Healthcare is F*cked – Part 932

When I wrote the first half of this story, I had no idea exactly how infuriating the second half would be.   For those too lazy to read the earlier post, here’s the cliff notes:

1) I went to the urologist

2) The urologist’s office ordered an ultrasound and booked it for me at the local hospital, which they are a part of.

3) After the ultrasound, the urologist ordered an MRI, at which point I figured I’d better check with my insurance company to make sure I didn’t get crushed on an MRI bill from the wrong facility.

4) I ended up booking the MRI at the imaging center adjacent to the urologist’s office – not at the hospital which is on the other side of the building.

5) The imaging center’s rates with my insurance company – Anthem – are a fraction of the rates charged by the hospital.

6) So I was pissed at a) the urologist’s office for booking my ultrasound at the hospital and b) myself for assuming that the ultrasound would be of similar cost at all in-network providers.   The main lesson I learned – a valuable one – was that there is no “in-network” negotiated rate per procedure: every service provider negotiates their own rate for the procedures, and one should never ever ever get diagnostic work done at the hospital if one can help it.

So, at the conclusion of the first post, I’d mentioned that I’d already had a preliminary discussion with Concord Hospital’s billing department, telling them I wasn’t happy about the situation.  We agreed to discuss it again when all the final numbers came through.

Before I even got the final explanation of benefits (EOB) for the ultrasound itself, I got a confusing EOB from a radiologist for the reading of the ultrasound.  The EOB said that that total charge was $102, the amount allowed by my benefit was $68, and the amount I owed was $102.  Huh?  I have a high deductible healthcare plan – I pay for the first $ 8k out of pocket each year (wife + me) – so I expected to pay the $68.  I called Anthem to find out what was up with the confusing EOB which didn’t say anything about the provider being out-of-network.

“That provider is out-of-network,”  the Anthem rep told me.

Now I went ballistic.  This has nothing to do with the $34 difference here, it’s about the principle and making sure I’m protected in the future – I’ve heard tons of anecdotal stories of people who got reamed in exactly this manner for real sums: multi-thousand dollar bills – from Anesthesiologists at in-network facilities who sent out-of-network bills.

“I went to an in-network doctor, who booked me for a procedure at an in-network facility.  There’s no way I’m paying out-of-network charges on this procedure,”  I explained to the Anthem rep on the phone.

She put me on hold and came back and said that she could adjust it but that it would be a one-time thing.

“No. There’s no “one time” thing about this.  I did nothing wrong. I had absolutely NO control over where the radiology was sent.  If the facility is going to send me out-of-network bills then they can’t get in-network referrals to get me in the door. This is nonsense.”  I wasn’t happy.  She put me on hold again, then came back and said:

“Ok – I’m adjusting it for you, but it’s only this one time.”

“You can keep saying that, but I’m not agreeing to that.  I’m going to call you guys and fight the bill every single time i get an out-of-network bill from an in-network provider.”

I hung up, and Anthem sent me a check, mysteriously for the full $102 (not the $34 balance).

But wait. We’re just getting started.

The rep in the Concord Hospital billing office had told me that they post information online regarding cost estimates for their procedures.  I countered with the point that it was quite obvious that consumers didn’t know the costs – that the same procedure cost a THIRD as much at the facility next door.  No one would voluntarily get the procedure done at the hospital if they were aware of the costs.  Anyway, I looked on their website to see the costs for the renal ultrasound, and I found this:


The first column is what the hospital bills.  I honestly have absolutely NO IDEA what this number represents – as I’ll get to in a minute.   The N/A is a field for facility charge, the 3rd column is the total charge (ps: the radiologist’s fees are additional), and the last column is the uninsured “self-pay” rate.  Ok – so I mentally stopped myself out at the $505 that any idiot walking in off the street without insurance would pay.   New Hampshire has a (weird but good?) rule (RSA 151:12-b) that dictates “uninsured patients receive a discount consistent with amounts received from insurance for the same services.

