The View From Your Sickbed II

A READER FROM SULLIVAN'S BLOG:
11 Aug 2009 11:09 am

The View From Your Sickbed
A reader writes:

A comment from this reader finally got me to write out my experience.

“To me, the worst part of the American health care financing system is that you can't tell what your treatment will cost.”

Amen to that. I am a graduate student at a large state school in Illinois. My wife and I wanted to start our family before graduating. Her biological clock was ticking, so she said. The first thing we did in planning was look into health insurance. The school provides insurance to its students at a low, subsidized rate. However, if a student wants to add a spouse, the rate jumps to about $1200 per semester (less for a child). Pretty high percentage of a grad student stipend, but at least it would cover a pregnancy within one year of purchasing the policy (nothing else I found would). It is a typical 80/20 plan after deductible. Naively, we thought this meant that after the deductible was met, they would pay 80% of the remaining cost. Not so. They pay 80% of what they call the “usual and customary” charges for whatever procedure you have. Anything over that magical number is completely your responsibility. How do you find out if your hospital/doctor/surgeon will charge you at or below this number? For all intents and purposes - you can’t.

This is how it was explained to me: There is a code for each procedure in every region of the country. And this code is the only way an insurance rep can look up what they deem usual and customary. They cannot look up the procedure name, only the code. So if you really want to know what, say a pregnancy is going to cost, you somehow have to get the hospital/doctor office to tell you what the insurance code is for every possible procedure you may have – a separate one for everything from a simple blood test, to an ultrasound, to a c-section surgery - and then tell you how much that procedure costs. Just imagine how much work this would be for everything associated with even a routine pregnancy. I certainly don’t have that much time to spend on the phone (assuming you can find someone who knows the codes and is able/willing to tell you). Then after all that, you have to call the insurance company and ask them what the usual and customary charges are for the codes and compare that to what you got from the doctor. Of course I have yet to mention that you have to figure out if there is a discount negotiated between your doctor and the insurance company (probably), which changes everything. We really had no idea if the prenatal visits and delivery would end up being thousands of dollars above the usual and customary amount. Maybe a vaginal delivery would be under, but a c-section wouldn’t. You don’t know. And what about emergencies? You’re supposed to do all this after realizing you’re having a heart attack so you know which hospital you should have the ambulance take you to?

Now here’s some irony for you. My wife had to quit working when she was put on bed rest at 28 weeks. This lowered our income enough that we qualified for Illinois’s All Kids program (thank you ex-Governor “Blago”). The entire pregnancy ended up costing us nothing. Now, a year later, we are extremely happy with the All Kids care my wife and son are now on. The money we save on medical costs just about make up for her not working.