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For those not in USA, can someone summarize? I know (from reading online) that if you go a hospital, the bill can be scary. But what happens when companies offe

• mayneack 6y ago
  In theory you can predict the total cost for things covered by insurance, but there are many layers of complex bureaucracy involved and the insurance company is actively trying to get you to fall through a crack and end up on the hook for a real bill. The insurance company also is practically the arbiter of whether or not you did it correctly. The best example, is that you can go in for a surgery or something at a covered hospital for a covered procedure, but you can be surprised because some doctor assigned to you isn't in your network. Sometimes this happens after you're already under knocked out for the surgery, so you can't practically consult your complex policy at the time.
  • dr-detroit 6y ago
    This is one of those things they should teach in highschool. You pay $200/person premiums and you have to go to WAR with these clowns over the phone to get them to cover things when they owe you.
  • phkahler 6y ago
    That has created an entire industry called "medical billing" where the job is to submit claims properly so as not to be rejected. To be fair, fraud is probably a thing from every angle so having some process to prevent that makes some sense. But for patients with serious problems or families of those that just died, battling bureaucracy over large sums of money can be brutal.
  • mmcnl 6y ago
    How can your example even be legal?
    • jpindar 6y ago
      The lawmakers have good insurance and are wealthy enough to pay for the rest of it.
    • mayneack 6y ago
      The positive spin on this is that it allows for more "consumer" choices. With 300 million people, it's easy to find a few individuals pushed into a worse situation. People consistently underrate how bad the status quo is.
• brundolf 6y ago
  It's equally confusing from the inside.
• jschwartzi 6y ago
  So the way it works is that the insurance covers X% of something up to some pre-set limit which doubles or triples if you have a family. This is called co-insurance. So if you have a 50% co-insurance then you are responsible for 50% of the cost of treatment up to the yearly limit for your insurance. If your yearly limit is $9,000 then that means you rack up a $9,000 bill from $18,000 of medical treatment. Where it gets complicated is that if you add another person to your insurance then your yearly limit goes from EG $9,000 to $16,000 which can bankrupt most people. And this is for a "high-quality" plan. And what's worse, because it's a yearly limit it resets in December. This means that if you get sick in December, you can rack up $9,000 of bills from December, then roll over into January and rack up another $9,000 worth of bills. Or $32,000 as a family. This is strangely still sold as insurance.
  • lotsofpulp 6y ago
    You can buy platinum level health insurance that covers 90% of your expected healthcare costs and has out of pocket maximums of a couple thousand dollars. Most people just can’t afford the monthly premiums for it. It’s just a simple result of the actual healthcare itself costing a ton more in the US than in other countries, since all up and down the healthcare business a lot more people make a lot more money than in other countries.
    • erentz 6y ago
      We helped a friend through this last year. Where she lived there was only two insurance providers providing ACA plans. And both were HMO only. And both only offered Silver and Bronze plans. I also checked this out in a couple of other counties and it was the same situation. (I didn’t find a single gold plan in my search.) So for a lot of people they can’t buy better plans even if they could afford it.
      • lotsofpulp 6y ago
        That’s a result of the political compromises that had to be made in order to pass ACA, which is people didn’t want to give up their silo’d white collar employer based health insurance, and insurers can’t compete across state lines. If there was a single marketplace for health insurance where everyone had to go, there would be sufficient lives for health insurance companies to be able to offer more options.
• Pfhreak 6y ago
  Most health insurance comes with a % copayment. Paying 10-20% of the bill is not uncommon, and generally considered pretty good health insurance. Add to that a high deductible -- some families have to pay thousands of dollars out of pocket before health insurance will even start to cover you. If you have a major medical event, you might be on the hook for tens of thousands of dollars.
