Insurance companies, do they know they are being scammed? - Page 2 - Mothering Forums

Forum Jump: 
Reply
 
Thread Tools
#31 of 52 Old 06-10-2006, 12:34 PM
 
laohaire's Avatar
 
Join Date: Nov 2005
Posts: 7,115
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
The scamming goes both ways, guys. The insurance companies decide "we won't pay more than $X for this procedure." Then the hospital has to make up for the loss by charging more for other stuff.

Furthermore, the overhead is enormous. You're paying for administrative staff. Lights. Heat. Front desk workers. The upgrade to the new maternity wing. Security. Telephones. TAXES. So they have to pad everything to cover that overhead.

That's what any business does - if you pay a lawyer $300 an hour, the lawyer isn't pocketing $300 an hour. About $100 goes right to Uncle Sam. There's the rent on the office, the assistant, the equipment, phone bills, association fees.

I don't feel sorry for either the insurance company or the hospital. I just feel like medical care shouldn't be a business at all. I realize there are some very good arguments for it (competition, etc.) but ultimately I think we'd all be better off if everyone had access to the basics, even if the advances in medicine (cure for cancer, etc.) get stalled out as a result. But my stance is a very unusual and controversial one, and I realize why.

Homeschooling mama to 6 year old DD.

laohaire is offline  
Sponsored Links
Advertisement
 
#32 of 52 Old 06-10-2006, 03:10 PM
 
gentlebirthmothr's Avatar
 
Join Date: Jul 2005
Posts: 2,268
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by annakiss
Insurance companies are making money hand over fist, they're not getting scammed. We the consumers are the ones getting scammed. Especially if you're poor and can't afford insurance as the costs are passed onto you if you self-pay.
AnnaKiss,

gentlebirthmothr is offline  
#33 of 52 Old 06-10-2006, 03:18 PM
 
Orion'smommy's Avatar
 
Join Date: Jan 2006
Posts: 180
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
What really bothers me is the fact that I decided to have a homebirth which ended up costing $3500 out of our pocket and BCBS only imbursed us $1,000. My neighbor had a C-section and her birth cost BCBS $13,000, which of course they paid.
Orion'smommy is offline  
#34 of 52 Old 06-10-2006, 03:24 PM
 
gentlebirthmothr's Avatar
 
Join Date: Jul 2005
Posts: 2,268
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
//
gentlebirthmothr is offline  
#35 of 52 Old 06-10-2006, 03:25 PM
 
gentlebirthmothr's Avatar
 
Join Date: Jul 2005
Posts: 2,268
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by laohaire
I don't feel sorry for either the insurance company or the hospital. I just feel like medical care shouldn't be a business at all. I realize there are some very good arguments for it (competition, etc.) but ultimately I think we'd all be better off if everyone had access to the basics, even if the advances in medicine (cure for cancer, etc.) get stalled out as a result. But my stance is a very unusual and controversial one, and I realize why.
laohaire,

gentlebirthmothr is offline  
#36 of 52 Old 06-10-2006, 04:25 PM
 
wifeandmom's Avatar
 
Join Date: Jun 2005
Posts: 1,419
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by Orion'smommy
What really bothers me is the fact that I decided to have a homebirth which ended up costing $3500 out of our pocket and BCBS only imbursed us $1,000. My neighbor had a C-section and her birth cost BCBS $13,000, which of course they paid.
That is so incredibly backwards to me. You would THINK that insurance companies would LOVE women who chose homebirth or care with a midwife vs. OB, etc.

Unfortunately, I'd venture to guess that they've had an actuarial study done on the numbers to see if it would REALLY save them money and found that it wouldn't. Why?

I'm figuring a woman who strongly desires a homebirth will usually just pay out of pocket for it instead of saying 'Oh well, guess I'll have to go the standard OB/hosptial route since my insurance won't pay for HB.' And they have likely studied how many woman would opt for HB instead of the standard OB/hospital care the insurance is already covering if insurance started covering HB to the same extent and found it wouldn't be THAT many women overall.

It's all about the numbers, I can assure you they've looked to see if they'd actually save money *overall* by covering some of these things and found that while they'd certainly save in *some* instances, it's not enough to create an *overall* savings.

Look at your case....they STILL saved money on your care cause YOU paid the difference.
wifeandmom is offline  
#37 of 52 Old 06-10-2006, 05:01 PM
 
gentlebirthmothr's Avatar
 
Join Date: Jul 2005
Posts: 2,268
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by wifeandmom
That is so incredibly backwards to me. You would THINK that insurance companies would LOVE women who chose homebirth or care with a midwife vs. OB, etc.

