Just was thinking about this the other day while looking at my insurance. How do people in the U.S. accumulate huge bills without hitting their max out of pockets? Are cancer treatments not usually covered by insurance? Are the doctors that provide the treatment just happening to be out of network?
I guess I’m wondering if there is anyway I can plan to not be in a situation of me or my husband rejecting treatment and dying or having huge medical bills cripple us. We’re relatively healthy now, but the future is near.
I’d like to understand better how it seems to be so *common* for people to not be covered by their out of pocket max.
Thanks.
In: 4623
Keep in mind that insurance companies are in it for profit, not to help people. [Health insurance providers are reaping simply *massive* profits](https://www.beckerspayer.com/payer/the-house-always-wins-health-systems-face-worst-finances-in-decades-as-payers-rake-in-record-profits.html), and all that profitability comes from maximizing income and minimizing spending. Which means they’re trying to pay as little in benefits as humanly possible.
So if you work for a big company, you might have a decent plan, but you’ll often have to fight your insurer for all sorts of things your providers say is necessary care. If you don’t have insurance from a group plan, you may pay astronomically for shit insurance.
My wife and I (both self employed) dropped from the insurance pool when out premiums (for shit coverage) hit a grand a month. I looked into insurance last year and it would be $1400/month for us (52 & 60, perfect health, non-smokers and no pre-existing conditions) for a pretty crappy plan. My wife injured her hand a while back, severed a nerve and tendons and required an ER visit, micro-surgery and PT, total over a year was about $18K. But we’ve avoided paying something like $40K for premiums, so this time – we’re ahead. next time, who knows.
“For-profit health insurance” is one of the most abysmal phrases in the English language. It’s just another absolutely, blatantly stupid thing we just seem to accept in the US.
I once got a $105k anesthesiologists bill because they were “out of network”
We fought back and said “we picked an in network hospital for this procedure. We assumed everyone here would be in-network. Sounds like someone chose an out of network anesthesiologist hoping to fuck us out of our retirement.”
And then suddenly that doctor was some how in-network.
A significant factor in medical bankruptcy is missed work. Even if your insurance and your HSA cover all your medical bills, if you have a condition that causes you to take significant unpaid time off or causes you to lose your job entirely, you won’t be able to pay your other bills.
We had “good” insurance when my wife became seriously ill.
When you are hospitalized in the US you don’t get one medical bill. You get a bill from the hospital, a bill from the internal medicine physician, a bill from the obgyn physician, a bill from the critical care physician, a bill from the lab, a bill from the radiologist private practice, etc.
The insurance company can and will say that some or all of those bills are not covered for a ton of different reasons that you agreed to when you signed up for the coverage. Those reasons for lack of coverage will change and overlap as you try and fight for them to be covered. The amounts will also change over time as the insurance fights with you and the hospital to pay as little as possible. Some of those bills won’t show up for months. Just trying to keep track of everything to be able to properly fight with the insurance is a nightmare.
And if you can’t convince the insurance that the costs should be covered then they aren’t included out of pocket maximums. Which means you are on the hook for all those dollars.
In the case of serious illness, like my wife’s, that can be hundreds of thousands of dollars. Even when you have “good” insurance.
We managed to get the largest things covered so we didn’t go bankrupt, but it took almost two years, hours of times, oodles of stress and frustration.
After living in the US, the UK, and Canada, I can confidently tell you the US system is terrible. The UK and Canada aren’t perfect – but the US system is terrible.
Ok let’s say someone in the family has a chronic illness. It’s not that first year that bankrupts you. It’s the couple years down the road. My max out of pocket was $7k per year for years In three years you’re $21k down.
The out of pocket maximums are for in network, approved treatments.
And your insurances is going to do everything they can to say your treatment was from an out of network provider or that it wasn’t necessary.
For example, I had open heart surgery because of an aortic aneurysm. It was slowly increasing in size for twenty years and finally had a big jump one year to the next that put it right at the upper edge of where repair surgeries are effective.
The thing about aneurysms is that they’re pretty much fine right up until the moment they aren’t. Then you die very fast. Basically the tissue in the largest artery in my body—the one that comes directly out of the heart and splits off to take blood to your brain and literally everywhere else—was stretching out. You can imagine a slowly inflating balloon as a good analogy. They’re built to stretch some, but eventually it stretches too much and rips apart. You can see why that would be particularly problematic for a major blood vessel.