• jccalhoun 6y ago
  This summer my gallbladder started acting up and after going to the emergency room twice I finally got it removed last month. I have insurance but there is a deductable and a copay and the insurance company will decide not to cover things. I have gotten bills from the hospital, the radiologist, the surgeon, and the anesthesiologist even though they were all in the hospital. One of them has been sending me notices saying that - again even though they were in the hospital - the insurance company won't accept their billing so the insurance company will apparently at some point send me a check then I am supposed to send it to them and they will tell me how much I owe. My insurance company says so far I have been charged over $200,000 even though I have only had to pay around $4000 so far. But most of that $200,000 is fake because hospitals have a price they charge the insurance and then the insurance says "no, we're only paying this much" and the hospitals will say "Ok." I got a bill for $1600 three weeks ago and there were no details on what it was for except for the date of when this started back in May. My insurance company didn't have anything that corresponded to that date so I called the hospital billing department. They were like, "Ok. we will refile it." and I haven't heard anything since. I've also gotten bills in the mail for like $36. I go to the bill pay website and they say I don't own anything. The actual surgery was 5 weeks ago tomorrow and I haven't had any bills about that at all.
• erentz 6y ago
  What you ask would take many paragraphs to explain in full. The short is that is varies a lot depending on your employers plan. A small percentage of working age individuals get coverage outside on “Obamacare” and those plans vary a lot too. Initially there were decent plans but over the years now in most areas you can only get “silver HMO” plans that limit who you can see, carry very large (several thousand dollar) deductibles that have to be met before insurance pays, then have high coinsurance amounts (up to 30% that you have to pay even after meeting the deductible) and have max put of pocket limits of several tens of thousands before you finally don’t pay anything. As a result it’s generally not financially advisable to get insurance unless your employer provides it because you won’t be able to use it. Medicare kicks in for over 65s or those who have been disabled for over 2 years. Medicare requires a 20% copay for everything which can be taken down to zero by using a supplement plan which generally costs between 100-300 per month depending on your age and region. You also then need separate prescription insurance which costs $20-50 per month and has really insane complex rules that mean you may still end up paying tens of thousands a year if you have specialty drugs. Medicaid is for “poor” people but varies depending on states. The cut off for eligibility is very low and in some states it still doesn’t cover adult age people unless they have a child or are on social security insurance. Those profiting are a mixture of medical professionals, administrative staff due to the bloated administration required, of course all the private hospital and clinic systems around the country. And the insurance companies who take their increasingly large cut. In defense of the medical professionals many want to move to single payer for a variety of reasons (eg American college of physicians group and others have come out in support). Although they may make more revenue in the current system it also causes an insane amount of extra overhead and distracts from their ability to do their job. By 2027 the US health spending is projected to become 20% of GDP. This is not a healthy economic situation to be in. Our current system is both morally indefensible (65,000 die every year due to lack of coverage) and also fiscally indefensible ($500 billion would be saved every year moving to single payer). Yet it persists. That is the power of bested interests, lobbyists, and legalized political corruption. Edit: That wasn’t very short in the end. I’m on mobile or I’d provide more detail and references.
• mturmon 6y ago
  The topic resists summary. Yes, bill will be scary if paying out of pocket. Health care is often tied to employment (you or spouse). There are different insurance options, even when employed. A good plan will cover everything but a relatively small fixed amount of even large bills (e.g., emergency delivery of child). A bad plan will have a lot of excluded procedures or very large "co-pays" where insurance pays some, you pay some. Other plans have mixes of the above approaches. If you have a professional job, your plan will typically be pretty good; if not, there can be problems. To pay for the co-pays, a system of tax-free health care saving accounts (HCSA) was set up. You pay into the HCSA, and the co-pays come out of that, and it's tax-free up to a point. So you notice there is this piecemeal and patch-atop-patch theme to the whole thing. When you get older, typically 65, there is a government health pool called Medicare that you can enroll in, that takes over most of the role of employer-provided insurance. Most older people do this. Then, you can get further insurance on top of that to plug holes it may have. Also, there is a very lucrative prescription drug plan that's now built in to Medicare, thanks to big pharma. A lot of doctors really don't like the insurance companies controlling whether procedures are considered acceptable. But, historically, the American Medical Association, the US physician's professional organization, has lobbied hard against public health plans. Finally, this is just one citizen's description of some of the major features of this so-called "system". There are a lot of other parts to the puzzle -- for instance, it varies by state, and there are 50 states -- and there are special cases, like veterans. It's wacko.
