Unexpected Medical Expenses and Bartering

[MrsCoolCat]

Hi everyone. I have been keeping busy but need the MMM community's advice on negotiating medical bills which we recently calculate to be no more than $11.5k as I believe those to be the figures. So story time.

Mr. OneCoolCat had something not so cool happen yesterday after work. He slipped and fell hard on his shoulder at home. So hard that he fractured and dislocated his humeris. "Humeral head fracture, right, closed, initial encounter" to be exact. He fractured & dislocated it. He'll probably need surgery but we'll find out more on Monday when we see the Orthopedic surgeon. He'll probably need to go to rehab afterwards, too. We were at both the Urgent Care and the ER.

So today we look more into his health insurance and it's worse than we thought. $1,500 deductible, 50% coinsurance and $10k member max out of pocket. We want to know if anyone's negotiated their bills, how to do it (tips) and if you think we should. Lastly, we have the Xrays from the Urgent Care. Any MMM doctors want to provide their free medical advice? He's mainly wondering if he'll need surgery and how long the recovery should take and any other tips, etc. Thanks everyone in advance.

[forummm]

Sorry to hear about the accident.

You have health insurance, so you likely can't negotiate--they've already negotiated for you. Their rates should be much less than what you could have negotiated on your own.

The good news is that you don't add your deductible to the OOP max. So you're only on the hook for up to $10k--not $11.5k.

[MrsCoolCat]

Thank you and we did not know that about the deductible and that makes sense about the already negotiated rates. That was helpful! Though I knew a woman with insurance that said she negotiated her high bills. Yea, we just think it could have been worse and in this day and age that's very true. Ty again.

[forummm]

You can try to negotiate. But if they are in your network they have an agreement with your insurer already. So I don't know how that will work.

Sometimes people get billed from out-of-network providers. They do not have an agreement with your insurer. And their bills are often absurdly inflated (like literally 10 times what an insurer would pay them). You can definitely negotiate those.

[Cranberries]

I have successfully negotiated medical bills after insurance had been taken into account. It isn't uncommon to be able to get an additional 10% knocked off by asking for a discount and being prepared to pay on the spot.

[MrsCoolCat]

I have successfully negotiated medical bills after insurance had been taken into account. It isn't uncommon to be able to get an additional 10% knocked off by asking for a discount and being prepared to pay on the spot.

10% on $10k would be good. It just seems like the hospitals with negotiate compared to not paying at all, or as my friend jokes $20 for the rest of my life. We're gonna pay but it is a lot and was unexpected. Ty.

[Norrie]

I'm sorry to hear about your husband's accident. That sounds awful.

There are two routes that you can go with hospitals:

1. Ask for a discount for paying in full as soon as you receive your bill. They'll have already adjusted for insurance at that point, but may be willing to reduce by another 10-15%. Be prompt about it.

2. Hospitals will allow you to set up a monthly interest-free payment plan that is comfortable for you, but you won't be able to negotiate an additional discount. You can set it for $150/mo., but pay it off as fast as you'd like.

We've done both in the past (and are actually trying to decide which way to go right now with a large hospital bill). Good luck!

[MrsCoolCat]

Thank you Norrie. 😊

[nienajadly]

I've been on the provider side for billing and medical coding since 1998, so I hope my input can be helpful.  First, the deductible IS on top of your out of pocket.  You have to satisfy your deductible before the insurance carrier will kick in.  That's also when your 50% coinsurance kicks in, which is what accumulates to your out of pocket.  So you're looking at $1500 without help, then 50% of the balance.  The GOOD news is that's not off the billed charges if your providers and hospital are contracted.  You'll be paying 50% of the discounted rate, not the billed rate.  That's also why you can't negotiate further.  They have a legal obligation in their contract with the carrier to hold you to the negotiated price on your explanation of benefit.

So if your billed charge for the hospital is $10,000 but the contracted rate is $8500, you'll pay $5000 total ($8500-$1500 deductible =$7000 / 50% coinsurance = $3500.  $3500+1500 = $5000).

