Ever take a really close look at one of those “EOB”s, or Explanation of Benefits, from your health insurance company? I know it’s not exactly riveting to read, but it could be. Take a look when you have a minute or two. I did.
If you don’t happen to have one of those lying around, let me share one of mine with you. The occasion was a surgery, after which I was put into a little area for “observation”. This wasn’t a room, mind you; I was not considered to be “inpatient”; I did not have a room to myself. This was a little cubicle with a curtain for a door. The nurse came in and checked on me every once in awhile. I think they checked my vitals a couple of times, but mostly the nurse would pop her head inside the curtain and ask, “You doin okay?” Not much hands-on stuff going on there, other than a pain pill every several hours. The lab guy stopped in around 0430, and the surgeon stuck his head in briefly at 0600 to ask how I was doing. The surgery had gone well, he said, only took about an hour.
The eye-opener came in the mail a few weeks later. It was my EOB, which showed a whopping $52,935.98 had been billed by the hospital, which name will remain anonymous. (Hint: it’s a non-profit in Tacoma, Washington.) Wow! My responsibility, or co-insurance, would be $800.73. The amount billed, but not covered in the contract between the hospital and the insurance company, was $36,909.96. Which left $16,026.02 to be paid by my insurance company to the hospital.
Please understand, this is just the bill for the use of the HOSPITAL. This is not the bill from the surgeon ($5424), or the anesthesiologist ($1440), or the surgical assistant ($2620). So if you add that all up, it amounts to $62,419 billed to my insurance company for that simple surgery, not requiring hospitalization overnight. Can you imagine what an actual inpatient, overnight hospitalization would have run?
This makes me wonder how those contracts work, between the insurance companies and the providers. And what about people who are not insured? How much do they get billed? And if they can’t pay, guess what? All those unpaid bills get disbursed, eventually to be recouped via increased fees and premiums charged to the paying customers. So the providers jack up their fees, bill more to the insurance companies (because they know they can), the insurance companies further restrict coverage, deny claims and increase premiums, and so on and so on and so on.
Remember: Insurance companies are NOT benevolent entities. They are set up to make a profit~a hefty profit! Insurance companies are not there to provide healthcare. That’s what doctors and nurses and therapists are for. Insurance companies are simply paper-pushers, who’ve set up contracts with medical providers to pay mostly on a fee-for-service basis according to an agreed-upon schedule, if the providers agree to contract with that insurance company as a “preferred provider”, thereby giving the insurance company all those sweet, sweet premium-paying consumers.
Insurance companies have done their homework, and they know just which procedures to cover at 40%, 50%, 60%, and 80%, which procedures to consider experimental or elective, and therefore not covered at all ~~ by definition, a pacemaker is considered elective by most insurance companies! You’d be surprised what insurance companies consider “elective”. Insurance companies build in profit by cutting and denying coverage, thereby keeping more of our hard-earned money in their giant, greedy coffers. It’s not accidental that they can afford such lofty salaries & bonuses for their CEOs. Blue Shield CEO’s annual salary = $4.6 million.
So next time you get one of those EOBs in the mail, take a good look at it. It will be riveting.
©Janet L Mitchell