Unfortunately, I'd venture to guess that they've had an actuarial study done on the numbers to see if it would REALLY save them money and found that it wouldn't. Why?

I'm figuring a woman who strongly desires a homebirth will usually just pay out of pocket for it instead of saying 'Oh well, guess I'll have to go the standard OB/hosptial route since my insurance won't pay for HB.' And they have likely studied how many woman would opt for HB instead of the standard OB/hospital care the insurance is already covering if insurance started covering HB to the same extent and found it wouldn't be THAT many women overall.

It's all about the numbers, I can assure you they've looked to see if they'd actually save money *overall* by covering some of these things and found that while they'd certainly save in *some* instances, it's not enough to create an *overall* savings.

Look at your case....they STILL saved money on your care cause YOU paid the difference.
wifeandmom,

, I wonder if they did this for an alternative hospital birth and free standing birth center birth as well.
gentlebirthmothr is offline  
#38 of 52 Old 06-10-2006, 05:23 PM
 
grumpyshoegirl's Avatar
 
Join Date: Mar 2006
Location: South Shore, MA
Posts: 940
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by maxmama
you know, I don't feel sorry for the insurance companies at all.

You know what's left off your itemized bill? Nursing care. We come with the room, just like the towels and the bendy straws. We cannot bill for our time, but the lab person who draws your blood can. One way for the hospital to recoup the cost of a pharmacy (in-house, 24 hours a day -- not cheap) and nursing care is to inflate the costs of things the insurance companies will pay for.

Besides, insurance companies don't pay the sticker price on hospital stays, only private pay patients do. Insurance companies pay their negotiated price, which is usually at least 40% lower.
Yup! I billed for an ER while I was in college and the prices we charged were only ever paid by those who could least afford it-- people who made too much to be on Medicaid but not enough to have their own insurance. Every once in awhile, we'd have a patient visiting from out-of-state (I live near Cape Cod, after all) who had non-participating insurance that would pay the full amount, but that was rare. A lot of insurance companies won't pay for medical care out-of-network for this reason.

Another reason I think insurance companies would continue to pay for c-sections is the same reason that so many OBs are so ready to do them even when they're not necessary: fear of lawsuit. I think an insurance company could get into some deep doo-doo if a baby died when a mom wanted a c-section and was told no.
grumpyshoegirl is offline  
#39 of 52 Old 06-10-2006, 05:58 PM
 
gentlebirthmothr's Avatar
 
Join Date: Jul 2005
Posts: 2,268
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by grumpyshoegirl
Yup! I billed for an ER while I was in college and the prices we charged were only ever paid by those who could least afford it-- people who made too much to be on Medicaid but not enough to have their own insurance. Every once in awhile, we'd have a patient visiting from out-of-state (I live near Cape Cod, after all) who had non-participating insurance that would pay the full amount, but that was rare. A lot of insurance companies won't pay for medical care out-of-network for this reason.

Another reason I think insurance companies would continue to pay for c-sections is the same reason that so many OBs are so ready to do them even when they're not necessary: fear of lawsuit. I think an insurance company could get into some deep doo-doo if a baby died when a mom wanted a c-section and was told no.
Amy,

:
gentlebirthmothr is offline  
#40 of 52 Old 06-11-2006, 05:43 AM
 
JSerene's Avatar
 
Join Date: Nov 2004
Posts: 751
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by happydoulamama
Great thread! Maybe someone can explain this one:

With my first baby, we were charged a $1000 flat fee for "Nursery care". My baby was with me the entire time. I called the hospital to ask about it, and they told me that it was "standard procedure" for any newborn. So basically, I was paying for other women to have their babies kept in the nursery while they slept, while I was up every hour feeding and caring for my own. The insurance company paid for it as well! If I would have had to pay it, I would have fought it all the way and they wouldn't have seen a cent.
I can explain this one. Calling it "nursery care" is very misleading. Really, it's all the care your baby recieved from the nurses in the hospital. Just because your baby wasn't in the nursery doesn't mean a nurse wasn't monitoring the baby during your stay. Here are some general cares the nurses probably provided:
-at the birth a nurse was in attendence and ready to resuscitate if necessary.
-after the birth, an nurse weighed, measured, bathed, and examined the baby.
-a nurse or nursing assitant monitored vital signs every four hours for the first day, then every eight hours until discharge to make sure the baby was doing okay.
-a nurse weighed the baby everyday and monitored feedings, ever on the lookout for dehydration.
-a nurse was there to help with breastfeeding if it was needed.
-a nurse was there to provide basic instruction on baby cares.