  • johnward 6y ago
    "If you have a professional job, your plan will typically be pretty good". Define good. I'd say 80% insurance, 20% co-pay is good in the US.
• aidenn0 6y ago
  It's complicated. Here's the basic rundown: There are two types of plans offered a PPO and an HMO. PPOs usually have larger deductibles, larger premiums or both, so if your employer offers a PPO, it will usually come with a larger out-of-pocket cost for you. Here's how each works in theory for non-emergency care: HMO: You have a physician that is your "primary care provider." This physician must have a contract with the insurance company. Any non-emergency care must be mediated by this physician. e.g. you go to the physician and they will refer you to a dermatologist if you have skin problems. The insurance company will pay for any care that the primary care provider recommends, possibly with a nominal co-pay (e.g. $20 per visit) and possibly with a per-year deductible. If you go to any doctor without a referral for non-emergency care you must pay everything out-of-pocket. PPO: You can go to any doctor for any reason. If you go to a doctor that has a contract ("in-network") with the insurance company, insurance pays some fraction of the cost (usually around 80% for non-routine things). There is a maximum per-year out-of-pocket cost for in-network care. If you go to a doctor without a contract with the insurance company ("out of network") they pay either a smaller fraction of the cost, or the fraction of what the in-network would have cost (so if it's $4000 out-of-network and $2000 with an in-network doctor, the insurance would pay say 60% of the $4000 or 80% of the $2000 leaving you with a $1600 or $2400 bill respectively) All of the above is for routine care. There are two levels of "emergency" above that: "urgent care" and "emergency room". Urgent care is "it can wait hours, but not a week" emergency room is "it needs help immediately" For urgent care, it's more-or-less like routine care, except that you don't need a referral with the HMO. Just like routine care, if the urgent-care facility you go to lacks a contract with the insurance company, you will have to pay for everything out-of-pocket. For emergency-room (ER), usually in-network doesn't matter, but usually you must pay at least $100 out-of-pocket to visit as a "co-pay" (compared to $10-$20 for other visits). However, if a doctor sees you in the ER that is not employed by the ER, and they do not have a contract with your insurance, you pay the out-of-network rate for just their services (i.e. you are stuck with the entire bill for an HMO, and you pay a larger percentage of the cost with a PPO). That's how we got stuck with a $4k bill after taking my son to the ER with an HMO. That's all the "in theory" cost. In actuality there is a lot of fine-print in the contracts giving ways for insurance companies to deny claims for various reasons, and they will almost always refuse a large claim for some bogus reason (e.g. I got a $90k bill when my daughter cut her hand on some broken glass and needed 60 stitches because the insurance company coded it as an "elective surgery") there is usually something like a 6 month limit for challenging claims, so if you don't spend about 20 hours on the phone over the next few months, you can end up stuck with a bogus bill just because you didn't challenge it soon enough. > Who are the people who is becoming profitable with this? Doctors? Companies? Are doctors allowed to open their own offices and have high prices? From the outisde everything seem so confusing! It's confusing from the inside too. Doctors do open their own offices and usually have very high prices. However, the insurance companies negotiate a lower price, and if you do get stuck with a bill, you can usually negotiate a lower price yourself (Insurance companies usually pay 1/3 to 1/2 of the original billed price). The insurance companies make money, but the cost they impose is far larger than the profits they make, because of all the inefficiencies and administrative staff. A medium sized doctors office will often have at least 1 full-time employee whose only responsibility is to work with the insurance company. People often delay or forgo care because they plain just don't know if the insurance company will pay for it.
