An Interesting Look at Medical Insurance

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Veteran Member

Date Joined Aug 2009
Total Posts : 2448
   Posted 8/1/2010 11:31 AM (GMT -6)   
So I am just sitting around today trying to catch up on some loose ends. I decided to reconcile my medical payments and the report I get from the Health Insurance Carrier every time a new claim is submitted. Thankfully I have reached my total out of pocket for the year and won't pay anything else for anything medically related.

I downloaded a year to date summary of all claims into a spread sheet and then totaled each of the categories.

Now it shouldn't be a surprise but two of the totals kind of jumped off the page. Makes one say Hmmmm!

Total of all submitted claims for my family, Me, Lynn and Son, $162,022.00. And the total paid to the billing entity by contract with the carrier, including my portion, $46,438.00.

Now if I had been a poor sap with no insurance, I would have been expected to pay the full amount.

I know that this is not uncommon, but it is the first time I have looked at it on my own personal expenses. I don't even want to go back to 2006 and look at the disparity of billed versus accepted in the year of Lynn's stem cell transplant, major chemo, radiation, and 45 day isolation stay in the hospital, just to name a small portion. And oh yeah, there was one of the drugs she was on that the supplier was billing at $9,600 per month and our co-pay was $45.

Just an observation and put forth for conversation,

60 years old when diagnosed
PSA 11/07 3.0
PSA 5/09 6.4
da Vinci 9/17/09
Post Surgery Pathology: GS 4+3=7
Stage: T3a
Tumor Volume 12.5%
positive margin, extra-prostatic extension
30 day PSA 0.4, 50 day psa 0.53, 64 day psa 0.6
IMRT completed 1/15/10 35 treatments- 70Gy

2/24/10 FIRST POST RAD PSA 1.0---CARRRP --waiting for the next test.
3/22/10 Second Post RAD PSA 1.5 Dammmmnnn stubborn son of a gun
4/19/10 YAHOO PSA dropped to 1.2 Moving in the right direction.
5/7/10 PSA test 1.3 Sodium Fluoride PET Scan & CT SCAN -performed
5/20/10 PSA test 1.2 Holding off on future tests for 3 months- single lytic lesion found and scheduling radiation.
7/22/10 PSA test 1.3 - Begin radiation for MET on leg

Veteran Member

Date Joined May 2008
Total Posts : 1010
   Posted 8/1/2010 1:11 PM (GMT -6)   
As one who is well aware of the cost of medical treatment when one is uninsured your observation reinforces my perception and experience. When I was going through the testing to confirm the PCa (CT and Bone Scan) I was in a bigger battle with the hospitals over the charges. My daughter works for a well know insurer and gave me some typical reimbursements. The hospital was charging me three to four times the insurance amount. They also tried to tell me that the patient had to make up the difference even if insured. I knew this was BS as I had previously been insured and if the provider was in network there were no extra charges to the patient. I was finally able to secure a meager 10% discount by paying cash upfront. The financial director at one institution told me the reason for the higher charge was there was a higher risk of recieving payment. Huh?! I reminded him that I was the one taking the risk as he was holding my check for the full amount in his hand and I had received no treatment as of yet.
My experience with my urologist and radiation oncologist was better. They gave me a 30% discount and billed me once a month. I always paid in full. My lupron was well below the cost I had been quoted by the pharmacy and was most likely at the urologist's cost. So, there are some compassionate souls in the medical business.
One of the hopitals that agreed to the discount later sent my account to a collection agency for the 10%! After a few choice words with their accounting department this was quickly corrected. Insult to the injury. Even more galling was a request for a donation to the hospital a year later. This was so they could offer the less fortunate in the community medical care at a reduced cost as they were a "non profit" organization.  Reduced to whom?
My second opinon required me to pay cash up front as well. The check was $3000 just to get in the door. They took thier time with the refund of the balance but still made off with $2200 for a three hour meeting with the doctor. By the way, they first sent in a PA to discuss the findings. It was only after I complained that I was expecting to see a urologist or an oncologist that I finally saw the doctor. He seemed a bit miffed that I would not accept the PA as the sole arbiter of my condition. It took some doing but I finally got a decent evaluation and report from this institution.
Be thankful for the insurance company that can deal with the providers on your behalf.
Apologies if this comes off as a rant. Not my intent.
Best Regards,
Diagnosed 04/10/08 Age 58 at the time
Gleason 4 + 3
DRE palpable tumor on left side
100% of 12 cores positive for PCa range 35% to 85%
Bone scan clear and chest x ray clear
CT scan shows potential lymph node involvement in pelvic region
Started Casodex on May 2 and stopped on June 1, 2008
Two years on Lupron completed 01/2010.
Started IMRT/IGRT on July 10, 2008. 45 treatments scheduled
First 25 were full pelvic for a total dose of 45 Gray to lymph nodes.
Last 20 to prostate only. Total dose to prostate 81 Gray.
Completed IMRT/IGRT 09/11/08.
PSA 02/08 21.5 at diagnosis
PSA 07/08 .82 after 8 wks of hormones
PSA 10/08 .642 one month after completion of IMRT, 6 months hormone
PSA 03/09 .38 six months post radiation and nine months into hormones
PSA 06/09 .36 or .30 depending on who did the test
PSA 09/09 .33 one year after IMRT and 16 months into hormone
PSA 03/10 .32 18 months after IMRT Still on hormones
PSA 05/10 .42 Rising a little as the lupron wears off. Last lupron shot 01/10.
PSA 06/10 .322 Maybe the .42 reported in May was in error?PSA 07/14/2010 0.1