So my open heart surgery was an emergency, but it was urgent. It was to the point where doctors were worried that it was very likely to rupture, and so in the 3.5 weeks between when I had my routine annual scans and when I actually had surgery, I was severely restricted in what I was allowed to do. Ordinarily, the process of getting all the presurgery tests and measurements and consultations takes a week. I did it in two very long days.
Part of the surgery process is getting pre approval from insurance. Basically, your medical team sends a detailed list of what they plan to do to the insurance, and explain why everything is necessary, and the insurance approves or rejects the plan. I got everything pre approved.
Fast forward a few weeks and the bills start rolling in. And lo and behold, the insurance is rejecting nearly everything. Basically they decided that I didn’t really need the surgery, that I had ELECTED to have a chunk of my heart cut out just for fun, and so they weren’t going to pay.
Strictly speaking, there are only two categories of procedure—emergent and elective. If you aren’t actively dying or in imminent danger of dying, it’s elective. At least, so says my insurance. And they have provisions against covering elective surgeries.
It took—and I kid you not—over a year and a half of at least weekly calls to force them to pay it. The only reason I actually got it to work out in my favor is that my mom has been managing my condition my whole life and has learned how to navigate the process and not take no for an answer. If she had been working full time and nit been able to fight for me, I’d be looking at $500k of medical debt. All because my insurance went back on their pre approval and did their best to weasel out of paying.
So, how do you avoid this? Get everything in writing. Keep all your documents—appointment reminders, bills, procedure dates etc— together and organized. Be prepared to fight back and call your insurance every day. Tell your doctor what’s happening and get their office to help you. But most of all, don’t take no for an answer.
I developed an autoimmune disease a few years ago.
I pay $280 per check to have insurance. My out of of pocket max is $8500.
I’m on year 4 of hitting the out of pocket max each year. $15,220 per year. $60,880 over 4 years. And it’s January 13th. I hit my max at 11:30AM on the 1st.
I make $75,000 per year. That means 20% of my pretax income is for health care. Every year.
If I ever decide to switch employees, I’ll hit my out of pocket max twice that year.
If I lose my job, my monthly treatments are about $14,000. Without them I’ll lose my ability to use my arms properly. My eyes won’t work right. Probably won’t be able to walk. Sure as fuck can’t drive. I don’t think I’d be a top candidate to be hired at a new job.
Long story short, with my medical bills it’s not if I’ll get fucked. It’s when I’m going to be fucked, and how hard.
I get so angry thinking about medical insurance. Both of my parents had excellent insurance and moderate health issues as they got older. They spent so much time and energy arguing with hospitals, clinics, and insurance companies that I’m convinced it shaved years off their lives.
One specific time my dad was in the hospital for 3 days they were overcrowded and his bed was in a hall for all three days. They charged him $3k a day for a room. He fought them on it since he had proof he *wasn’t in a room.* They removed that charge and added a $3200 daily peak occupancy charge, claiming it cost more to be in the hall and thanked him for pointing out the error.
Substandard care and/or treatment apparently costs more money.
Fuck the whole medical insurance industry.
Edit: eli5: they’re not your friends and will fight to find any reason to charge more money, or to keep from paying out money, depending on which side they’re on.
Medical Insurance companies have people on full-time payroll, from development to customer support to legal, to make sure they don’t have to pay for any medical expenses incurred by those who pay them. They make their plans difficult to use, they make their websites difficult to use, they make their claims process difficult to navigate, and they make their EOB impossible to understand. Their literal business model is not covering as much as possible.
I work in health insurance and it’s not unusual to see out of pocket maxes that are $15,000 -$20,000. Not everyone has twenty grand just laying around to cover an unexpected car wreck or cancer. Throw in costs like late fees, interest and the fact that serious health issues tend to keep people from working for long periods of time and you have a perfect storm for financial hardship.
Also, the authorization process is incredibly complicated. It’s very easy to forget to cross a t or dot an i and those mistakes can result in thousands of dollars in medical costs that aren’t covered by insurance.
Lastly, there can be a lot of unrelated costs associated with health issues. Like, a car wreck means you need a new car, equipping your house to accommodate someone who can’t use their legs, specific foods to accommodate special dietary requirements….. those can all cost more and more money.
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