• Kagerjay 6y ago
  I've recently been going through this process learning how terrible our medical billing system is in America Here's some examples... 1. You might go for a surgery. You'll get a bill from the anesthetist, doctor, and the facility. The anethestist might not be in your network, so insurance doesn't cover it. Not only that, all three places can bill whatever they want, multiple times even. 2. You go to the specialist doctor for a visit. I recently went to two different ENTs just for a nasal checkup. One billed a claim for $1000 just to inspect my nose on a first time visit and billed it as a "surgery" procedure code. To be fair I signed a waiver stating I would pay things outside of insurance, that's just because I don't know any better and scheduling doctors appointments take forever. Insurance covered a small portion of it, hospital reduced it a bit, but now I have to pay $250 on top of a $60 normal pay for visiting (copay) So basically, I have to pay $300 for visiting a doctor, for a basic checkup. I expected to pay $60 with my insurance. AFAIK, in other countries, there's just a catalog of prices of how much everything costs. The doctor tells you how much things cost up front, you agree and pay for it. That's how things should work Here in America, we artifically mark up everything by a huge amount, and insurance pays a portion of it, depending on your setup. You pay the rest of that inflated amount past a certain amount in your insurance coverage. You can negotiate rates after the fact, but the hospital networks can just say no. You have to pay it anyways. Basically you're always in financial jeopardy when you go to the hospital. The people profiting are all in the medical industry. The end user (you) is always screwed over. If you want to fight a bill, you call the insurance company, they'll tell you to call the doctor. The doctor will tell you to call the insurance company. Either that they'll say they will try and renegotiate terms in 10 days, which at this point you'll probably get tired of fighting it and pay up anyways. Its pretty much a waste of time. Health insurance does provide a financial net, but only to a degree. My out of pocket max I might have to put out in a year is $10k. The average out-of-cost payment after insurance might be $2k, so I might expect to pay $2k out of pocket. But the hospital can bill whatever I want, so I might be out $10k in cash now. I have no control over how much I will be billed for, even though I know how much things generally get billed for. The analogy is like going to a restaurant. You order a burger. You don't get to see the menu prices, but the waiter tells you its $10. You get a check for $50. You don't understand why but you have to pay it anyways. That's the medical system here in the states.
  • 6y ago
• AgloeDreams 6y ago
  So I actually had a health-related bankruptcy. 1: Your insurance is tied to your employer but you can also get insurance on the private market. Generally Employer insurance is much much cheaper as the employer can negotiate with a large number of seats over costs and has a vested interest in employee health. 2: Health insurance generally works like car insurance with a deductible that you pay out of pocket to a point and then everything past that point is covered by insurance. Some services (such as a doctors visit or ER visit may be covered at a set price [such as $40 a visit]) whereas an Xray or such would be billed to you until you hit deductible. The deductible on a PPO plan may be something like $2,000. Now..let me tell you the insane ball game here. You may think: Well if health insurance is like $400 a month, if I'm healthy, why even have it? For one, there was a Tax fine for not having health insurance of ~$600. For another...Hospitals bill non-insurance patients full amount but insurance companies (who when you have health insurance act as middlemen) an agreed upon amount. These amounts are massively different. I had just lost my company insurance when I became a contractor for another company, I did not have insurance yet. I ended up in the ICU for 6 days due to a really crazy blood pressure related inter-cerebral hemorrhage. I found myself two weeks later being asked to pay over $100,000 over the phone by their billing department. Talking to someone, I was told to ask for an itemized bill. It was over 50 pages long. It noted an MRI as a $6,500 procedure. Later I got insurance and went back for a follow up MRI. The insurance company sent me a bill for the co-pay and on it I saw the same $6,500.00 bill...but with a line item below it: `Insurance Group Discount -$6,120.00` America. The fact of the matter is that healthcare costs are really not that high, but insurance companies are hedged into the position that they are made necessary by the system and everyone is required to hold it. In a country with universal healthcare none of this exists as all prices are set and approved by the country making it all public.
  • erentz 6y ago
    > Your insurance is tied to your employer but you can also get insurance on the private market. Generally Employer insurance is much much cheaper as the employer can negotiate with a large number of seats over costs and has a vested interest in employee health. Another reason might also be that an employers group consists mostly of healthy working age adults. Once they’re not healthy they often are no longer able to work for the employer and aren’t in the group.
