In which I learn a little more about insurance

One of my personal summer projects is to tabulate all my healthcare expenses to evaluate just how much all these fertility treatments are costing us. How cheap are certain treatments/tests? Who covers them? How are clinics billing differently? I’d love any suggestions for questions to look into!

All of my day yesterday was in tracking down all my (fertility-related) bills, crossing them with my clinic receipts to see what each procedure/test costs. (Still not done. There’s several expenses that I haven’t been able to figure out what they were). Some of what I learnt is probably obvious to others but was a revelation to me.

Probably the biggest thing I learnt so far is the concept of an ‘adjustment’. Basically amount billed by doctor = amount I pay + amount insurance pays + magic money that no one pays. The magic money is the adjustment. Personally, I’m calling it fake money because it’s money that no one really cares about. The doctor doesn’t get it. The insurance doesn’t pay it. It just magically disappears from the system. Ofc, as my dad said, if you don’t have insurance that number becomes very real money. What irks me about it is the insurance company gets credit for that money. In their statements it’s “money you paid” and “what we took care of”. Umm, no you didn’t. Or did I miss something and magic money comes from.. the government? I’m not sure what other options are.

It’s actually a pretty big amount. Somewhere in the range of 50% of the costs seem to be this magic fake money. Diagram is still preliminary but the pink is the adjustment, purple is what the insurance company shelled out and brown is me. The “prep for cycle” is the birth control pills cost ($0 for me). “Gynec attempts” is the time spent monitoring in the gynec’s office + 1 clomid only cycle. I pay an awful lot for thyroid stuff – that’s because I’m on name brand synthroid because I had a weird reaction to the generic and I still have to deal with all the red tape to get that properly covered. Annuals are free to me. Good – that’s how a system should be designed. I included annual check-ups in this just because some of the testing/immunization was related to fertility.cost_split_by_payer.png

 

As for costs to date:

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Numbers are rounded so the totals might not work anymore 🙂 I’m actually surprised that the ectopic cost so much. After all, that’s an emergency issue that can happen to anyone. Isn’t that exactly what insurances are supposed to cover? We switched plans right before starting the IUI’s at the beginning of the year so some of the difference in coverage is from that. We pretty quickly hit our deductible but are (surprisingly) still well below our Out of Pocket max. Not sure we’ll hit it this year actually, even with an IVF cycle.

The interesting question to me was “How expensive am I to the insurance company?” A priori, I would think I’m an expensive patient – fertility treatments are expensive, aren’t they? But.. actually not so much. So last year, premiums = $1900. Money that insurance company paid out $1750. (Caveat – I only counted fertility expenses — there’s also hubby’s medical costs and a couple of non-fertility related costs for me. But those are pretty small). So.. they made some money off us. Even this year — our YTD premiums are $1600 (more expensive, lower deductible plan). YTD amount that they shelled out ~ $3000. Ok, that’s significant. But let’s not forget that this is employer sponsored so the insurance company is getting our premiums + whatever employer spends on it. Oh and the decade before this when I paid for insurance and barely used anything. So.. overall, even with fertility treatments, I’m actually still a good bet. Even if I missed some details, broadly that conclusion should hold, right?

More to come… I should have prefaced this post with the caveat that I know almost nothing about insurance. And all these are preliminary thoughts.

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4 thoughts on “In which I learn a little more about insurance

  1. You’re missing “employer premium payments” which are 75-90% of the total collected by the company! And yes, it is all mystifying/ kind of scammy.

    Facility fees are not, in fact, double billing in the traditional or illegal sense. They just suck.

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  2. The “magic money” yes. That is the wonders of group insurance. You know how your doctor “accepts” your insurance. That means they have a contract with them, in which they detail out the amounts of magic money that will exist. In network = more patients + less overhead = we can waive some of our jacked up fees.

    Interestingly, we had one brain surgery where the bill was something obscene like $60k – and our insurance paid $78k, because apparently their contract with that department was not so great. We still paid nothing out of pocket, but I was stunned that the magic money could work in the other direction too. (Side note: I realize it’s really strange that i said brain surgery all casual and implied there’s more than one. Which there has.)

    One thing I’ve been seeing a lot of lately (and fighting, too) is “double billing”. I went to see my RE, and they billed for me visiting the doctor, but also a facility fee for the office being in the hospital. They tried to charge me a copay for someone taking my vital signs! Also one doctor’s office here bills a lab visit as a full office visit because the lab is in the building with the office. Very frustrating.

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    1. It just seems like if everyone agrees to remove the magic money, the system would be so much more efficient.

      Oh wow, that’s so weird. I had no idea it works in reverse too! (well, as shitty as it must have been to go through that, I think it’s pretty awesome that you’re able to talk about it casually).

      So far I haven’t noticed any double billing. As far as I can tell, my unknown costs are really just blood tests that either I don’t know the results for or (for instance) initially when they tested _everything_, I have no idea what test matches what amount. But it’s good for me to keep in mind so I’m aware in case double billing happens.

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