The Joy of American Medical Insurance.

Because I had a knee injury that required a visit to the emergency room, I’ve had the joy of dealing with insurance afterwards. Knee injuries are painful, I’ll take childbirth over a knee injury any day. Insurance add insults to the injury. It’s a long painful story, so get yourself a cup of tea or wine and enjoy.

First problem deals with orthopedic doctors. The one that the ER room referred me to likes surgery. So much so, he was ready to prescribe knee surgery without really examining my knee. When I protested that the knee was healing, he dismissed it. Said he would make a referral for an MRI scan and I could make the decision to proceed. But then he commented that I would be ok only if I was walking within a week. No suggestion of any exercises (wouldn’t help) or other followup except the MRI. Since I had done some reading, I knew that knee injuries (especially sprains) take 4-6 weeks to heal and it’s not uncommon to be on crutches for that long.

Finally the MRI got approved by insurance. But the place the doctor recommended was so expensive, the insurance company called me to let me know the standard price of an MRI was 400-500 dollars. The place he wanted to send me would not negotiate with the insurance company and would not provide prices. Big issue, at this point I did not know what my bills would be from the ER. I didn’t want to take on more debt and I was healing. In fact, I started using a cane after 4 weeks. I’ll be using that for another week or two, but at this point I don’t want to go back to the first orthopedic doctor. So this whole recovery thing has been based on my judgement, not hard data.

One of the benefits of my insurance is that they will help you find a doctor. I asked them to find me another orthopedic doctor (for a second opinion) and a general practitioner for everything else. They did find me another orthopedic doctor. I go to him on June 3rd. Main reason for the visit is to make sure I don’t do something stupid that will make me relapse and find out when I can do things like biking, hiking, or backpacking again. I’ll start swimming this week or next at the Wave in the mornings. Don’t think I can hurt myself by swimming.

For the GP, I had four conditions. One — it needs to be a female doctor. Two– she needs to be accepting new patients. Three — she needs to be accepting my insurance. And four — I want the doctor to be reasonably close to home, preferably on the way to work. Doesn’t seem like much; but those turn out to be almost impossible conditions to meet. The first round of searching produced 2 female doctors in San Diego County 30 miles from home and 45 miles from work who were accepting new patients next DECEMBER. Yep, almost 8 months from now. Talked to the nice representative who said there is a big issue finding general practitioner doctors who are accepting new patients. It’s not uncommon to have 30-50 mile drives even in the big cities like Boston or San Diego. So we went to the second string doctors and there may be one available in Vista. I’ll put my name on the wait list for the good doctors and tomorrow I’ll make an appointment for a physical with the second string GP.
Next step was finding insurance for next year. The bills have been so bad, I’ve been scared to go to the doctor. Every time a family member goes to the doctor we end up with hundreds of dollars in bills. Even simple procedures seem to cost hundreds. Many conversations with HR and various insurance people have helped enlighten me.

First, balance billing is not allowed. Consider a bill of 100 dollars. The insurance company negotiates a price of 35 dollars as a reasonable payment. They pay that after you pay your copays and deductibles. Then the doctors office sends you a payment for 65 dollars — the balance of the bill. Per both HR and the insurance company; this is not allowed if I am within network. I am sure that the local medical groups have been doing this. Next year, we will get much more proactive about calling the insurance company and my HR department to prevent this. Sounds like “fun”.

Second thing I learned is that basically all the insurance plans available to me will require an up front payment for deductibles of roughly 2000 dollars. Plus copays and other minor expenses of 20 – 40 dollars per visit and per item. For example, a lab test is considered another item even if the doctor collects the sample. And then we keep doing those copays and pay 20% of the bills until we’ve paid a total of about 11,500 dollars. UGHHHHH. That’s a big bill especially if one is not expecting it. Now I know, so I can put money into a separate account just for that 2000 dollar bill in July / August of this year. And I’ll expect to keep paying lots of other money. But we probably won’t get to the full 11,500 dollars unless something goes terribly wrong. After the deductible, bills should be at a reasonable level of 100 dollars per month or less. I can handle that amount of uncertainty. And if all hell breaks loose, I’ll probably be glad the bills are capped at 11.5K.

Next issue to deal with is the hospital bill. It looks like the total bill will be close to 1600 and my share is about 620 dollars. Not that bad. Requested a full bill showing all itemized items from the hospital, am curious to see how they do the billing. And plus, when I asked for the bill, the finance guy put a notation on my account that an itemization was being sent, I would not pay until after that was received. Interesting that they assume I don’t want to see the bills and will pay the amount asked without any questions.

Continuing the joy, called Express Scripts today. This year our insurance had a unique twist, we could not go to a pharmacy to get medicine, but had to use a mail order service for everything expect emergencies. So they sent me (it was my name on the bill) for 50 dollars. It was for two prescriptions in march. The bill basically said: INVOICE A = 40 dollars and INVOICE B = 10 dollars – Pay now. But I got no prescriptions in march. The first pills I’ve had in years were pain killers prescribed in April by the Emergency room. So I called them and asked what the bills were. However, because there are multiple people on my policy and because of patient privacy rules, they cannot tell me what those invoices are covering. I’m supposed to go find the offending member of my family and have them tell me what the bills are for. I don’t want to ask my 23 year old daughter if she got pills in March. It’s none of my business. Yes, she’s on my insurance, but she’s an adult and doing a great job of supporting herself. It turns out there is a loophole. They can’t tell me what the bills are, but they can send me a physical copy of the bills. And better yet, Bob thinks he’s already paid several invoices for medicine in March. I’m so glad we get to dump Express Scripts this july and will have the choice of going to the CVS pharmacy if we want.

There has to be a better way to handle medicine. Per various expat sites, a couple can live in Sicily for 2000 dollars per month and buy a good medical insurance policy there for about 3000 dollars per year. None of the hassles with copays and balance billing. No need to argue over indecipherable bills. Decent medical care. A few weeks ago, the New York Times published a list of standard surgery prices. I learned that one can get the same procedures in france for about 10% of the cost of an american hospital. So if you have procedure here that costs 100,000 dollars (and there are a lot of them), it will cost about 10,000 dollars in France. That leaves you with 90,000 dollars for an extended stay there. I think I ‘ll take that option if needed.


Author: Heres to ART not Cockroaches

Welcome to my life. My life as a mom is changing as the kids grow up, leave home, and build their own lives. This gives me a chance to rebuild myself as an artist, develop a spiritual path, and most fun of all, start going out on dates with my husband. Come here the stories about the small things in life that can make one very happy. Dogs running on a beach, great breakfast dates, kids and their adventures, and my own adventures in this wacky life. I'll share some of my progress in learning art while juggling a full time job as an engineer. And best of all, it's a chance for me to practice writing stories while keeping in touch with my kids. I look forward to hearing from you. Comments, thoughts, and invitations to meet for coffee are all welcomed. Enjoy the stories.

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