Americans - Have you had a hospital stay or expensive treatment with health insurance?

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cloudeleven
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Joined: Sun Sep 11, 2011 8:17 pm
Location: USA

Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by cloudeleven »

I'm 41. Thankfully I'm currently healthy and have never had a hospital stay or expensive treatment, but I was wondering about Americans here who have and had health insurance (not Medicaid or other govt program), especially in ACA era (since 2010). How much out of pocket did you end up owing and paying? Any nightmare stories?

I'm pretty scared of healthcare, even just visiting a specialist office for some tests, because of the potential for astronomical bills, even though I have an ACA Silver plan. The only thing I'm comfortable with is my annual physical with my PCP. Although I could easily cover the $1,575 out-of-pocket max (in-network...out of network is $12k!) of my current ACA plan. But there's always the potential for denials, "prior approval required" denials, uncovered stuff, incorrect bills (90% of hospital bills have errors), etc.

A nightmare story like this has me concerned (occurred in 2012. ACA went into effect in 2010, but I'm not sure if it helped her situation or not, seems like it didn't):

https://www.huffpost.com/entry/your-mon ... _b_8926910

She was 39 and had Texas BCBS health insurance which denied coverage of the $60,000 drug her doctors said she needed for survival, and she was totally denied treatment by the hospital with the drug until she paid for the drug upfront. They wouldn't even allow a payment plan. Even the pharma company wouldn't help her. She paid the full $61,131 by having to sell some of her property. They charged her more than 3x what they would charge an insurance company.

The only state that has medical price anti-gouging laws is Maryland that I'm aware of.

M
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Joined: Wed Sep 29, 2010 7:34 pm

Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by M »

Yes - healthcare in America scares me also. My wife went to the hospital just to have something checked out which turned out to be a non-issue. It was a one hour stay and cost 5k out of pocket, with employer health insurance. The insurance paid the rest. This was just for basic bloodwork, an ultrasound, and one hour stay in ER. Maybe I should start investing in hospitals.

Of course - I also know a ton of people on Medicaid who have had helicopter rides, open heart surgeries, cancer treatment, broken legs fixed up, all paid 100% by Medicaid with no issues. Sometimes I wonder if taking care of your body + Medicaid is the answer in America.

prudentelo
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Joined: Sat Jan 22, 2022 8:55 am

Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by prudentelo »

For major treatment/large bill, significant attribute of US health plan is "out of pocket maximum".

Co-pay does not matter (bill will be huge, and inflated, giving huge co-pay anyway). In network/out network matters less than should (you can go to in network hospital and get billed by one out network doctor who never spoke to you and "treated" you without knowledge or informed consent)

Unconditional out of pocket maximum is only protection against non-contractual bill at non-market price

edit:

In fairness to US, expensive cancer out-of-plan drug is usually not "pay and live or save and die" but "pay and 1% higher chance to live". It's a sort of blackmail because dying people dont think in such terms, but society generally better not paying. Single payer systems make such decision for you without telling you about alternative, which is kinder, but outcome is usually not different.

recal
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Joined: Sun Nov 14, 2021 12:29 pm

Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by recal »

prudent is right. Deductibles matter for routine care, out of pocket maxes matter for hospital stays and outpatient treatments.

California has the strongest consumer rights laws in the nation with regards to this, which is a big reason why I choose to stay here.

Know the laws and know that you can fight both the insurance and the hospital about your rights.

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Sclass
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Location: Orange County, CA

Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by Sclass »

cloudeleven wrote:
Tue Aug 30, 2022 9:51 am
How much out of pocket did you end up owing and paying? Any nightmare stories?
I had an open heart surgery in 2010. It was before ACA. I was insured through my employer. I didn’t pay more than $500 if I recall. The insurance paid for everything. The long story is quite a quirk, I think I should have paid a few thousand given the operation being about $300,000. But I never received a bill or EOB. There was some kind of record keeping debacle. Even my doctors were confused whether I actually had surgery or not. My surgeon knew of course. So did my specialist who happened to be a neighbor. But according to the provider’s current records I was diagnosed as very sick in 2009 and then nothing happened after that. Bottom line, I didn’t pay for it. This is a quirk and I think it was either due to 1) really bad billing, 2) the provider trying to avoid malpractice since my PCP had clearly botched his diagnosis for over a year. During the crisis my PCP got transferred across the organization and I never saw him again.

