April 19 2020
Q: Hi Dr. Why, here is a list of medical expenses we discussed. I went through the EOB’s and scanned them here. University called and said that I have an appointment on May 8 and have an out of pocket expense they want to discuss with me. I imagine this will be expensive as it is out of network. One question I had on the excel file was that the column “your cost” was less than what the imaging center charged me. Does that mean I am due a $1,400 refund? That would be great because it would offset the amount I am getting billed from the university and laboratory. Hope all is well. Thanks.
A: Hi, impressive!
Re: imaging center. The refund will depend on what they charged you for and their contract with insurer, in particular if insurer allows “balance billing” (most do), or their contract forces provider to accept what insurance allows. Balance billing is the difference they billed insurance for and what insurance paid. I suggest calling imaging center to find out. You can request the statement from them to see what they charged you for.
A few notes:
The total billed is $23,534.85. Insurance allowed $5,418.25 (23%) but paid only $2,360.66 with the rest applied to your deductible, coinsurance and copay. This is a downside of insurance with high deductible. Of course, it costs less, so it balances your total expense at the end of the year. I consider this is a great deal for you – paying ¼ of what provider asks in most cases.
I also consider this terrible for providers, because they are left holding the bag. For instance, the lab got paid $719.57 and, once you pay your portion, it will get only 16% of the amount billed. Not bad for you, but terrible for the lab.
The two “smart” providers are Dr. M and Dr. J who got paid 100% of what they asked for, because they do not accept insurance! See spreadsheet attached.
No wonder many docs do not accept insurance and those who do are forced to see 30-40 patients a day just to make ends meet. Imagine, I would ask you to sell your product or service for 20-25 cents on a dollar!
Hence, the unfortunate state of healthcare in our country – one of the wealthiest in the world. Doctor gets 22.2 cents on a dollar you pay to insurer.
You met your deductible and 1/3 of your out-of-pocket maximum, therefore your cash outlay will be dwindling down soon. Once you met out-of-pocket maximum, you will still be responsible for co-pay and whatever balance is left after insurance pays to out-of-network providers. As you can see, they are allowing roughly 25% of doctor M charge. BTW, did you submit Dr. J claim? You will get approximately 25% back;
Please note that ALL services provided were approved (other than cancelled MRI). I have a dedicated person who does approvals for imaging which costs me $75 per study x 8 studies = $600. I do it as a curtesy, because I do not want any aggravation – many people complain when insurance denies services, even although I am not responsible for the denial;
Your health and time are only non-renewable resources and it is your fiduciary responsibility to you family (and somewhat to your employer) to stay healthy. We live in a “free” country but I do not think you have a choice but take care of yourself.
I hope this helps to put things in perspective. Let me know, if you need any further help with this.