I hope that makes sense.  Feel free to PM if you want :)

[forummm]

I've been on the provider side for billing and medical coding since 1998, so I hope my input can be helpful.  First, the deductible IS on top of your out of pocket. 

Sorry, that's not true. Maybe pre-ACA or something.
http://www.bcbsm.com/index/health-insurance-help/faqs/topics/how-health-insurance-works/out-of-pocket-maximums.html

All the money you pay toward your plan's deductible, and for coinsurance and copays, go toward your out-of-pocket max.

https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/

The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.

http://healthinsurance.about.com/od/healthinsurancebasics/a/Out-of-pocket-Maximum-how-It-Works-And-Why-To-Beware.htm

The health insurance out-of-pocket maximum is the largest amount of money you pay toward the cost of your healthcare each year. After you’ve paid enough in deductibles, copays, and coinsurance to reach your out-of-pocket maximum, your health insurance company pays for all of the rest of your healthcare that year.

[nienajadly]

That may have changed with ACA.  Thanks for the links :)

[Sibley]

Maybe you can negotiate or not, but you can make sure the bill is accurate! Medical billing errors are extremely common, so you can potentially save by making sure they're not double billing, you actually got services, etc.

Ask if everyone involved is in-network.

Ask why, a lot. What is this test for? What will this brace do? Why is this medicine needed? If nothing else, it's good to understand what's going on. But you may also find out that something's on autopilot and isn't actually needed, or worse could cause a problem. Then make sure you don't get billed for it!

[MrsCoolCat]

Maybe you can negotiate or not, but you can make sure the bill is accurate! Medical billing errors are extremely common, so you can potentially save by making sure they're not double billing, you actually got services, etc.

Ask if everyone involved is in-network.

Ask why, a lot. What is this test for? What will this brace do? Why is this medicine needed? If nothing else, it's good to understand what's going on. But you may also find out that something's on autopilot and isn't actually needed, or worse could cause a problem. Then make sure you don't get billed for it!

Good advice; thanks!

[Credaholic]

They have a legal obligation in their contract with the carrier to hold you to the negotiated price on your explanation of benefit.

This. Since what you're paying the doc/hospital is calculated into your out of pocket maximum with your insurance company, they aren't allowed to negotiate lower with you because then you'd have potentially met your out of pocket max while not actually paying that much. However, in actual practice they still might let you, so it's worth asking and being prepared to pay immediately and in cash to do so.

[zinethstache]

to confirm what others are saying...

yes, new ACA rules mean your deductible counts as part of out of pocket...

It is true that for the "hospitals" you get a limited window of time after procedures to either 1. pay off in full for a discount (our hospital was 15% within 60 days) or. 2. opt for lowest payments possible no interest.  - we chose 2.

However, for our primary care doctor's system (it is pretty large) My account had aged and they offered me a 15% discount to pay in full - I just did this in May and It felt great to get that monkey off my back

I've had a really bad run of medical luck in my household for 4 years running. So review ALL bills very carefully, question everything. I know it is annoying, but stay on top of them.

Don't choose the discount if it will stress you out and make you pay on cc's or something that could end up costing more interest, go for the no interest low payment. If you have the funds sure go for the discount (I did just pay off my last clinic bill in May for the 15%, it felt nice and wasn't a huge amount)

I am so sorry about your husband's accident, such a bummer, and I sure hope he doesn't need surgery. Keep us posted!

Ah, don't be afraid to get 2nd and 3rd opinions, surgery can be life changing, and not always in a good way.