Everyone is charged a flat rate, whether they had a baby who was a born breastfeeder and cared for by mom, or a baby with a tight frenulum, who sucked on his own tongue, and refused to latch onto moms large and inverted nipples :-) (breastfeeding problems are VERY time consuming for us nurses).

I hope your nurses were wonderful and helpful and worth the expense in your mind - that was what you were paying for.
JSerene is offline  
#41 of 52 Old 06-11-2006, 05:05 PM
 
MindOverLaborDoula's Avatar
 
Join Date: May 2006
Location: WV
Posts: 36
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Here are the amounts that I was given by our local hosp comptroller for an epidural, I'm typing it as she wrote it:
catheter $57.70
epidural $90.30
pain pump $40.25
epidural needle $15.60
straight catheter $16.70
epidural tray $90.30
Fentanyl $9.50
sensorcaine $30.00
anesthesia professinal fee $344.00
anesthesia $54.65
anesthesia $387.88

Now, from my calculations that is $1136.88 just for an epidural. And keep in mind that this doesn't include the saline bags, EFM, catheters for your lack of peeing ability, BP readings, etc.. . I asked her how much Medicaid pays for a standard birth and she said that whether or not it is vaginal or c-section they pay right around $6,000. It doesn't matter if you decide that you want an epidural or not, IV or not, EFM or not. And, this is the same amount if you stay 48 hours or 4 weeks. Wonder why the state might be losing money. Here 80% of the babies born are Medicaid.
But when we were talking about a private pay b/c of no insurance, it can cost anywhere from $2900 (if come in when you are about to start pushing)-$19,000 (if you have the whole workup with pit, all the way to a c/s). Love It!!! Oh, and I love too that she said that every 4 minutes you are on the EFM you are billed something like $35.
Hmmm... maybe that's why a lot of my clients understand now that Doulas really do save them $ if they are a private pay patient.
Why the difference? And why wouldn't state covered insurance want women to be educated to save them $$ so that they would only pay for what is used?
MindOverLaborDoula is offline  
#42 of 52 Old 06-11-2006, 06:50 PM
 
wifeandmom's Avatar
 
Join Date: Jun 2005
Posts: 1,419
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by MindOverLaborDoula

Now, from my calculations that is $1136.88 just for an epidural.
Aside from the actual supplies used for the epi, which I have *no clue whatsoever* how much that stuff really costs, I can tell you how much the going rate is for someone to put in your epi. Keep in mind that once that epi is running, someone from anesthesia has to be IN HOUSE (thus still getting their hourly wage) until it is taken out.

So, let's say you get your epi at 4cm, dilate the 'textbook' 1 cm per hour, that is 6 hours til you're at 10cm, then you push for 2 hours. That's a grand total of 8 hours your epi was in place and someone was getting paid from anesthesia that entire time.

They get roughly $75-150 PER HOUR. And this is if you had an anesthetist. And anesthesiologist will get twice that much per hour.

Let's just use $100 an hour for easy math (and it's super duper easy to find places willing to pay $100 an hour for 24/7 anesthesia coverage). For that one epi, that's $800 going to the anesthetist straight off the top.

Now, obviously if it's a busy L&D ward with several epis going, the anesthetist still gets $800 but the hospital has billed out for SEVERAL epis. But for smaller hospitals, it is NOT uncommon AT ALL for them to actually LOSE money on epis because the hourly rates are so high for anesthesia providers.

Also, this is assuming the hospital hires their own anesthesia staff, something that isn't super common in smaller hospitals. They often can't find anyone to hire, so they end up going with an agency that places anesthesia staff. They still pay $75-150 per hour to the anesthesia person, but they ALSO pay another $50-200 PER HOUR to the agency that sent them the anesthetist.

It is EXPENSIVE to have anesthesia staff in house, so that $1100 for an epi is NOTHING in terms of what the hospital is actually paying out. Most places figure they can't really offer L&D services without having someone from anesthesia available though (even if just on call), so they break even or even LOSE money on that aspect of care in order to continue delivering babies.

Also, you have to consider the places paying to have anesthesia coverage in house 24/7, yet they only deliver a baby or two per day. Those folks are losing their butts (think...$2400 per day for anesthesia coverage and they are NOT going to re-coup that much in epi charges if they only deliver a handful of babies each day). And it's not surprising at all when they drop the 24/7 coverage and then are unable to offer VBAC services because of it.

