Most of these things are controlled by managed care and by health care networks. When you see an in-network provider, they have agreed to a pricing schedule with your insurer, the “usual and customary” price. If you see someone out of network, they have no such agreement. The insurer will pay their share of usual and customary, and you are left with the rest, unless the provider agrees to write off the rest. As long as you stay in network, the base price should be close to the same, no matter who you use.
With prescriptions, it’s going to depend on several factors - is the company purchasing coverage from the insurer, or are they self insured, and paying the insurance company to manage their plan? Will the prescription plan be managed by the insurer, or will it be separate? Many companies use Caremark for the prescription coverage, but again they have many different plans. My husband works for 3M, so the health insurance is through a MN insurer who manages the plan, but 3M is “self-insured” and ultimately pays the bills. Our pharmacy coverage is through Caremark, but prescriptions the carry over seamlessly to our deductible and out of pocket as well. When we anticipate needing a prescription, we can do a price check on the Caremark website, and it will show our coverage, including whether we’re still paying toward our deductible, or OOP. We can also check the prices at multiple pharmacies.
We can see what was billed when we look at our explanation of benefits (always higher than what is paid, whether by us or the insurer). The transparency is available, but most people don’t seem to care. Our last prescription filled was “non-formulary” so would have been the highest category for co-pays. After deductible, insurance covers 20% (they cover 80% for formulary). The first month it was billed at $1113, of which insurance paid $222 and the rest was covered by a savings card. The second month the savings card covered $400, leaving us with about $500. That $500 plus the $1300 from the savings card both apply to our OOP (or our deductible if it wasn’t already met). Next month we will most likely pay little to nothing out of pocket, as we are within $500 of our maximum, and the savings card will again cover $400. Previously a pharmacist told us about a savings card for a different medication, and our doctor told us about this one, but they can also be found online. There are ways to save, but it may require a small amount of work. We have it maximum OOP for one daughter each of the past 5 years, some years earlier than others. When it comes time to choose insurance plans (we usually have 3 options). we consider that in our calculations. High deductible works best for us. It also works best for those who don’t utilize it much. The folks in the middle might be better of with managed care or another option.
However, there are some situations where it is difficult to ensure that one gets an in-network provider. For example, when one has a network PPO or HMO, it is not always assured that an in-network facility has only in-network physicians. For example, going to emergency or scheduled procedure at an in-network facility may result in getting an out-of-network anesthesiologist not of your choice and an accompanying surprise large medical bill.
Speaking as someone who lives in an area with a high degree of hospital monopoly and corresponding high health costs, yeah, I do think government should block hospital monopoly formation by acquisition. Every time Sutter Health buys a hospital, they raise prices.
20 states have “balance billing” laws to protect individuals,. These are especially for (but not limited to) emergencies where there are narrow networks. Again, imo it helps to learn where your state stands on this. As we often found in the past, reports by the common media tend to alarm.
State. Not federal. Not “our healthcare system,” but how different states oversee. Or not.
In cases where people get surprise bills from emergency room doctors, usually it’s not a matter of people having insurance with narrow networks. Rather, usually it’s because the hospital employs emergency room doctors who do not participate in any insurance networks at all. The surprise bills are a scam that should be outlawed in every state.
That’s not necessarily true. Our insurer, Aetna, has preferred providers. So we have to get an annual MRI done. The Dr.'s office does it for $2,500. The preferred provider, with a nicer facility – $500.
The whole hospital model needs to change. We have been lucky in that all the providers we have seen are still “in network.” But I can see where more and more will elect to not sign up and send big bills to unsuspecting patients. What really sucks is getting 5 or 6 bills for one visit.
DD went to the ER for an emergency. She was admitted to the hospital less than 30 hours later.
The surgeon who admitted her said they should never have let her leave the hospital.
Our insurance waived the ER copay if admitted within 24 hours. We disputed the charge and the insurance company waived it.
The ER doc, it turned out, was not a participating doc in our plan. I very politely called the insurance company (my policy and I had DDs permission to chat) and said “when you are in the ER, are you supposed to ask the doctor in your cubby whether they participate in your insurance plan? And if they don’t…do you ask for a different doctor?” Company decided I was right and waived the out of network charges.
