Our insurance pays maximum for "in network" providers and we have a significant co-pay if we are out of network, unless the services are for an emergency. This summer I had a severe GI bleed and the nearest hospital is out of network. No problem, says my insurance. It was an emergency. I spent six days in Intensive Care. My insurance determined that after the third day (when I was still receiving medicines to maintain my blood pressure and was not allowed even ice chips by mouth) my care in the ICU did not constitute an emergency, so they paid the out of network payment for the remaining days. Guess I was supposed to pack up my IVs and travel 25 miles to another facility.
Last year, my physician's group joined the local hospital. My physician is still in network for my insurance, but the hospital is not. Since the hospital does the billing under its own billing number my insurance no longer recognizes my physican as in network.
In December, my husband had major orthopedic surgery at an in-network hospital. The hospital bill alone (not anesthesia, physicians, radiology, transport, etc.) was well over one hundred thousand dollars. Our insurance paid the discounted contracted fee to the hospital, far less than the actual bill, and we had no liability for payment.
In January I had a screening study at the same hospital. The insurance statement explained that I was responsible for a significant co-pay because the hospital was not in-network. I called the insurance and discovered that the hospital had refused to re-negotiate a contract with our insurance. Coincidence? Perhaps, but the hospital had been under contract for more than 10 years and suddenly decided not to participate.
Both my husband and I are healthy with no major diseases. Prior to my GI bleed, my only hospitalizations had been for childbirth. We carried good insurance because we could afford to do so. But what about those who cannot? The simple truth is that our hospital bills this past year represented payment not only for our care but for those who did not have insurance. If people believe they do not have to worry about the uninsured, they are quite mistaken. We all pay for their care.
I bring forth these examples to show that providers and insurance companies have methods for increasing your out-of-pocket expenses. I am truly thankful that we are able to absorb these costs and I feel terrible for those hard-working individuals for whom big medical bills send them so deeply into debt.
A word of advice...please carefully compare your insurance statements to the bills you later receive. On Friday we received a sizable bill from an anesthesia provider. Our insurance statement indicated they were a contracted provider, were paid according to the contract and that we had no responsibility for payment. I called the provider and after an lengthy conversation received this reply, "Oh, someone made a mistake. You are correct and we will 'write off' the payment." No explanation, no apology, just "a mistake." Thank goodness we keep track of these things. I have little doubt that others simply pay the bills without questioning them and that is terrible.
Impossible as it may seem, we are under a winter weather advisory with predictions of yet another snow storm. Hey, isn't this March? And in sunny North Carolina not in the high mountains?