For the past five years, our family used Samaritan Ministries, a healthcare sharing ministry (HSM), which provides generous, affordable coverage for healthcare needs. I've shared several stories about how an HSM provided for ER trips, surgeries, and childbirth. Due to national increasing health costs, our monthly HSM contribution increased 40% over five years, similar to many families' experiences with health insurance premiums.*
We decided to transition from an HSM to an employer-sponsored plan, based on the financial impact of three possible health outcomes: 1. No problems, 2. Maternity, and 3. Catastrophic event. With Wally's employer's contribution, traditional health insurance was slightly less expensive for each of these scenarios.
One feature of the Affordable Care Act that most appealed to me was free preventative care. I happily called doctors at the end of December to schedule 2017 wellness check-ups for both Wally and me.
When Wally visited his doctor, the receptionist told him it would be charged as a "new patient" appointment, instead of a "wellness" check-up.
The office charged us $136 up front.
Wally's doctor did a physical, said he looked good, and drew blood for basic lab work.
We received a bill from the lab for $54.49.
When I visited my doctor, there was no fee for the appointment; I received a physical, and the nurse did some lab work.
I received a bill from the lab for $8.66.
When I called the insurance company to ask about how preventive care billing works, they pulled up each of the claims for review.
For Wally's appointment, the doctor's office had billed insurance $250 for a "wellness" check-up, despite charging us $136 for a "new patient" appointment. By double-billing, the doctor's office collected full payment from both parties.
There was no record of our $136 payment in any part of the claim, and it hadn't been applied toward our annual deductible. Once the insurance company realized what happened, they reached out to the doctor's office on our behalf to secure a refund. Insurance has called the office several times and sent a letter, yet no refund has been issued. (I'll update this post if/when the refund occurs.)
|Nowhere is the "new patient" appointment fee of $136 recorded.|
When I asked about Wally's lab work, done as part of the wellness check-up, the insurance rep said none of it was covered as preventive care.
She also mentioned that many of the tests -- from cholesterol to Vitamin D screening to everything in between -- were categorized as "preventive" care prior to the Affordable Care Act. However, once the ACA made preventive care no cost to patients, these basic tests were re-coded as "diagnostic" care.
So we are responsible for $54.49 in lab tests from Wally's wellness appointment. Still, I'm grateful for the 90% insurance discount. As a previous self-pay patient, I can verify that no amount of negotiation will convince labs to discount uninsured bills more than 30%. Most labs would only offer a 20% discount, if paid in full.
Given that insurance paid $0 toward Wally's lab work, I didn't expect them to cover my lab bill for $8.66. But I'm glad I asked about it, because somehow, in the convoluted world of health insurance (which sometimes, possibly might lead to healthcare), the same customer service rep who denied Wally's lab work as "diagnostic" confirmed my lab work as covered 100%.
Interestingly, when the lab that processed my test wasn't satisfied with the payment given by insurance, they just sent a balance of the bill directly to me -- instead of negotiating with insurance. I have no doubt that many patients shrug and pay the difference, probably because they value their time and sanity more highly than repetitive phone calls and emails with customer service departments. (I do not.)
So insurance cut a check to the lab for $8.66 and zero'd out my balance due on the claim.
1. If you're expecting free preventive care, keep a side fund to pay unanticipated costs.
2. If you get bills from your medical providers, always double-check with insurance, because they might not be accurate. Our "wellness" medical costs were cut by 73%, just from a couple of phone calls and emails.
3. If you don't already use your health insurance company's website to track claims, it's worth settin up an online account. It's a great way to track spending toward your deductible, double-check claims, and grow increasingly despondent over the "charged," "negotiated," and "paid" rates that run the insider's club of healthcare in America.
*While our family's increased healthcare premiums and costs are indisputably linked to the increases in regulations, provisions, and coverage mandated by the Affordable Care Act, I remain in favor of comprehensive national healthcare reform. Whether that means fixing "Obamacare," or replacing it, I DO NOT in any way favor repealing the ACA without a viable replacement that continues affordable coverage for the many hardworking Americans with pre-existing health conditions or employers who do not offer health insurance. It is unconscionable that our first world nation has inaccessible healthcare for so many.