You know…there is a lack of common sense in some of this. I mean really…in the ER…are you supposed to ask the doc if they take your insurance plan? Most docs wouldn’t know anyway.
But back to RX coverage…I’m still trying to figure out why my generic copay is $5, but I had one generic for $3 and change and another for $6 and change. That makes no sense.
Another ER scam is insurers not paying claims for ER visits if the diagnosis was something benign. This is ridiculous. Patients are not doctors; we can’t diagnose ourselves.
I once went to the ER late at night for chest pains. Turns out I had some random benign stress-related thing that went away soon, but the cardiologist emphasized that I was right to call 911. I’ve never had a heart attack. How am I supposed to tell the difference between extreme chest pain that is a heart attack and extreme chest pain that isn’t a heart attack?
I still remember having a big battle with my insurer. We were at an in-network med center for my S to get an in network procedure performed. Unbeknownst to us a Non-participating pediatric anesthesiologist assisted. We got a big bill from them. Eventually we were able to get insurer to cover but sheesh!
Maryland is one of those 20 states, but must have adopted that policy fairly recently. I got nailed by a non-network hospitalist when I was in a PPO network hospital for my cardiac arrest. Tried negotiating and got nowhere. This is good info to know!
Well…my state of residence and where my insurance was held…and the state where my kid had the ER doc who wasn’t in network…are both on the comprehensive list. Maybe that’s why the ER out of network doc issue was solved so easily (CA and CT).
Um, not the millions of us who have been self-insured (the self-employed, for example) or uninsured.
Since we spent over a decade in that situation, I became very aware of how completely uncomprehending people who had always had some kind of standard plan through an employer were.
When I see someone say they have a “high” deductible, and it turns out to be $1,500-2,500 or the like, I laugh. We used to have a deductible of $15,000 per person per year. Even recently, under a good corporate health plan, we had to have a deductible of $5k in order to be allowed to have an HSA. At least they have changed things so that it is no longer “use it or lose it” annually. That was ridiculous.
H is extremely adept at managing this stuff and negotiating with providers. He’s had years of practice. One thing which many people don’t realize is that if you have a lot of medical expenses that would exhaust your HSA, for example, you can arrange monthly payment plans with virtually any provider to stretch out the cost over time so that you can continue to cover it with your HSA.
Last month Cigna called me to inform me that my scheduled CT scans were through an out-of-network provider, and that although we had fulfilled the in-network deductible and out of pocket, we had not fulfilled the out of network out of pocket, only the deductible. So they said the provider could charge us for the difference between what they would pay and what we were billed, and they had no control over it. They were actually very helpful in helping me get set up quickly with another local radiology provider. I was grateful, especially as it would like not have cost THEM any money. (Ironically, the OON radiology provider was with my oncologist’s practice! Go figure.) It would never have occured to me to question this in advance.
I used to do that, but now our choices are so limited I don’t need to. I even contacted a health insurance broker, and she said the plan we were on was the only one that made sense.
I’m thinking about going to Medi-Share next year after DH is on Medicare. I will gladly forego Rx coverage and pay for preventative care if I’m saving hundreds of dollars every month on premiums. And yes, I understand the limitations of the program - I’ve researched it carefully. I can’t put D on it since she has a pre-existing condition. I’ll keep her on traditional insurance.
The short answer is yes. HDHP plans are good for the employer, but they generally suck if you actually have to use it. Usually the company will put some money into the FSA account to help pay a portion of the ludicrous deductible, but it goes FAST. The idea is for you to put the savings from the lower premiums into the FSA account and use the that to pay for everything. If you’re young and never use insurance, it’s fine. There’s over the counter medicines that can treat acid reflux.
There is a separate type of pre-tax account for medical costs (flexible spending account or FSA) that is “use it or lose it”. The HSA that is not “use it or lose it” is associated with higher deductible insurance plans but the FSA, when available, is not tied to having a specific insurance plan.
One thing which many people don’t realize is that if you have a lot of medical expenses that would exhaust your HSA, for example, you can arrange monthly payment plans with virtually any provider to stretch out the cost over time so that you can continue to cover it with your HSA.