Looking back at all this I guess my advice is not to worry too much. I was told to get my affairs in order in 2010. Losing all my money was not even an issue at that point. There were points at the last moment where I would have given everything to survive. I realize now I’d eventually rebuild my nest egg the same way I’d done so before. It’d be faster because I knew how to do it. But death? Game over dude. I had to face that and it was really awful. Talk about changing of perspective.
Last edited by Sclass on Sun Sep 11, 2022 11:54 pm, edited 1 time in total.

shaz
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Location: Colorado, US

Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by shaz »

Over the past several years I have undergone extensive cancer treatment that took me to my OOP max each year, about $10k total. On top of that I have another $20k in bills that I am disputing with the insurance company. These are for procedures that were pre-authorized and I had every reason to expect would be covered but now the insurance company is denying that they were pre-authorized even though I have the actual physical letters they sent with the pre-authorization. This dispute has gone on for almost 2 years now. It is very stressful. I don't know what I could have done to avoid the mess aside from not getting sick in the first place. My doctors say I had no risk factors that I could have controlled so not getting sick also seems to have been out of my control.

7Wannabe5
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Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by 7Wannabe5 »

@Sclass:

My friend who was worth north of $100 million applied for reduced cost for one of his cancer drugs and was approved! The system is totally whack-a-doodles.

@OP:

For better or worse, I very recently (just last week)started a very expensive drug treatment for a serious chronic condition, and it appears to be working (Yay, health! Boo, finances!) So, I am currently stuck on Medicaid cliff with likely $10,000 annual out of pocket (one way or the other) if I increase my income to ACA level or acquire middling quality employer insurance, unless/until I make leap to very good employer provided insurance or Medicare (which I will qualify for in 7.5 years.) I have little difficulty living on Medicaid qualifying expense/spending level, but I find earning less than Medicaid monthly max (approximately $1450 in my state) to be somewhat confining, especially now that I am starting to feel better(fingers crossed!)

jim234
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Joined: Tue Aug 04, 2015 6:46 pm

Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by jim234 »

My plan has a $200 max out of pocket and no Provider can legally bill me. NY Medicaid.

cloudeleven
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Joined: Sun Sep 11, 2011 8:17 pm
Location: USA

Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by cloudeleven »

Thanks for the replies so far. I'm just trying to get an idea of how common it is for folks to be billed more than their annual out-of-pocket max. I'm currently on an ACA silver plan, and the possibility of being billed way more than the OOP max (like the story below) due to claim denials, prior-authorization problems, uncovered stuff (yet medically necessary), etc. is one thing that kinda worries me. :( The health insurance & billing system sucks and is broken.

The ACA and the No Surprises Act (banning out-of-network charges at in-network facilities and out-of-network charges at all ERs) this year are a step in the right direction though.
shaz wrote:
Wed Aug 31, 2022 11:12 pm
Over the past several years I have undergone extensive cancer treatment that took me to my OOP max each year, about $10k total. On top of that I have another $20k in bills that I am disputing with the insurance company. These are for procedures that were pre-authorized and I had every reason to expect would be covered but now the insurance company is denying that they were pre-authorized even though I have the actual physical letters they sent with the pre-authorization. This dispute has gone on for almost 2 years now. It is very stressful. I don't know what I could have done to avoid the mess aside from not getting sick in the first place. My doctors say I had no risk factors that I could have controlled so not getting sick also seems to have been out of my control.
Sorry to hear. Hope you get better soon and can get the $20k squared away. Which insurance company is this, if you don't mind?

jim234
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Joined: Tue Aug 04, 2015 6:46 pm

Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by jim234 »

Fear mongering, your max OOP is the limit for the year.

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Viktor K
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Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by Viktor K »

what if it’s out of network or not covered by insurance?

Western Red Cedar
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Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by Western Red Cedar »

We've had fairly positive experiences with insurance and medical expenses over the last 10 years. I avoid the HDHP and the option to contribute to an HSA so that I have a better quality plan with lower deductibles and OOP ceilings. An FSA with a better-quality plan works well for our family.

I actually had to take DW to the ER a few weeks ago while we were out of town on a trip. We've only received an explanation of benefits thus far, but the visit was completely covered, except for $140 towards a cat scan. We spent 7 hours in the ER and 2 hours in the waiting room. DW spent four days in the hospital a couple years ago, and our bill was $500 - which was the OOP maximum for an in-network hospitalization. In both cases we made sure to use an in-network hospital.

The main issue we've had is finding specialists, such as therapists with a particular specialization, who will take our insurance and are accepting new patients. I think some of that is a result of the pandemic though and the huge demand for mental health services. In general, the medical staff are great, but it was a huge learning curve for DW to figure out how to navigate the authorization and billing process to make sure our insurance covered a therapist specializing in EMDR.