• nwallin 6y ago
  If you have health insurance, and you keep your health insurance through whatever your medical emergency is, you won't have a financial problem with regards to medical bills. I'm splitting this up into two parts: how it works, and why that's the wrong question to ask. Here's the nitty gritty. Health insurance will cover each expense minus a deductible. Once all your individual deductibles have reached a set value called an "out of pocket maximum", health insurance covers 100% of it. So if your deductible is $200 and your out of pocket maximum is $2,000, and you have a serious medical problem that requires multiple hospitalizations, you'll pay $200 up to a maximum of ten times, at which point every hospital trip is free for you. If your out of pocket maximum is $2,000, you don't have to pay more than $2,000 for healthcare in a year. Here's why that doesn't matter. It's too easy to lose your insurance. If you buy health insurance directly, and you miss a payment, and you are an expensive client to your health insurer, your insurer will drop you. If you get your health insurance from your employer, (which is a majority of insured people in the US) chances are pretty good that an expensive medical emergency will coincide with losing your job- which means your health insurance changes. There are systems in place to deal with this, but these systems suck. There are a lot of cracks you might slip through while transitioning from your employer provided insurance to whatever you transition to. Literally everybody loses with this system. Insurance companies have it the least bad, but health insurance companies aren't actually that profitable. Doctors can open their own practices and "set" their own prices, but insurance companies can and do ignore those prices. There's this weird nonsense where providers (hospitals and independent doctors) set prices, and insurers pay a percentage of those prices, so providers raise the prices quoted to insurers... so insurers lower the percentage. This is why you hear stories about people receiving ridiculously expensive bills for short/trivial hospital stays. The cost to the hospital might be $2,000, so the hospital quotes the health insurance company $50,000 with the expectation that the insurance company is going to write a check for 2.5% of that or $2,500. But the patient is uninsured and gets the $50,000 bill instead. If you're familiar with the system, you can haggle with the hospital and they'll be happy to accept $2,500 from you, but that's only if you're familiar with the bullshit system- most people obviously aren't. When you hear complaints about the 'lack of price transparency' this is one of the many ways that is presented. It is the worst of all possible systems. If the government literally repealed every law and regulation with regards to healthcare, that would be a less awful system. Significant change, whether that means going full socialism or full lassez faire free market, would require a filibuster proof majority. (60 votes in the Senate) Many politicians who want to improve the system would not be keen on voting in a half measure; for instance, breaking the link between employment and health insurance would be a huge benefit to all Americans, but it's a political loser for Democrats. So there's insufficient support for dramatic measures, (because people are either strongly opposed to socializing everything or they're strongly opposed to deregulating) and there's insufficient support for small improvements. (because if the system were less intolerable they wouldn't be able to run on a platform of significant change) It's bigger than just a problem with healthcare; it's a problem with the two party system. https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/ https://www.healthcare.gov/glossary/out-of-pocket-maximum-li... https://www.healthcare.gov/glossary/deductible/ https://www.healthcare.gov/glossary/deductible/
• esrauch 6y ago
  Even the best health insurance in the US generally leaves you paying a lot compared to any other developed nation. I had FAANG engineer health insurance, cracked my elbow. For the exam+x-ray+soft wrap the clinic billed the insurance like $15k, insurance actually paid like $5k and I paid $1k. I received 4 separate very unclear bills from 2 or 3 different sources. That's in-network with insurance considered so good I paid a "cadillac tax" for having it. I cracked a rib and had identical treatment in Sydney with no coverage as a non-resident (travel insurance reimbursed me later). They told me the costs upfront, made sure I agreed and understood. I paid maybe $400 for the same treatment. I think people incorrectly attribute it to lack of single-payer though: Switzerland doesn't have single-payer and one part of your insurance is provided by your employer; my partner paid full price for an x-ray there and it was much less than the post-insurance price I paid.