Glad to Have Insurance Coverage

[Beth Gallagher]

As discussed in another thread, we have a Medicare Advantage Plan through Aetna. Since we both retired from a major corporation, we still get our insurance negotiated as a group plan at a somewhat reasonable monthly rate. The coverage includes vision care and dental, which come in handy at this age.

In December I had eye surgery at an outpatient facility; I was there for about 2.5 hours. I got the billing claims documents earlier today and was stunned to see that the facility billed Aetna $36,000. Yes, $36k for 2.5 hours. The anesthesiologist billed $3800 and my surgeon billed the smallest amount... $2700. Naturally Aetna negotiated what each provider will receive and it is nowhere near those amounts. The reconciliation looks like this:

Facility billed $36,000. Aetna paid $1796. My part $430.
Anesthesiologist billed $3800. Aetna paid $183. My part $36.
Surgeon billed $2700. Aetna paid $816. My share $208.

So the total billed was $42,500.
Aetna paid their negotiated amount, $2795
My out-of-pocket cost was $674 plus some prescriptions.

Can someone make this make sense???

 

[Don Alaska]

As discussed in another thread, we have a Medicare Advantage Plan through Aetna. Since we both retired from a major corporation, we still get our insurance negotiated as a group plan at a somewhat reasonable monthly rate. The coverage includes vision care and dental, which come in handy at this age.

In December I had eye surgery at an outpatient facility; I was there for about 2.5 hours. I got the billing claims documents earlier today and was stunned to see that the facility billed Aetna $36,000. Yes, $36k for 2.5 hours. The anesthesiologist billed $3800 and my surgeon billed the smallest amount... $2700. Naturally Aetna negotiated what each provider will receive and it is nowhere near those amounts. The reconciliation looks like this:

Facility billed $36,000. Aetna paid $1796. My part $430.
Anesthesiologist billed $3800. Aetna paid $183. My part $36.
Surgeon billed $2700. Aetna paid $816. My share $208.

So the total billed was $42,500.
Aetna paid their negotiated amount, $2795
My out-of-pocket cost was $674 plus some prescriptions.

Can someone make this make sense???

That is all due to the Medicare laws. If the government didn't mess in healthcare, we (or private insurance) would probably pay less than the negotiated amount shown. Obamacare made the bill even higher than Medicare, but it is difficult to say how much.

 

[Krystal Shay]

We have similar type of insurance as Beth. Our insurance is through a corporate group plan also, which is considerably better than then the average medicare insurance, so I hear.

The charges are always crazy! My husband had a CT a few weeks ago. The hospital charged $3,200. The insurance paid $112. We paid $21.00 out of pocket.

 

[Beth Gallagher]

I remember that my cancer treatment in 2021 was nearly half a million dollars all told. I don't remember what Aetna paid for all of it, but my total out of pocket was $3000. That was 5 years ago and the current max out of pocket has increased to $4,000/year.

Health insurance is like income tax; it is all unnecessarily complicated.

 

[John Brunner]

Lots of moving parts here.

Health insurance never used to be a thing. When I was a kid, our family doctor was in the neighborhood, practiced out of his home and we paid cash. I believe that the insurance beast really took off during the Nixon years of Wage & Price controls. Employers needed a way to compensate their employees, and Benefits were a loophole in the law...so they started providing health insurance. One problem is that health insurance covers routine care rather than catastrophes. It would be like car insurance covering oil changes and windshield wipers...the insurance costs would skyrocket, as might the uninsured cost for maintenance. Obamacare all but got rid of the option to buy catastrophic health insurance.

Regarding the absurdly high billing amounts: I believe that those prices are put there because some insurances pay more for care & procedures than others do, so the providers bill high enough to get the maximum compensation and they ignore the rest...although you gotta wonder if anyone pays some of those prices.

What a perverted business model.
Customer: "$100 for a burger?!?!?!?!"
Restaurant owner: "Just gimme five bucks. Some customers pay $10, some pay $50, and I got one that will pay $85, so I put $100 on the menu. You want fries with that?"

 

[Mary Stetler]

As discussed in another thread, we have a Medicare Advantage Plan through Aetna. Since we both retired from a major corporation, we still get our insurance negotiated as a group plan at a somewhat reasonable monthly rate. The coverage includes vision care and dental, which come in handy at this age.