In other words, if you don’t have insurance, they can’t just bill you a random number – they have to bill you something in line with what insurance reimburses for the same procedure.  This is a great thing for consumers! It almost (*almost*) makes me think about not needing insurance, as I thought the main benefit of insurance was to make sure you don’t get completely hosed by top-line billing rates.   Now then, what is the $842 number that the hospital “bills” ?!?!? It’s just a random number that no one actually pays. No one.  In fact, when I got my EOB from Anthem for the procedure, it informed me that the maximum allowable rate under my benefit was $672, which was what I owed – and then things started to make sense in a perverse way – but we’ll get to that in a second.

So Concord Hospital sends me a bill for $672.  This is the the rate my insurance company -the largest insurance company in NH, and the sole provider of individual plans until recently – has managed to negotiate using their mighty heft and market position  (sarcasm alert).  Needless to say, I called CH billing.

“Hi – for some reason my insurance company has managed to not-negotiate a rate for me that is worse than the rate you guys give any random person walking in off the street.  I’ll just pay the $505.”

I was talking to the same billing rep I’d talked with briefly a month before about this issue.

“Sorry, you have insurance, and your insurance rate is $672.”

me: “Um – yeah – so I’m gonna go ahead and NOT use my insurance.  Don’t bill it through my insurance.”

her: “We can’t do that.”

me: “Of course you can do that – I never even gave you my insurance information anyway: you just used what you had on file.”

her: “We DON’T do that – you have insurance, we know that from prior care,  we bill the insurance.”

me: “That’s not how insurance works. The holder of insurance doesn’t have to use his insurance policy.”

her after another 5 minutes of “arguing” with me: “Look, I’ll give you the $505 rate, but this isn’t how we do things going forward.”

me: “I want you to understand that I will fight the healthcare system every single time I feel like I’m being screwed over,” and then I went into the whole additional clusterfuck of the out-of-network billing for the radiologist, which I also took up with Concord Hospital’s customer service department.

Now let’s get back to that perverse logic of the top-line $842 billing numbers that no one pays: my *guess* is that the only reason they exist is to anchor crappy insurance companies into negotiating higher rates.  What confuses me is that Anthem should certainly have all the information they need about common reimbursement rates for renal ultrasounds.  They can even see on Concord Hospital’s public web page that the “typical” rate is $505.    Somehow, though, they still manage to negotiate a rate of $672 for me.

Earlier in this post, I listed the number of screw-ups in this medical diagnostic process:

a) the urologist’s office booked me at the hospital, when they should have booked me at the Imaging Center for a fraction of the price.  Needless to say, I mentioned this to them.

b) I was ignorant of the different prices and learned a valuable lesson.

but the subsequent explanation of benefits gave me a few more total “ARE YOU F*CKING KIDDING ME?” items to add to the list.

c) the in-network hospital used an out-of-network radiologist and couldn’t explain why.  Keep in mind that my insurance company is far and away the largest in the state.  I would have been much *much* better off in this whole process if Anthem had just told me Concord Hospital was not an in-network provider:  I would have gone next door and payed $300 all-in for the procedure, including the radiologist’s fee, and not had to waste 10 hours on the phone.

d) my insurance company somehow managed to “negotiate” a rate for this procedure for me which was 30% higher than the rate someone with no insurance would receive.   I can’t even explain this. It boggles my mind and infuriates me.

e) the Hospital didn’t seem to understand that I feel entitled to the lower of 1) their “random uninsured guy” rate and 2) my insurance company’s negotiated rate.  Am I in the wrong here?  I’d be shocked if someone could convince me that I’m being unreasonable about this one.

And that, my dear readers, is why I can confidently declare that our healthcare system is indeed fucked.

I am actually working with the NH House of Representatives to get a bill passed which would require all providers at in-network facilities to accept in-network reimbursement rates, but I’m told that it will be heavily lobbied against…

As always, your anecdotes are welcome in the comments – as are your defenses of the way the system worked in this case: if you have any…


My prior posts about health insurance



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