I think it's nothing short of a miracle that hospitals don't charge WAY MORE for an epi considering their cost to provide the service.
wifeandmom is offline  
#43 of 52 Old 06-11-2006, 08:19 PM
 
MindOverLaborDoula's Avatar
 
Join Date: May 2006
Location: WV
Posts: 36
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
No no no... I wasn't saying anything about the costs vs how much they should cost. I was meaning that coming out of your own pockets, it would save you money if you hired a Doula and decided to not have an epi.


I get so peeved off when someone says, "but I needed an epidural". No silly, your body didn't need one, you wanted one. : wait a sec... I do believe that there is a time when one might be beneficial to a mother (ie when she can't stay in control of how she is reacting to her contractions and so it is in her best interest so that she can relax)
With that said, if you want to save money and do not want an epi hire a Doula or have really awesome support with you so that you stay in control. I always tell my clients that "you can't control the contractions, only your reactions".
But, I also have many many clients that want an epi the second that they walk into the hospital. As long as they know the risks, it's fine and dandy with me. This isn't my birth, it's theirs.
MindOverLaborDoula is offline  
#44 of 52 Old 06-11-2006, 11:03 PM
 
Rio Mama's Avatar
 
Join Date: Apr 2006
Posts: 148
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by GooeyRN
About the expensive medications...

You are paying for the doctor to write the order.
You are paying for the unit secretary to transcribe the order.
You are paying for the pharmacist to check if there are any possible interactions with other medications you may be taking.
You are paying for the pharmacy tech to deliver the medication to the unit you are on.
You are paying for the nurse to administer the medication according to the six rights of medication administration.
You are paying extra for the medication because it comes individually wrapped to prevent medication errors.
You are paying for the little plastic or paper med cup.

Thats why a $0.05 tylenol (or other inexpensive medication) can cost $15.00 for one dose.

I had never really thought about this, but it makes perfect sense. Thanks for spelling it out!
Rio Mama is offline  
#45 of 52 Old 06-11-2006, 11:42 PM
 
doctorjen's Avatar
 
Join Date: May 2003
Posts: 3,082
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
It's funny that in the US, with all our third party payers, we don't really know what medical care actually costs. We bill much more than cost, or than we expect to get, because insurance companies pay only a fraction. The actual consumers in modern medicine do not directly foot the bill, so have no idea of the value of the services they receive. Conversely, the docs are so separated from the actual price-setting that they often have no idea what the actual charges are. Add to that, that many things are unbillable and have to be factored in to somewhere else in the bill, and the "cost" of medical care is pretty unfathomable.
Also, medicare, medicaid, and consequently private insurance companies pay more for procedures and billable items than they do for physician care, especially primary care physicians. I can bill quite a lot for taking a mole off someone's arm, but absolutely nothing for spending an hour on a conference with a nursing home patient's family.
Often, if a client of mine chooses an epidural, more is billed (and collected) for the epidural than I receive for all the prenatal care, attending the birth, and the postpartum care - even if I have 20 prenatal visits with a high-needs client, spend 14 hours with her in labor, and then take 12 phone calls in the first 2 weeks of the baby's life.
doctorjen is offline  
#46 of 52 Old 06-12-2006, 11:34 PM
 
stellimamo's Avatar
 
Join Date: Jan 2006
Location: Indianapolis, IN
Posts: 2,699
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Besides, insurance companies don't pay the sticker price on hospital stays, only private pay patients do. Insurance companies pay their negotiated price, which is usually at least 40% lower.
I have rarely seen a negotiated price reduced by 40%. The only time that happens is when the provider has hugely inflated the price in the first place. The price is that insurance companies usually pay is what is reasonable and customary not some arbitrary % of the total amount.

Insurance companies do pay sticker prices for many hospital charges.
stellimamo is offline  
#47 of 52 Old 06-13-2006, 02:23 AM
 
wifeandmom's Avatar
 
Join Date: Jun 2005
Posts: 1,419
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by stellimamo
I have rarely seen a negotiated price reduced by 40%. The only time that happens is when the provider has hugely inflated the price in the first place. The price is that insurance companies usually pay is what is reasonable and customary not some arbitrary % of the total amount.

Insurance companies do pay sticker prices for many hospital charges.
I just got a statement today from Tricare (military health insurance and NOTORIOUS for crappy reimbursement rates). My first OB appt for this pg was billed at $145, and Tricare paid $117 for it. That's just shy of 81% of what was charged.