In December I had eye surgery at an outpatient facility; I was there for about 2.5 hours. I got the billing claims documents earlier today and was stunned to see that the facility billed Aetna $36,000. Yes, $36k for 2.5 hours. The anesthesiologist billed $3800 and my surgeon billed the smallest amount... $2700. Naturally Aetna negotiated what each provider will receive and it is nowhere near those amounts. The reconciliation looks like this:

Facility billed $36,000. Aetna paid $1796. My part $430.
Anesthesiologist billed $3800. Aetna paid $183. My part $36.
Surgeon billed $2700. Aetna paid $816. My share $208.

So the total billed was $42,500.
Aetna paid their negotiated amount, $2795
My out-of-pocket cost was $674 plus some prescriptions.

Can someone make this make sense???

It is all a racket. I don't know how they will ever fix this after they kick Obamacare to the curb, though.

 

[John Brunner]

It is all a racket. I don't know how they will ever fix this after they kick Obamacare to the curb, though.

There's a bunch of people sitting around the Medical Practice conference table:
-Politicians
-Federal regulators
-Professional organizations (AMA, etc)
-Health insurance companies and regulators
-Malpractice insurance carriers
-Lawyers
-CEOs of hospital conglomerates
-Others I cannot think of right now

The actual doctors stand out in the hallway waiting to be told how to do their jobs. Another intended outcome of Obamacare is a consolidation of the industry. Individual practices do not have the resources to deal with all the regulatory burdens, so they get absorbed by the regional beast, making the industry easier to control.

 

[Mary Stetler]

There are a few concierge doctors popping up around here. Retainers. No insurance accepted. I hope it takes off. Some teach actual healthcare and nutrition instead of constant check ups. I know that won't work for some but many will be pleasantly surprised.

 

[John Brunner]

There are a few concierge doctors popping up around here. Retainers. No insurance accepted. I hope it takes off. Some teach actual healthcare and nutrition instead of constant check ups. I know that won't work for some but many will be pleasantly surprised.

My last GP went to a concierge program (MD VIP), but he accepted insurance (I think he only accepted insurance from 1 or 2 carriers to limit his administrative workload.) The fee included an annual "Executive Physical" and an agreement on his part to limit the number of patients he would accept. That meant appointments would be on-time and not rushed, with time open every afternoon for same-day emergency appointments. The contract limited his patient workload to a maximum of 900. Six hundred of his existing patients signed up. He had been carrying 2,400. His stress level was visibly reduced.

 

[Don Alaska]

The idea of cash-only practitioners or concierge clinics sounds like a good solution for both the docs and the patients. It was once the standard of care. A doctor could set up a practice with one provider, a nurse and a receptionist/cashier. Now, mostly after Obamacare, that same doctor would require around 15 employees to handle not only the multitude of insurances, but all the regulations and bookwork required incase the government decides to inspect your office/clinic. That is why there are no single doctors practices any more in the U.S. The inspections were placed into Obamacare apparently so the government could punish any doctor who did comply with the instructions. He/she could be inspected into bankruptcy.

 

[Marie Mallory]

As discussed in another thread, we have a Medicare Advantage Plan through Aetna. Since we both retired from a major corporation, we still get our insurance negotiated as a group plan at a somewhat reasonable monthly rate. The coverage includes vision care and dental, which come in handy at this age.

In December I had eye surgery at an outpatient facility; I was there for about 2.5 hours. I got the billing claims documents earlier today and was stunned to see that the facility billed Aetna $36,000. Yes, $36k for 2.5 hours. The anesthesiologist billed $3800 and my surgeon billed the smallest amount... $2700. Naturally Aetna negotiated what each provider will receive and it is nowhere near those amounts. The reconciliation looks like this:

Facility billed $36,000. Aetna paid $1796. My part $430.
Anesthesiologist billed $3800. Aetna paid $183. My part $36.
Surgeon billed $2700. Aetna paid $816. My share $208.

So the total billed was $42,500.
Aetna paid their negotiated amount, $2795
My out-of-pocket cost was $674 plus some prescriptions.

Can someone make this make sense???

So far no bills with UHC, hope it stays this way. But it does cost us around $600 a month, but we can't afford a huge hospital bill.Could even cost us our home,