Btw I understand and feel you how rough the hospital is, had 4 little ones each spending several months in the NICU hold on it gets better and the debt will eventually be gone.
Yes, 7% of the US isn't insured, which is a lot, but it's hard to believe they make up 99.9% of healthcare discourse.
Are people genuinely getting $100k in debt, or are they only telling the internet how much the total bill was and forgetting to add that their insurance picked up $94k of that.
Maybe the difference is that it was all "elective" and therefore planned out weeks or months in advance, with ample time for insurance pre-approvals?
I've had a harder time getting reimbursed for psychotherapy than they had getting covered for their surgeries.
However, prior to the No Surprises Act, you could get hit with unlimited costs from out of network providers in the event of an emergency. For example, if an anesthesiologist that was not employed by the hospital put you under, and you get a separate out of network bill from them (but that should not happen since 2022).
I'm not sure if you know how hard a surprise 10-20K bill can be. And some out of pocket maximums are huge (generally, the worse the plan is)
These systems aren’t in place for the people who fight back. They’re in place for the people who give up.
You go in for X. Insurance company defines X as a set of ICD-9 procedure codes for that health care organization, for that treatment for that indication. Not all providers will use all of those codes, usually some subset as the exact treatment may vary across providers under that health care organization. The health care organization instead sends over claims for those ICD-9 procedure codes, plus some other ones that your insurance company feels aren't appropriate for your treatment.
You then get an explanation of benefits from your insurance company, stating that they covered X, Y and Z, but A, B, C, D, E, F and G are your responsibility, because it exceeds the negotiated or "allowable rate" between the insurance company and that health care organization.
Or worse, the whole claim was merely coded incorrectly by the health care organization. Insurance company feels it's then not their obligation, and straight up denies the claim.
A through G is some amount of money that would absolutely crush the average person.
Your insurance company stands behind what they laid out in their statement of benefits for the claim, and won't budge beyond that, saying the rest of the costs are your responsibility. After all, they feel those procedures weren't relevant for the treatment, and it exceeds the negotiated allowance with that health care organization for that treatment. The health care organization's billing department is aggressive, and says since your insurance company won't pay, you need to.
TL;DR: "Balance billing."
-- -----
Here's a case where your child falling off a bicycle and needing stitches could cost you $19,000 if you don't lawyer up: https://wamu.org/story/20/11/25/a-kid-a-minor-bike-accident-...
Entirely unrelated to the specific scenario I laid out is ending up in an out-of-network emergency room. Again, easy to end up with a $20,000 hospital bill for falling off a bicycle because your insurance company says it's not their problem: https://www.vox.com/health-care/2019/1/24/18195686/vox-zucke...
I ended up forking out $58,000 (excluding 10 months of my lost wages fighting it) to attorneys to have a $412,000 balance bill for my mom ultimately withdrawn by a hospital.
When I had back surgery a few years ago, my out of pocket was something like $600. The surgery itself and inpatient was $250k, PT and follow ups went on for a year. For most HMO patients, it would be more like $5000 or more. Stuff like the supportive vest you wear for weeks is typically uncovered, cost $2500. Some plans will only cover PT for a few weeks. Today with a high deductible plans, it’s nutty - my brothers 4 kids got a nasty infection, which required an antibiotic that costs $15. Total cost? $1200 out of pocket for the visits, etc.
For chronic conditions like diabetes, supplies and scripts get expensive quickly. For cancer, if you work for Google or the US Government you’ll get treatment at MD Anderson, Dana Farber, MSK, etc for $0 and get travel reimbursement. If you have a high deductible plan, you’re going to be shelling out $10k or more a year just for the deductible, and may find yourself paying out of pocket for labs, drugs, etc.
But only up to the max out of pocket, right? Once you hit the max out of pocket, you stop paying the 10%.
So while you pay the full burden of the first $1500-$3000, you only pay a percentage of anything after that and not one penny more than your max.
Do you have a link to a real policy like you're talking about?
A few thousand to meet the OOP max shouldn't break you, or at least the government isn't going to cut you a break.
We had a surgery that wasn't completely resolved until about 8 months after the fact after spending 10-15 hours per week on phone calls. The hospital billing told me this was all normal and they usually have to resort to lawyers before stuff gets paid. SOUNDS LIKE EFFICIENCY TO ME! This is just one of a half dozen shitty experiences I've had even with $3k/mo health insurance.
So yeah, in my experience it sucks even if you are insured. The whole system is a dumbass way to do things and a huge waste of fucking time.
For "covered" expenses. Have to go out of network for a specialist? Not covered. The insurance company considers the life-saving procedure you need "experimental"? Not covered. The insurance company rejects the optimal treatment for your injury, disease or malady as being not necessary? Not covered.
Max out of pocket doesn't mean what the insurance company marketing arm wants you to believe (and most people believe).
When you actually have large medical expenses, the insurance company will use the full strenght of their lawyer army to deny everything, claim it was all unnecessary and unauthorized and deny deny deny. Your "max out of pocket" doesn't apply to any of that since they get to unilaterally say it wasn't covered. That's how you end up with hundreds of thousands in debt even though the paperwork claimed your max out of pocket is 7K or whatever.
As others mention here, you can fight it but it will become a full time job for a very long time and you'll be an amateur fighting full-time professionals at denying. You can win some but it'll be an uphill battle.
https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...
Frankly negotiated prices should just be illegal. They should just provide prices for services. Insurers should have plans on how much they’ll cover you, but they don’t change any pricing. The hidden bullshit smoke and mirrors producing fraudulent pricing that may or may cover you depending on a million different reason is as far from market competition as it gets.
Sadly, if you're sitting around a hospital room, researching and reading up on insurance billing is probably a worthwhile use of time.