Last week I received an EOB (explanation of benefits) from our health insurance company. (I won't call them a provider because they don't actually "provide" anything.) It seems I'm expected to pay over 50% of the ambulance bill because the ambulance (which is a county service) is not in the network.
I'm going to date myself here. It's okay. I know I'm old but I remember when you actually paid your own medical bills. After you met your deductible, you filed a claim with your health insurance company and were reimbursed for what you'd paid over your deductible. You could choose any doctor you wanted. You didn't need to worry about networks or referrals.
When insurance companies decided to start paying the doctors directly, eliminating our need to pay up front and then file for reimbursement, we thought it would be a great convenience. I am convinced that we, as consumers got the short end of that stick (as we usually do). Aside from the occasional dispute about "usual and customary charges" (a term you don't hear anymore) the old plan worked.
I think it was the early to mid-80s when my employer, who was self-insured, decided to switch over from being self-insured to using a third-party insurance company. Initially, it all worked pretty much the same - you filed your claims after you'd met the $100 deductible and they sent you a check. But with this changeover they introduced what became known among the employees as "the $5 doctors". If you went to one of the doctors on this list, you paid $5.00. It didn't apply to your deductible but you'd have to go to the doctor 20 times to equal your $100 deductible. (Back in those days, the average doctor visit was $15 to $20 dollars - so it was a cost savings to you.) Again, it seemed like a good deal for the consumer. After visiting two of the $5 doctors, I came to two conclusions. 1. You DO get what you pay for. If the average price is $15 and you're paying a third of that, there is a reason. 2. If the office furniture and paint was last updated two decades ago, leave. Leave now. This is not a doctor you want to see.
But then came the day when we no longer had a choice. We had to see a doctor who was "in network". Well, you didn't have to but there were serious financial consequences if you didn't. I lived in a very small town and I remember my doctor asking me to get him whatever paperwork he needed to join whatever networks his patients were in. I also remember a number of friends being duped into high charges because they phoned the doctor's office and asked "Do you take XYZ insurance?" And of course the response was "We take ALL insurance." The correct question is "Are you an "in network" provider with XYZ insurance?"
I had a car accident in the 90s. Not my fault, but I had to keep track of what I paid and what the insurance company paid so a claim could be filed with the "at fault" party's auto insurance. That's when I first realized that I paid more than the insurance company. I paid almost two thirds more than they did.
The same was true for prescriptions. Back in the 80s and 90s I paid less than $3 for a 90-day supply of a generic muscle relaxer. Then the insurance company got involved with it and the minimum charge for any prescription was $5. AND now I could only buy a 30-day supply. So it was now going to cost me $15 for something that had previously cost less than $3. And don't get me started about all the times we were going to run out of prescription meds while we were out of town and couldn't get refills because the insurance company couldn't be reached for a vacation override approval.
But back to the EOB. I called the insurance company to ask, for future reference, how I could be sure that I got an "in network" ambulance when I called 9-1-1 in the middle of the night. The customer service rep clearly had no genuine thoughts on that so I asked to speak to a supervisor. Even though I was told it would be no more than 48 hours for a supervisor to call me back about that, perhaps I misunderstood. Maybe she said 48 weeks, since it's already been a week and a half. And even though I'm retired now, I still have more to do than sit on hold with insurance company representatives for the entire afternoon. And the thought of calling them back makes my jaw clench.
So here we are over 30 years in to letting the insurance companies pay doctors direct instead of reimbursing us and they now drive the entire process. Insurance company executives make an obscene amount of money. Healthcare costs in the US have skyrocketed since we allowed the insurance companies to take over. And apparently calling 9-1-1 at 3 am is something that could cost you several hundred dollars.
I've heard so many people who are fearful of the evils of socialized medicine (and there are evils to be fearful of) because they don't want the "government" meddling in their healthcare. Does it really matter to anyone whether the high-school educated clerk who is going to determine whether you get care or not works for the government or a private insurance company? I'm in favor of putting doctors and patients back in charge.
Rant over.
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