It would be hard to devise a better system for making it impossible to figure out what's going on. It makes a nice case study of just how broken our healthcare system is.

CT scan

Before going for my CT scan, I double checked the online directory of "in-network" providers and facilities to make sure that Desert Medical Imaging was on my list. It was. But when the bill was submitted to UnitedHealthcare, they rejected it as "out of network." When I called and pointed out that the facility was indeed "in-network," they professed to be mystified and would resubmit the bill "for review." Weeks later, my monthly statement showed the bill had been paid, less $50 which was to be my co-payment. (Two years earlier, two sets of MRIs were fully covered at the same place with no co-payment and no hassles.)

DescriptionAmount BilledAmount Paid by InsuranceAmount I Owe
"Radiology services"$1893.001894.32$50.00
"Radiology services"$794.75$258.29$0.00
"Radiology services"$410.00266.50$0.00
Totals$4196.00$2419.11$50.00

You'll notice that the amount paid by insurance plus the amount I owe is always less than the amount billed by the provider. The difference is a mysterious "discount" that UnitedHealthcare applies to the bill. I think it means "We've decided how much this should cost, so we've discounted your bill to what we think it should be."

Biopsy

The specialist I had been seeing, for a $40 co-payment per visit, would perform the biopsy which had to be done at an outpatient surgical center because of the need for anesthesia. The Desert Regional Medical Center, where the El Mirador Surgical Center is located, is on my list of network providers. Should be OK. Yeah right!

The first surprise was being told that my co-payment would be $200. Yikes, $200! The Friday before "the procedure" I dutifully reported for necessary tests, consisting of an EKG and an X-ray, carried out in the main hospital building on the other side of the driveway.

After the procedure, there were more surprises as bills started to come in.

DescriptionAmount BilledAmount Paid by InsuranceAmount I Owe
Doctor, perform the biopsy$710.00$231.21$0.00
Anesthesiologist, put me under$450.00$0.00$405.00
Tests (EKG, X-ray)$1272.50$1133.80$0.00
"Laboratory services"$207.60cell184.97$0.00
somebody prof$20.00cell$0.00$8.96
Surgical center$1134.27$213.49$365.65
Pathology$225.00$146.25$0.00
"Radiological services"$41.00$9.93$0.00
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