Medical insurance blues

Posted by Allen Rucker in Life After Paralysis on September 12, 2019 # Health

Unlike many people out there in Disability Land, I have rarely had problems with the medical care I’ve received over the last twenty plus years of my paralysis. There have been slip-ups here and there, of course – doctors are human --- but given all the potentially deadly complications that I’ve endured – from necrotizing fasciitis (otherwise known as flesh-eating bacteria) to infections with no apparent antidote to pulmonary emboli to TIA’s, or mini-strokes – I’m surprised I don’t have more to complain about the competency of doctors and hospitals. I don’t.

On the other hand, this whole business of medical insurance and medical charges and what you the patient ends up paying – the “patient responsibility” – confuses, frustrates, and angers me no end. The older I get, the stupider I feel. The original charges, from almost any doctor for any specialized service, are often ridiculously priced. Then the Medicare discount or adjustment lopes off a big chunk of that, then my secondary insurer lopes off a little more, and yet I end up paying a co-payment, sometimes a sizable one.

And lest we forget: there are many necessary, life-enhancing medical costs that neither will pay for, or only pay pennies on the dollar. Medicare doesn’t cover hearing aids, eyeglasses, and teeth, for instance. You can be deaf and blind and toothless and they don’t care. Does that make any sense?

Medicare isn’t my central beef. It’s how doctors and hospitals are forced to game the insurance system to get as much compensation as they can. Doctors hate Medicare – the regulations, the paperwork, the additional staff costs – which is why many simply opt-out of the system. My favorite orthopedic guy just did that. He must have a ritzy clientele.

I’m no expert in these matters, just someone who looks at a lot of “Explanation of Benefits” reports and scratches his head in befuddlement. I’m looking at one right now. It’s for wound care services, a two-times-a-week routine in my life for the past year and a half. For one visit, the original billing is for $2,420 for “surgery.” That right there is a huge red flag. A doctor flipped me over, took a look at a pressure sore, did a little debriding, added a drop of some ointment, stuck a bandage on it, and sent me on my way. It was, at most, a five-minute procedure. If you can call that “surgery” and charge $2,500 for it, I, for one, missed my calling.

Everyone along the chain of payment simply assumes the charge is legit. First, Medicare imposes a discount of $1,906.29 for such a procedure, however they arrive at that figure, leaving a balance of $513.71. They pay 75% of that, then my secondary insurer pays for 60%, and my patient responsibility ends up at $104.41.

I should be high fiving my checkbook, right? $104 isn’t that much. But what if the original charge had been half of what it was, or $1250, still a lot for the service rendered? Then, after the Medicare discount and benefit, plus the benefit from the secondary insurer, my portion would be, according to my shaky calculations, zero! Multiply zero times the dozens of doctors’ visits I made last year and the total is…zero.

The whole system is built on obfuscation and in my mind, an invitation to chicanery. Doctors are allowed to indicate the service rendered and their fee. Medicare looks at a chart and comes up with what they think is a fair price for those stated services. From one source or another, the doctor gets that reduced payment, which they no doubt think is a fair or close to fair one.

No one in this cockeyed arrangement is thinking they are doing anything wrong. The doctor pumps up the charges so that he or she can get fair compensation after all the dust has settled. Medicare is an unfeeling machine churning out its standardized rates. The secondary insurer does its part and the patient pays the balance. What’s the problem?

I had a whole stack of these small payments due to one doctor, adding up to one very large payment, so I called that doctor’s billing office to complain. Being completely selfish, I told them that I didn’t care what they charged Medicare but that I shouldn’t personally be billed for their need to “maximize” their charges. They listened to my rant and called back the next day to say that I should disregard all the bills I’d received. I didn’t ask why. Zero is zero.

There are other such billings that seem very fair, for instance, a $5000 charge for a life-saving endarterectomy for which I was charged $241.07. But far too many seem fishy and I think this is one of the reasons American healthcare costs are double per capita those of other countries. Think of the games doctors must play to get paid what they think is a fair return. Think of all the people needed to make this multi-layered system function. A lot of money is being wasted here and most of it, from runaway Medicare costs to co-payments you are stuck with, are coming out of your pocket.

The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.