Why Is It This Hard?

 

There seems to be a common perception that the way to fix the healthcare system in the US is to get everyone insured. But anyone who has ever had to deal with the health insurance system already knows what an opaque, impenetrable mess it is. What other business would expect you to make purchases without knowing what they were going to cost you? And yet for health insurance we do it all the time.

It is bad enough that costs and prices are top secret, but even if you do try to look into it the system will block you at every turn. In fact, in some cases, a healthcare provider would be violating their contract with an insurer by revealing their prices. The system is so complex and so devoted to secrecy that it is an enormous task to get an answer to the question "What is this going to cost me?" before you see your bill. 

Let me give you just one example that I read about recently. A woman was scheduled for a procedure that was going to require anesthesia. Having read that the use of an out-of-network (for her) provider was one of the most common reasons for large, unexpected charges on a hospital bill, she called her doctor's office to ask about her coverage. The doctor's office did not know the answer and suggested she call the hospital's billing department.

The person at the billing department said it was "impossible" to know, since she only found out about expenses after they had already been incurred. She suggested that she call the anesthesia group directly.

Now the anesthesia group itself was out of network, but some of its doctors were not. But the person she spoke with said that since she did not know which anesthesiologist would be working on the day of the procedure, she could not answer the question and suggested she call her doctor's office and ask "who he usually worked with". Then she could call back and find out if that doctor was in-network. Although there was no guarantee that same doctor would be working that day.

When she called her doctor's office (again) she was told that there was no "preferred" anesthesiologist, they just worked with whoever was on that day. They suggested calling the insurance company directly.

When speaking with the insurance company, she was told that since the hospital itself was in network, if the anesthesiologist turned out not to be, she should "simply" appeal the charge after she got the bill. The company could then reprocess it as an in-network expense.

This might be funny if it was not true... and common. Health insurance is one of the largest expenses that many people have. And yet you don't find out what it really covers until after you use it. We might ask why transparency is so carefully avoided. Why should it require five phone calls to still not know what something is going to cost you? Why should you have to appeal your bill to get the coverage you paid for?

The lesson to take away from this is that when it comes to protecting yourself from unexpected medical bills, you are on your own. Neither you doctors nor your hospital nor your insurer is going to help you much, if they even could. Is this really the insurance system that we want to expand?