Phoenix Rising: The Gift That Keeps on Giving All Year Long
This holiday season Jody Smith turns her eyes to the people of Phoenix Rising and gives thanks for you all ...
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Discussion in 'Finances, Work, and Disability' started by AbbyDear, Sep 5, 2013.

  1. AbbyDear


    So, I used out-of-network insurance coverage for a variety of reasons, but thought about the cost per a $500 deductible, and 75% coverage thereafter. As it turns out the doctors submits a charge to the insurance company for a different amount than what I paid (out-of-pocket), sometimes the same, sometimes not the same. Then the insurance company turns around and decides just how much they would be willing to pay for the service, if it were up to them. Well, that turns out to be about 50 cents on the dollar. So either the doctor is severely over charging (by 100%), or the insurance company is not being fair. I understand with in network coverage, there is a numbers game being played with the providers charge and the 'contract' coverage that was negotiated and agreed upon apriori. However, I assumed, that when paying out-of-network, the deductible would accumulate true out-of-pocket expense, and the co-insurance (75%) would also be with respsect to what I, the patient, paid out of pocket. How wrong and misinformed. So, the $500 deductible is really like a $1000 deductible, and the co-insurance thereafter is like 37% (patient pays 63%). Seems like something unethical, or worse, to me. I was not expecting to pay so much, not even close. This is not good for someone on a no-income income.

    Anyhow, just wanted to vent a bit, and let anyone else who may not be aware be informed of this trickery. Any thoughts or other stories like this welcome.
    taniaaust1 likes this.
  2. taniaaust1

    taniaaust1 Senior Member

    Sth Australia
    Sorry to hear you have been caught out Abby, I so hate insurance companies. Mine hasnt payed me for two things they were supposed to do so, I even phoned them and checked before I went ahead with things, they now dont want to pay out and give me crap.

    That's another battle Im going to have to fight some time (cant right now as Im already trying to fight too many other things) as I cant see how they can go against what they previously told me. Life with this illness is a constant battle to get treated fairly.
    AbbyDear likes this.
  3. Sparrowhawk

    Sparrowhawk Senior Member

    West Coast USA
    This recent Time article gets into this in detail. The entire system is rife with practices none of us would tolerate in any other business we patronize.,9171,2136864,00.html

    Since I left the HMO I was with, I saw exactly the billing issues you mentioned. My deductible was much more than $500 so I was really paying attention as the bills rolled in. The healthcare providers are getting in the habit of charging the absolute maximum because they assume from the start that the insurers are only going to pay a fraction of that.
    AbbyDear likes this.
  4. vamah

    vamah Senior Member

    Washington , DC area
    I feel the same way. Last year I paid out of pocket for some lab tests my HMO wouldn't do. I recently had the tests redone, this time covered by my new insurance, and when I got the statement I saw that the insurance company payed less than 10% of the stated cost! I know the actual lab test must cost more to do than that, so people without insurance get overcharged because big insurance companies can name their own price?

    I don't know what the solution is though. Reading this forum, it is clear that people in countries with a government run health system have an even tougher time getting care.
    AbbyDear likes this.

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