Included in that $145 charge was my pap smear, cultures for chlamidya (sp?) and gonnorhea (sp?), vaginal u/s for dating purposes, and all the initial questions and such on your first OB visit. I didn't think that was bad at all considering I paid more than $145 for a vaginal u/s ALONE during our infertility days. I think those were $198 a piece IIRC.
wifeandmom is offline  
#48 of 52 Old 06-13-2006, 05:01 PM
 
huggerwocky's Avatar
 
Join Date: Jun 2004
Posts: 5,396
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by Orion'smommy
What really bothers me is the fact that I decided to have a homebirth which ended up costing $3500 out of our pocket and BCBS only imbursed us $1,000. My neighbor had a C-section and her birth cost BCBS $13,000, which of course they paid.
Then you're group plan sucks, we also have BCBS and they pay 60 %....which is still far less than for in network hospital deliveries :
huggerwocky is offline  
#49 of 52 Old 06-13-2006, 06:28 PM
 
BetsyS's Avatar
 
Join Date: Nov 2004
Location: world of craziness
Posts: 5,307
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by doctorjen
Conversely, the docs are so separated from the actual price-setting that they often have no idea what the actual charges are. Add to that, that many things are unbillable and have to be factored in to somewhere else in the bill, and the "cost" of medical care is pretty unfathomable.
This is so true. I work in a clinic setting. We also have a small private office that is set up to take insurance (the clinic only takes private pay and Medicaid) When someone needs a prescription, if they ask us to, we will often call the pharmacy to get an estimated cost. If they don't ask, well, frankly, I don't usually think about it, and I write for the most common drug.

For instance, if you have herpes, it is recommended that you take an anti-viral for the last several weeks of your pregnancy. If I write for a name brand, that Rx can cost $500+. If I write for a generic (that has the downside of having to take more than once a day), then the same time period will cost $45. That's a huge difference. Most of my patients, whose average income is about $350/week, will choose the several times a day cheaper drug.

Insurance will pay for the name brand without a second though, though.
BetsyS is offline  
#50 of 52 Old 06-13-2006, 06:37 PM
 
Rani's Avatar
 
Join Date: Oct 2004
Location: Skokie IL
Posts: 862
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Speaking of which - my babe was in my room the whole 1.5 days I was in the hospital. Only went to the nursery for a bath. So why was I charged the Nursery fee? Because its standard...sigh....based on the thread, I guess that is how they covered the EXCELLENT nursing staff (I mean it - hated the stand in OB, loved the nurses!)...but still..would rather have seen "nursing care" charge instead of being charged for an isolette that was never used!
Rani is offline  
#51 of 52 Old 06-13-2006, 11:19 PM
 
Quagmire's Avatar
 
Join Date: Sep 2005
Location: Quahog, RI
Posts: 1,812
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by maxmama
NPs are independent providers. RNs are not. For billing purposes, NPs aren't nurses.
Well that's a stinky double standard
Quagmire is offline  
#52 of 52 Old 06-13-2006, 11:24 PM
 
Quagmire's Avatar
 
Join Date: Sep 2005
Location: Quahog, RI
Posts: 1,812
Mentioned: 0 Post(s)
Tagged: 0 Thread(s)
Quoted: 0 Post(s)
Quote:
Originally Posted by Orion'smommy
What really bothers me is the fact that I decided to have a homebirth which ended up costing $3500 out of our pocket and BCBS only imbursed us $1,000. My neighbor had a C-section and her birth cost BCBS $13,000, which of course they paid.
Seriously.

If the insurance companies started covering out of hospital options (homebirths, FSBCs, etc) and dedicating some marketing dollars to advocating those choices and encouraging women to do their research they would benefit in the end. I really don't understand why even insurance companies just accept hospitals as the standard when it would behoove them to do a little bargain shopping.
Quagmire is offline  
Reply

Quick Reply
Message:
Drag and Drop File Upload
Drag files here to attach!
Upload Progress: 0
Options

Register Now

In order to be able to post messages on the Mothering Forums forums, you must first register.
Please enter your desired user name, your email address and other required details in the form below.
User Name:
If you do not want to register, fill this field only and the name will be used as user name for your post.
Password
Please enter a password for your user account. Note that passwords are case-sensitive.
Password:
Confirm Password:
Email Address
Please enter a valid email address for yourself.
Email Address:

Log-in

Human Verification

In order to verify that you are a human and not a spam bot, please enter the answer into the following box below based on the instructions contained in the graphic.



User Tag List

Thread Tools
Show Printable Version Show Printable Version
Email this Page Email this Page


Forum Jump: 

Posting Rules  
You may post new threads
You may post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off
Trackbacks are On
Pingbacks are On
Refbacks are Off