Medical Billing is a Scam—And I Have the Receipts
Insurance companies and healthcare providers are playing a rigged game, and guess who’s losing? (Hint: It’s you.)
Another Monday, another fight with an insurance company.
I truly feel terrible for people with life-threatening illnesses who are bankrupted by the absolute grift that goes on with medical care in the United States.
Let me be clear: I’m not celebrating single-payer systems either, as they’re rife with ridiculously long wait times and doctors who don’t earn what they’re worth. No system is perfect.
But I’ve uncovered the most absolutely ridiculous practice—which is or at least should be totally illegal—by insurance companies and institutional medical care providers who are in cahoots against insurance-holding patients.
More painful than a toothache
It all began when my daughter needed her wisdom teeth extracted. I won’t bore you with the details that sucked up weeks of my life, but suffice it to say, the surgeon had to overbill a ridiculous amount ($16k) so by the time my 20% coinsurance payment was due, it was EXACTLY equal to what the cash price would’ve been.
In other words, I paid the actual price of the procedure, but first we did a confusing, elaborate dance as insurance company allowances, write-offs, and negotiated rates were stripped away. Lesson learned.
If we could just get the cash price up front, we could evaluate whether it’s in our best interests to even bother with the paperwork.
Buyer beware
Medical care is the ONLY thing you buy without knowing the price. And even if you THINK you know the price, you’re wrong.
Take my husband’s recent shoulder surgery: at the time of service, we had to prepay our “expected” contribution in cash.
But, later, we got more bills. Lots more. Because the facility and the surgeon and the anesthesiologist all bill separately. And this can be a hot mess that gets so confusing, it’s hard to even understand the total cost. They count on you staying confused!
The kick in the teeth is that your surgeon may be “in-network”, but the facility may not be. Or maybe the anesthesiologist isn’t. And no one gives you a head’s up. If you don’t know to ask, you’re up a creek when the bills roll in.
Mammos and MRI
If you’ve been here since the beginning of my publication, you’ll know I went through several rounds of imaging for an inconsistency noted on a routine mammogram. By the time I got to the point of needing an MRI, I was bill-fatigued. So when the scheduler called to confirm my appointment and tell me my expected financial responsibility was nearly $800, I balked.
“Wow, that’s a lot. What would it cost if we skipped the insurance and I just paid cash?”
“You can’t skip the insurance,” she said. “That would be fraud.”
“What? Nooo… Fraud would be me using YOUR insurance or claiming to have insurance when I don’t. Choosing not to use my own insurance isn’t fraud. I pay for it. I can use it or not.”
Even as I said this, I wondered if it was true. It made logical sense to me, but that doesn’t count for much when dealing with medical care.
“Well, do you really want to know?” she asked.
“Yes, I do. I’m curious.”
She clacked on her keyboard for a minute then said, “If you paid cash it would be $161.80.”
“Wait a minute,” I said. “If I go through insurance, I have to pay $800, but if I skip insurance I only pay $162?”
“Yes.”
“Well, I’ll take that option, please!”
I mean, who wouldn’t!? Why on earth would it cost me more than four times as much WITH my insurance? Is this the new thing now? Penalize the people who have insurance? Are we just to pay $1,000/month in premiums and then get bent over at the point of care, too?
The no-insurance route
A good friend of mine doesn’t have health insurance. She and her spouse pay cash for everything and have a medi-share membership where thousands of participants cost-share in case they need an expensive procedure they can’t easily afford. When she told me about it, I was fascinated. People sign on to help diffract medical bills for each other if something costly happens? What a novel idea!
The best part of the medi-share model is that each member knows the prices of procedures from several providers in order to comparison shop. The ridiculous game of doctors overbilling in order for insurance companies to obligate insureds like me to co-pay percentages that net up to the actual cost completely vanishes.
👍🏻 My friend’s colonoscopy will cost $300.
🤑 Mine will be billed at $4,500 and I’ll eventually be expected to pay $925.
👍🏻 Her blood work will cost her $125.
🤑 Mine, after overbilling, insurance-negotiated rate decreases, the co-pay and my coinsurance (since I never hit my out of pocket deductible) will be $325.
Who’s the idiot?
Out-of-Pocket doesn’t mean out of pocket
Another enraging part of insurance is when you’re trying to compare plans during open enrollment. The “Pay Now” vs “Pay Later” farce makes my blood boil, especially since it often hinges on different “out-of-pocket” maximums.
👉🏻 Here’s the lie: what you actually pay out of your pocket isn’t what they consider an eligible “out-of-pocket” expense.
Case in point: I live in NJ. I’m 15 miles from Manhattan. Everything is more expensive here than, say, Akron, Ohio (where I also lived). Perhaps a doctor’s appointment in Akron costs $125. Here, it’s $550. So, when I go to an out-of-network doctor and I pay that $550, the insurance company only counts what they say it should cost toward my out-of-pocket deductible—$125. The remaining $425 that literally came OUT of MY POCKET, doesn’t get counted!
I learned this after having $12,000 worth of out-of-pocket medical costs and still never hitting my $5,000 out-of-pocket maximum as calculated by the insurance company.
HOW IS THIS LEGAL?!
Cost of living and cost of services based on geography should certainly be accounted for in these figures, but they’re not. Just like property tax deductions are not—a rant for a different day.
Which takes me back to my MRI story…
On the day of service, I triple-checked with the registration clerk that the procedure would NOT be billed to insurance after I paid cash. She assured me. I proceeded with the MRI.
And here I am, five months later, fighting with them because OF COURSE they submitted it to my insurance without my authorization (a blatant HIPPA violation) and they’ve changed the price I’m supposed to pay (bait & switch), and they say my account is past due and they’re going to send it to collections! Despicable!
✅ Emails have been sent.
✅ Letters have been written.
✅ The law has been read.
Insured persons in New Jersey ARE NOT OBLIGATED TO USE THEIR HEALTH INSURANCE if it is more cost-effective to pay cash. Yet here we are.
Because clerks don’t know the law.
Because employee training is lacking at these medical centers.
Because insurance billing is de rigueur.
Because people don’t understand the difference between a self-pay discount for impoverished people and a cash price at the point of service.
Because we all let them get away with this financial abuse.
Stay tuned.
I’m not letting this go.
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Don’t let it go! I know it’s frustrating but at some point enough of us have to stand up and say “enough!” for anything to ever change. It’s highway robbery is what it is.
This makes me crazy. The dental stuff is so expensive and not much is covered. The idea of people creating their own insurance network has a great deal of appeal.