Scott 2
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Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by Scott 2 »

I've been learning to use the medical system and my insurance over this past year. In general - I find it's possible to get affordable, in network medical care. But, I live in a state with very solid participation on the healthcare exchange.

A problem started over the past few months - the good in-network doctors are booked. My physical had to be scheduled 3.5 months ahead of time. My wife had another doctor - it was almost 7 months to her next appointment. So you're left with the choice - do I wait, or do I gamble on the recent grad?

I think this is an area where money can help. Some better doctors are opting out of insurance. When I was looking at oral surgeons, the top two options were out of network. One doesn't even bill insurance. They give you the information needed to get reimbursed. Some doctors are also starting to opt out of original Medicare, which presents another set of risks.

The last company I worked at was in the insurance industry. They let retirees remain on the high end corporate medical plan. Why would you want that instead of Medicare? Well, doctors opting out is why. Everything was out of network, premiums were high, but the max out of pocket was very reasonable. If you can afford it, that probably provides a more premium healthcare experience. Anyone making it to retirement age with that company, could afford it.

WFJ
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Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by WFJ »

Yes, usually had to pay a copay plus $1,000 out of pocket. These ranged from, melanoma several visits and procedures ($200) suspected heart attack ($1000), false appendicitis ($1000), serious car accident with major surgeries ($2000), appendicitis's ($2500), emergency room death ($1000). Main risk in the US is if you develop a condition that is rare, long-lasting and has new therapy, which will usually be expensive to subsidize all the failed therapies that an insurance company may or may not cover. Staying healthy is the only way to mitigate this risk.

prudentelo
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Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by prudentelo »

In-network is far less important than believed. First you do not know what the network is like until too late. Second, ""in network"" can suddenly and retroactively become ""out of network"" with no recourse to ordinary protections against speculative invoicing.

Biscuits and Gravy
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Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by Biscuits and Gravy »

DD spent 24 hours in ER + 3 days in PICU due to a URI and severe asthma attack and my insurance was billed $34,019. They negotiated it down to $21,432. My out of pocket was $175, so I guess my experience really isn’t to your point, and I’m glad it’s not. My employer offers over a dozen insurance plans, and—as a parent of young, accident-prone children—I opt for the plan that caps ER visits and hospitalizations versus making me pay a percentage. I am so glad I didn’t have to worry about the healthcare cost on top of DD’s life. All that peace of mind costs me is my continued enslavement to the Man. I would say “luckily the hospital was in network,” but I had confirmed long ago that it was. Holding a limp, unresponsive four year old in your arms, the furthest thing from your mind should be “huh is that hospital in my network?”

BWarrior
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Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by BWarrior »

Hi Biscuits & Gravy and all,
My husband & I have a silver plan through the ACA and our insurance has covered my cancer surgery & treatment 5 1/2 years ago, my husband's heart attack & treatment 4 years ago, and quite a bit in between. We have Blue Cross/Blue Shield. We have reached our out of pocket maximum 4 of the past 5 years (I think) and insurance covered everything after that without any fights. I'm sure this depends on what insurance company you have but we have been pleased with our coverage.
BWarrior

Hristo Botev
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Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by Hristo Botev »

FWIW, the only reason DW continues to work is for the health insurance. She works 1 day/week at the hospital which means that we pretty much break even once her premium, the HSA contribution, and the (small) 403b contribution are taken out. Seems nuts, but it is what it is, as my FIL says. I hate that healthcare makes it so difficult to start and run a small business; most everyone I know who does so is only able to do so because they have healthcare taken care of through their spouse's job.

I've personally had two massively expensive healthcare stays: 1 for a near fatal bike accident in 2018 that left me as a guest at a level 1 trauma facility for a couple weeks (a hospital that was thankfully owned by DW's prior employer); and a second 2-week stay at DW's hospital in late 2019 with a head-scratchingly bad case of (COVID?) pneumonia that had me hooked up to a breathing machine and almost sent me "across the river." Both stays were somewhere between 1/4 and 1/2 million in cost each, after being negotiated down by the insurance company (I think); we just paid our high deductible out of pocket, however; so, yeah for us.

IlliniDave
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Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by IlliniDave »

Viktor K wrote:
Wed Sep 07, 2022 11:16 am
what if it’s out of network or not covered by insurance?
My plan has OOP maxes for in-network and out-of-network, out-of-network being somewhat higher. Something not covered presumably you are 100% responsible for.

shaz
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Location: Colorado, US

Re: Americans - Have you had a hospital stay or expensive treatment with health insurance?

Post by shaz »

Update on my previous post - someone on this forum explained how to report my insurance company to our state regulatory agency and pretty much immediately everything over my OOP max was cleared up.

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