[bogart]

I'm so sorry to hear about your husband's accident.  I don't know that I'm any help on the financial angle, but as I broke off my humeral head about 4 years ago, I can speak to the medical/healing -- at least what my experience was like.  I had surgery -- a plate installed to reattach the two pieces of bone.  Once that was done I was in a lot less pain than prior, though still plenty.  Things that made a huge difference as I was healing were --

• t.e.n.s. unit -- https://en.wikipedia.org/wiki/Transcutaneous_electrical_nerve_stimulation -- way better for reducing my pain once the worst of it was over -- helped, but without side effects.  Also provided cool impression I was communicating directly with the MotherShip.  Prescribed, and covered by (my) insurance;
• electric recliner -- we had one that we had bought after my DH had hip replacement surgery, I probably slept (only) in it for a month or more
• a swimming pool -- getting in one was for some time the only way I could get my arm to raise or otherwise move away from lying against my body.  It felt wonderful.  As I healed, it was a great resource for PT
• PT -- I probably went twice/week for 3 months and another once/week for 3 more months.  It cost a lot (for me, $45 copay per visit and this was pre-APA so did not count against my OOP total).  It was worth it.

I'm sorry to need to let you and MrCoolCat this, but I really cannot overstate how long it took me to heal or be even the least bit useful.  I probably couldn't drive a car, at all, for 3 months.  There was this one moment when I was home alone and needed to run an errand into town -- about a mile in/out, simple drive, low traffic and I thought, "This is ridiculous and I'm just going to go."  I got in my car and sat there and was unable to move my (right) arm enough to put the key in the ignition, and I decided if I couldn't do that, I couldn't drive safely, so I didn't go.  I did resume work fairly quickly (getting rides from co-workers, telecommuting, or using public transport) -- by which I mean, maybe 2-weeks post-surgery -- but I work a desk job (and had access to those transport options, plus a flexible boss) or I'd have been out for months.

I hope MrCoolCat maybe broke his non-dominant arm, but even so:  tough situation.  Be kind to him and don't hesitate (and he shouldn't hesitate) to call on friends/family for help, if that's an option.  And remember, this kind of occasion is what an emergency fund is for -- I hope you have one, not only to help with the medical expenses but also with the numerous indignities and difficulties that healing will involve.

[MrsCoolCat]

Thanks everyone. Appreciate the comments & condolences. He may not need surgery but that depends on his ct scan results. Unfortunately the doctor said his shoulder will never be 100% the same. Maybe 75%... 😐 He'll def be out for 4-6 wks I believe. That's all I got for now. Starting to feel a bit depressed, not wanting to deal with any work stress or interview stress but hopefully a day for me to regroup tomorrow. Ty all again.

[bogart]

Thanks everyone. Appreciate the comments & condolences. He may not need surgery but that depends on his ct scan results. Unfortunately the doctor said his shoulder will never be 100% the same. Maybe 75%...

Obviously I am not your DH and my shoulder is not his shoulder and my break was not his break.  Also I'd be leery of surgeons who promise "too much."  All that said, based on your short description (after the CT scan we can swap pics, haha.  And yes, I still have one or two of my break, somewhere), the breaks really do sound the same and I am back to let's say 95%.  Maybe 98%.  I had a great surgeon, and as noted a LOT of (also really good) PT (and really I could and should have done more on regaining my upper body strength, myself -- heck, I still should...).

And I wasn't a spring chicken -- early 40s when I broke it.  I will note that the first surgeon I saw (bearing in mind that I was on vacation and out of town, and thus in a distant-to-my-homeplace hospital when I first got evaluated) told me that he, "shouldn't be the one to do my surgery."  Happy to respect that -- his reasoning was that my break was bad enough the surgery might need follow up attention and I should have it done close to home.  So I did (it didn't, however, turn out to need follow up).  Key point -- don't be afraid to get a second opinion.  Yes, this is major, and annoying, and painful, and you want to get it taken care of.  But you also want it really well done.  It matters, and it's worth asking around and finding out who does shoulder surgeries regularly and well, and seeing that surgeon.

[MrsCoolCat]

Thanks again for everyone's advice & concerns! My husband may need surgery but so far the bills are lower than I expected. $1,500 for the ER and he's expected to pay $950 which is all towards his $1,500 deductible. I'm sure the surgery will be a lot but this all validates how I've felt about healthcare and we have an EF. I feel for those who don't.