How Insurance Works Against You

oday I want to share some stories that show the absurdity patients and doctors deal with when they let insurance take over the health care system.

We’ll start out with a simple algorithm for ordering a routine cholesterol panel for a Medicare patient.

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Yep, want to check your cholesterol to make sure it isn’t high?  Well if you have Medicare, you’ll need to prove you have high cholesterol before they’ll pay.  Oh, and if you decide to get the test done anyway, your lab will bill Medicare for somewhere between $100-$200, and when it is denied, guess who is stuck with that bill? And the most ironic thing about this? The cash price of this test is around $7…

It can get much worse though.  One of my patients saw a specialist at a local hospital who was in his insurance network, and the specialist ordered a CT and MRI at the hospital imaging center.  Months later the patient got a bill for $7,000(!).  It turns out, even though the hospital and specialist were in network, the imaging center was out of network, and so when insurance denied the test, the bill was sent to the patient.  My patient tried fighting the insurance company and imaging center, but they would not budge and threatened to send him to collections.  Now the patient is stuck with a $7,000 bill.  The cash price of these tests?  Under $1000 total.  This is more than just a financial issue though, because now my patient is unable to do the important follow-up tests that I am recommending.

One more horror story that I heard from a fellow physician.  A patient asks for cash pricing from a physician’s office, the office provides them a cash price of $150 which the patient pays.  But the patient’s insurance info was on file, and the office mistakenly billed insurance (for $550).  Insurance denied the charge, and the patient was billed for the $400 balance….

To be clear, the point of this post is not “don’t have health insurance.”  Everyone needs some type of coverage for catastrophic health events.  My hope is that this will help shed some light on one of the reasons our health care costs are so high.  When insurance is involved, you are not paying the true cost of medical care or testing.  When your $1500 bill for your MRI says, “insurance saved you $2000” what they are not telling you is the cash price of that MRI was $500.

Let’s start changing these insurance horror stories by saving insurance for major issues, and not using it for routine care, relatively simple diagnostics, or when cash pricing is a reasonable option.

In good health,

Rebecca Bub, DO