You go to the doctor because you are concerned that you have a major medical issue. They perform a test and tell you to wait a week or so and you will find out the results. You wait, and wait, and wait and finally after 2 weeks you are told that you are completely negative.
And then a week later you get an email that you have a new insurance claim. So you log in and see an EOB for $2500.
Tears and anger ensue.
It turns out that the even though your doctor was in-network with your insurance that they lab they sent your test to was out-of-network. A lot of phone tag later you still have no idea what you are going to have to pay but the lab tells you that it won't be the whole bill.
Thanks... so you will owe somewhere between $0 - $2499. That makes you feel better.
The negative test and celebration turn so quickly into frustration, anger, and a bitter taste that you are being taken advantage of in some way.
This is mine and my wife's experience recently. We love her doctor and yet we are annoyed with them for a variety of reasons. I feel I have an excellent understanding of insurance compared to the average person since I deal with patient's every day and (unfortunately) modify my plans of care because of insurance limitations.
What should have happened:
- We should have known before hand whether the lab was out of network (burying which lab you use into paperwork given on the day of service does not count). The clinic doesn't have to look it up for us, that is what the insurance companies have search for on their own website.
- We should know what an out-of-network clinic wants to collect total for their services. I understand that you generally bill insurance a lot because reimbursement goes down every year (trust me, physical therapists are hit hard by this) but that max is not what you expect to get. Do they want $2500? maybe $1000? Do they have a max that they will make a patient pay?
- They should have made sure to emphasize that the EOB is not a bill, even though we already know that, due to being out-of-network and expectations of not charging fully.
Healthcare has many major issues. One of which is that really does anyone know what they are going to pay. And providers barely know any better what they are going to be paid. It is a mystery on all sides. Out-of-network facilities have an advantage in that they don't have to follow anything that an insurance provider generally contracts with providers for. But it is still a large mystery which can increase stress unnecessarily and force medical decisions based entirely on an unknown amount of money.
Providers need to do a better job of informing their patient's about what can possibly happen with their insurance and what they could possibly owe. It should be on the patient to do a lot of the research themselves, but a patient can't do any research if the information they are given is crap or they get no real information in the first place.
People need to feel empowered by the medical process, not beaten down because they don't know what is going on or what is going to happen next or how much they are going to have to pay.
Photo attribution: Peter Alfred Hess