Most of you who waste your precious time reading this blog know that I was hospitalized last year for a month spending a goodly portion of it in the ICU. I guess one can expect this sort of thing when you’re pushing 80. Well I’m still here and still living on my own.
Now having such an experience and several experiences since got me to thinking about health insurance.
I have original Medicare as opposed to a Medicare Advantage plan. It means I can go to any doctor or hospital that accepts Medicare. Everyone does because of the number of older Americans on Medicare. I can also go to any doctor or specialist without a referral.
Medicare Advantage is cheaper but restricts you to doctors and hospitals in network. Also many require a referral before you can see s specialist. Advantage plans are cheaper but come with restrictions.
Original Medicare on the other hand covers only 80% of you bill. One needs to purchase a supplemental insurance policy (I have Blue Cross) to cover the other 20%. The supplemental insurance policy covering 20% costs more than the Medicare which covers 80%.
That’s capitalism. So Medicare is more expensive than the Advantage plans but comes with less restrictions, primarily on which doctor or hospital you can use.
I probably racked up half a million bucks in medical costs last year between hospitals, specialists, surgeons, tests, x-rays, home nursing etc. Medicare covered all of it.
But a look at the billing reveals much about the health care industry.
First of all I would guess a hundred doctors billed Medicare during my hospital stay. I never heard of the vast majority of these folks. I think if they peeked in the door or took my pulse or listened to my lungs with the ever present stethoscope qhile I was sleeping they sent Medicare a bill for $895. I never saw any doctor other than my own and 2 surgeons while hospitalized.
What did these others do? I haven’t a clue but I didn’t have to pay them. The government did. They put in a claim, listed the provided service and got paid.
Unlike the drug program approved by George Bush, Medicare negotiates the price of various services. Doctors and hospitals which take Medicare agree in advance to accept the Medicare determination of the reimbursement rate for the service rendered in total payment. Medicare then pays it 80% and my supplemental insurance covers the remaining 20%. I am not responsible for anything over the Medicare determination.
As an example, I was discharged from hospital wearing a Life Vest, an electronic defibrillator. My cardiologist was worried about potentially fatal heart issues. This jacket was going to shock me if it sensed any potentially fatal heart rhythms. I was assured I would be unconscious before the shock. 🙂
The jacket had to ne returned after use. I had it about a month until heart doctor was satisfied and I returned it.
Medicare was billed approximately $3,900. Medicare said no no – you will receive $2,800 and paid 80% of this amount. Blue Cross covered the rest. It should be pointed pit someone without insurance would have been billed the entire $3,900 even though the company would accept $2,800 from Medicare in full payment.
Now comes the racked.
Vest company sent me a bill for $1,100. Now a lot of older people unaware of how our health care system works would have written a check and mailed it out although they are clearly not responsible for it. The bill came, explaining nothing and simply implied that insurance didn’t cover it all and I owned the $1,100.
This has happened several time this year. The largest was $1,750 and the smallest $95. These doctors and hospitals know the patient is not responsible to the difference in what they billed Medicare and what was approved. But they try to collect it anyway.
Send the old coot a bill. Maybe he’ll pay it. When you call and ask questions you get a “We’re sorry. It was a mistake.”
It happens too often to be a mistake.
One of the bill higher bills was from a couple of doctors who provided “critical care during the first hour” in the hospital. Their claim was rejected by Medicare and I was not responsible for the amount. Why? The doctors didn’t supply Medicare details of just what they had done. Hospital care is not divided into first hour and second hour. And if Medicare won’t pay it I don’t have to pay it either.
Medicare sent me a letter stating I was not responsible and sent a strong letter to the doctors stating if they wanted to get paid they could resubmit their bill with details details.
All in all, Original Medicare has served me well. Yes one needs a supplemental insurance policy to cover that 20a% but there is much less restriction. Doctors and hospitals routinely bill Medicare exorbitant amounts which are reduced and paid. The patient is not responsible for the difference.
Unfortunately many older folks cannot afford Original Medicare and a supplemental insurance policy and so they purchase an Advantage plan with many more restrictions.
Let me close by saying in spite of half a million in bills I have not had to pay a cent.