Why “Covered” Doesn’t Always Mean “Free” in Healthcare

Video Transcript:

Okay, I just got home. I was out at an appointment. It was supposed to be to get some labs done, and I wanted to do this video, even though this is my first video and not exactly what I intended to do as my first video. I didn’t want to forget the experience of this and how I was feeling about it and thinking about it, and so I wanted to do the video pretty spontaneously. I’ve not eaten because this was supposed to be lab work after fasting. It was a morning appointment — like a 10 o’clock in the morning appointment — and the idea was I’d come home and eat something, and I haven’t yet, so I’m gonna try to keep it together. Haven’t had coffee. Just water.

Anyway, so the deal is this: I went to this lab. I wanted to talk mainly about the [medical] insurance aspect of things because I think that insurance comes up for a lot of people, certainly when they’re coming to seek my services, since I’m not in network with insurance companies, and that’s something I’m going to talk about in greater detail at another time. But also, when we go to any kind of an appointment, and we do have insurance, and if they are in network. And what that means is they have agreed that they work together, basically, and that there’s a contract between them, and the insurance company basically determines what kind of amounts they’re going to pay for certain sorts of services.

So in my case, this was a lab, and with labs, the services are specific to what kind of information they’re looking to get. When they draw your blood, they charge for that, and then when they run the blood through different tests or spit or whatever, then they are going to charge for that. And it depends on the test. So the deal was my new primary care physician that I found and would like to use sent an order to this lab company. I don’t see the order, and that’s pretty typical, I think, that we don’t see the order that’s going in. Then I contact the lab company and set up an appointment at a particular location that’s accessible to me.

So they’ve got the order and I have the appointment and I showed up today to this appointment, and — this was actually really helpful, they don’t always do this — they showed me what tests they were running and what the expected costs were. This is the case of many doctor visits or procedures or things like that, that they can tell what it is likely to cost. If they’re in network and they have the procedures that they’re going to do, and they have an agreement with your insurance company about what they’re going to do, and they already have some idea of probably what what they know what they’re going to get paid, and they can guess based on your deductible — because they can look that up too — what you will probably owe. It’s the difference between what the insurance says that they will pay for that particular procedure, and what they still want to make, and what they’re allowed to charge, basically, because the insurance also dictates that what they’re allowed to charge.

So there’s usually a difference, and that’s where deductibles come in, and we’ll talk about that again at another time. But the point is, there’s usually going to be some kind of difference. If you have not met your deductible, there’s going to be something that the insurance company says, “Okay, doctor, lab, whatever. You’re allowed to charge this much. We are going to probably cover this much, and there’s a gap, and so the patient makes up that gap.” I hope I’m making sense. Again, I haven’t had anything to eat, and I just got in.

So I go in, and a lot of times they don’t tell you ahead of time before a procedure or a lab draw or any of those things happen before they actually perform the service. They don’t always tell you what those gaps are, what that amount is that you’re going to owe, because they don’t have to. And so this was the thing I actually wanted to bring up. It’s this thing called, well, there’s the Good Faith Estimate, which is part of the act that [the name of] is eluding me right now. [It’s referred to as the “No Surprises Act.”] And there was an act that was passed that allowed people who are not using their insurance to get an estimate. In fact, it required it.

So when I see people, I have to give them a Good Faith Estimate for what their services are going to cost because they’re paying out of pocket, and that makes sense. They need to know, “How much is this going to cost me, because I’m on the hook for all of it.” But what didn’t happen is that there is not a requirement to tell people who are using their insurance how much these things are going to cost, and so this lab didn’t have to do this, but they did, and I appreciated it because what it amounted to when there was a sum total was actually hundreds of dollars. And, so, maybe for some people that’s not a big deal, but for me to make household kinds of decisions like that for hundreds of dollars, spur of the moment, just before they’re going to draw my blood, I had to say no. So I actually walked out of there, and I really appreciated that they did show me what my costs were liable to be.

But it would have really been helpful is if I’d known a long time ago, at the very beginning, what kind of labs were going to be run. Then I could contact my insurance company and say, “Okay, insurance company, you know what I’m going to be on the hook for. If whether maybe this isn’t even covered at all, but you have an agreement that they can only charge me, you know, $35 for this particular kind of a lab.” And so they could tell me, at the very least, they could tell me whether they were going to cover any of it for that specific kind of lab, and if if they’re not, what the agreed upon amount would be, so that I could then do the math, or they could help me do the math and figure out, for this lab visit, what all these tests are going to end up costing.

So I guess I’m just bringing that up first of all, so you can be informed and think about, when you’re going in to see a doctor, much of the time we know what our copay is. And if it’s a visit to a primary care physician, then probably it’s going to be the same every time because we have a copay for that. If it’s a specialist visit, a lot of times with insurance, specialist visits are the same every time, and it doesn’t really matter what the specialist is doing. It just matters that it’s, if it’s an office visit, then you have a copay for a certain amount to see a specialist. And then after that, anything that’s, like, a hospital procedure, an ER visit, an urgent care visit, possibly any kind of a surgery, obviously those things have different costs associated with them. And it’s not just a one-fee thing based on “Oh, this is this such-and-such a surgery.” There are lots of other doctors in the room, some of whom might not even be covered by your insurance.

So there are lots of questions to ask before you go for a visit, and the point is, you if you’re covered by insurance, they don’t have an obligation to tell you what this is going to cost. If you ask, they will give you a ballpark figure, which is liable to be pretty close, but they are not required to say the way that I’m required to say. If you’re using insurance, then they don’t have to tell you exactly how much it’s going to cost.

And so, I’ve actually had the experience of having a thing done, or sometimes it’s if it’s an ER visit, then there’s really not time sometimes to think about this. But you just go and you do it, and then you get a bill later because — and it could be a while, like a month or maybe six weeks — before your insurance works it out with the provider, what the ultimate cost is going to be, and that gets hashed out between them.

And there are times when providers will send in their people and to the insurance company and say, “Hey, we actually need more money for this thing than we agreed we were gonna get.” And so I’m using really non-legal terms, and I’m not a lawyer, and I don’t do insurance law, so there’s probably some fault with some of what I’m saying But the gist of it is that, if you have something done, sometimes they can go back and appeal that they want more money. And really what they’re saying to the insurance company is, “We want you to agree that your member, our patient, is going to pay us more,” because the insurance company is not likely to pony up if they agree. And so you’ve got people advocating based on what they want, and you end up footing the bill.

So that’s the state of our insurance, at least some piece of it, as it stands today, and that is what I experienced today. There’s no way for me to know ahead of time, or it’s harder for me to know ahead of time, what I’m walking into, and so I walked out. And I’m just gonna have to call my doctor and find out if these tests are absolutely necessary. I am gonna call my insurance company, now that I have a list of what we were going to be doing, and say, “Here are all the things. How much is that going to cost really for me?” And then I’ll make the appointment or not.

So that’s that’s that’s my first video. It’s a little crazy. I think it’s probably fitting that I’m trying to be honest and real, and so here I am. So you guys take care of you. Talk to you later.