The Big Money

When your body starts doing weird, scary and painful things, paying for care is the last thing on your mind. Or at least it was for me – I was more concerned with actually getting treatment, which was difficult enough. It’s not that I didn’t think about it at all – at $100 for emergency department visits, $50 for urgent care visits and $10 for generic prescriptions, the co-pays were draining the family bank account. Once I was actually diagnosed and treatment began, though, I can honestly say I didn’t care about the costs. It was working and that was all that mattered. I didn’t know how my medical insurance worked or what other benefits were available.

It turned out that I was pretty lucky. My employer-provided health insurance has a $1000 per-person deductible, after which everything is covered 100% (not including co-pays). The explanation of benefits statements that I received, though, were pretty shocking. I tweeted a few weeks ago that I had racked up $700k in medical claims in the last three months. Since all of my care came from in-network providers, the insurance company only paid a fraction of the amounts claimed by each provider. Keep in mind that I spent 37 days in the hospital and rehab.

Medical claims, to date: $703,509.90

Total paid by carrier after member discount applied, to date: $84,904.21

Amount I have paid, or will pay, in co-pays and meeting my deductible: $2,081.30

Pharmacy claims, to date: $1,493.14

Pharmacy claims paid by carrier: $1,203.62

Pharmacy co-pays: $335.60

There is one little hiccup, though. The rehab hospital where I spent 15 days rebuilding strength and learning to use a walker is an in-network provider for rehabilitation services. Apparently, though, they are out of network as a hospital. I was assured that my stay would be covered 100%; now my insurance carrier wants to leave me holding the bag for nearly $17k in hospital fees. This is currently under review.

I was also extremely lucky that my employer, and my position, allowed me to work from home, the hospital and the rehab facility once I used up my vacation time. We have no paid sick time, like most private sector companies. So even if I had any money leftover after paying my deductibles and co-pays, I couldn’t go on vacation since all my time was used up trying not to die.

The point is, if I didn’t have insurance, I’d either have over $700k in medical bills or I would not have received treatment that I needed for a condition I had no way of avoiding. If my insurance plan had been one of those that only covered 80%, I would have been left with close to $140k to pay out of pocket, which is more than the price of my first house. Either way, I’d have been left with an insurmountable bill, leaving me little choice but bankruptcy. This is the tightrope we walk in the United States; getting sick or hurt means financial ruin. We don’t have the best health care in the world, just the most expensive.

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