For example, I might dispense a prescription for quetiapine, a generic drug that costs me $11 for 30 tablets. I bill the insurance $302. That's because the other options I could bill - like the brand-name drug, which retails for nearly $600 - would cost the insurance company much more. So they are willing to pay me a little extra for this generic. But they don't pay me what I ask for. They pay me a $4 dispensing fee, and $271.80 for the drug, which is 90% of the average wholesale price of the drug. Because they set their own pricing, and if I don't like it, I can just jump off a cliff. I like the $264 profit, though, so I stay on top of the cliff.
Or, I dispense a bottle of insulin that costs me $88 to a patient. I bill the insurance company a reasonable $96. They reimburse me $82.50, because the drug is the wrong brand. They prefer a different brand of insulin that costs $79.50, so they only reimburse me based on that drug, even though I don't have the authority to substitute it for the other brand. I lose money, but I can't do anything about it, because my contract with the insurance company says I can't turn patients away based on reimbursement. I'm considering jumping off the cliff.
Or, you go to the emergency room with a fever. They give you a tylenol, and you go home. You read your (whopping) bill later, and see that you were charged $9 for a tylenol. That's because you weren't paying for the tylenol. You were paying for the boxed lunch the hospital provided a Medicare patient who came in to the emergency room because she was too busy on Friday to go to her scheduled dialysis appointment, and now she's trending toward acute kidney failure. That, and she likes the box lunches that the hospital provides but Medicare doesn't reimburse.
Or, I have an outpatient surgery. The hospital bills my insurance $55, 000.
My insurance company disallows $45,000 of it and, between United Healthcare and I, pay the hospital $10,000.
Was the surgery worth $55,000? Heck no. That's stupid. They didn't give me a platinum implant, geez. Is it reasonable to reimburse just 9% of the bill? No, that's stupid, too! Of course the hospital can't bill the actual cost of the surgery, and the insurance can't just pay them back.
Ludicrous? Yep. Money has absolutely no meaning in the world of medicine.
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So you have to pay $10K????????
ReplyDeleteI'm on a major soapbox right now with all this insurance business. I'll keep my opinions to myself, though, but know that I 100% agree with you.
Well, I finally met my deductible (sadly!) so I only had to pay $2,200. Only...
DeleteThe hardest part of medical insurance for me is that $2000+ check we send off every month to pay our premium. Yes, the 3 zeros are not a typo. But paying only $400 for a hip replacement was pretty nice.
ReplyDeleteThat's just totally confusing.
ReplyDeleteOh, it's so, SO bad. I think that's one of the main reasons our health care system is so screwed up -- no one sees the real cost of anything, and things are priced & billed & reimbursed at totally different rates that have seemingly no relationship to each other. I was reading recently that you can go to four different hospitals & get the same surgery & the difference in what they charge can be up to 10x. Absolutely absurd.
ReplyDeleteGotta love the US health care system. To me the only fix is to allow competition between hospitals, insurance companies, etc as to who can offer the lowest price for something. Basically have a comparison site where people can plug in hip replacements, and see what place has the best offer - like we buy any other product. Insurance companies have so much power in this country its ridiculous. And since most of our bills are reimbursed by insurance, no one cares about how much it costs - since insurance is paying it.
ReplyDeleteYeah...I've never been able to figure out the US health-care system. It's mind-boggling. And speaking as someone who's about to LIVE there for a while, it's pretty frightening. Even doctors, I've read, have no idea what treatments actually cost.
ReplyDeleteDoctors especially have no idea about costs - they'll often send me a prescription for an indigent patient and a ridiculously unaffordable drug. But I can't expect them to know the copay when there are literally millions of insurance plans in the country!
DeleteYah the medical system is so incredibly messed up. When I had my sinus surgery, I think it was about $25,000. So a bargain compared to your surgery. ;) But mine was shorter than yours I am guessing? And I don't know if that $25,000 is what was allowed, it could have been adjusted already so maybe the original number was even higher. Regardless, it's all ridiculous!
ReplyDelete