Veteran Member

Date Joined Jan 2009
Total Posts : 2243
   Posted 8/1/2010 1:13 PM (GMT -6)   
Sonny it is very interesting when you look at what amount is billed and what the contracted amount that is paid out. I was happy to see my surgeon get far less than what he billed. But yes when you look at someone who doesnt have the power of insurance it can mean having to sell the farm to pay the medical bills. I have also caught errors by going on line to keep track of billing and payments. Caught one for 4,700.00 that was billed to me and I wasnt even at the Dr.'s office on that day. That had billed my account for service done on someone else. Whe I called the Dr.'s office the billing person said they would put in a disputed claim for me. I said there is no dispute as I wasnt even there that day, never saw that Dr, before and I told her I would let the insurance company know asap. Never did get a dispute form, but it was taken off my account.
Dx with PCA 12/08 2 out of 12 cores positive 4.5 psa
59 yo when diagnosed, 61 yo 2010
Robotic surgery 5/09 Atlanta, Ga
Catheter out after 10 days
Gleason upgraded to 3+5, volume less than 10%
2 pads per day, 1 depends but getting better,
 started ED tx 7/17, slow go
Post op dx of neuropathy
T2C left lateral and left posterior margins involved
3 months psa.01, 6 month psa.4, 6 1/2 month psa.5 on 11/28/10
Starting IMRT on 1/18/10, Completed 39 tx at 70 gys on 3/12/10
6 week Post IMRT PSA .44 a drop from .5 but maybe more
Great family and friends

Cajun Jeff
Veteran Member

Date Joined Mar 2009
Total Posts : 4119
   Posted 8/1/2010 1:35 PM (GMT -6)   
Just as a note. Look at the things that are not covered on our policy. Ex. the rec. pills. Look what the paramacy gets from incurance for the pills v/s what we have to pay. Something is wrong with all of this.

Cajun Jeff
9/08 PSA 5.4 referred to Urologist
9/08 Biopsy: GS 3+4=7 1 positive core in 12 1 pre cancer core
10/08 Nerve-Sparing open radical
Surgery Path Report Downgrade 3+3=6 GS Stage pT2c margins clear

3 month: PSA <0.1
6 month: PSA <0.1
10 month:PSA <0.1
1 year: PSA <0.1
16 month:PSA <0.1

ED - Started Cialis at 3 months, tried all 3, 6 months added pump, 9 months Tried MUSE (YUCK) Bad experience.
1 year mark Found new Urologist visit was at 14th month post surgery
Started Injections, Caverject! (Success)
17 month: ED making improvements : Oral Meds gets me 85%

Veteran Member

Date Joined May 2009
Total Posts : 2692
   Posted 8/1/2010 2:19 PM (GMT -6)   
Ok, rest easy, I'm from the government and I'm here to help.

I really expect it to get worse. Probably the big discounts will start to evaporate because the insurance will be forced to pay out more in claims, and we may be forced to make up the difference. And insurance rates, deductibles, and co-pays will go up.

But, I suppose I am pessimistic. It's a tough thought process to go between employer, insured, and taxpayer. I have different view points from each different vantage point.

As an insured, I am very thankful for good insurance. My total PC process, with second and third opinions, surgery, and follow up probably cost me less tha $200 out of pocket.
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

Veteran Member

Date Joined Jul 2010
Total Posts : 3892
   Posted 8/1/2010 2:33 PM (GMT -6)   
I think Obama wanted to change all this, I really think that's what he wanted to do..But the Medical Lobby descended on Congress with all their might, the Republicans linked arms to block any real change in the system, and the status quo has been pretty much maintained.

I suspect a very large percentage of the OVERALL medical care being provided in the U.S. is being paid for by Medicare, Medicaid or the V.A.

Instead of doing everything possible to control costs, the Medical Industry seems to do just the opposite..The sad thing is, for this money spent, we don't live any longer than people in countries that spend just a FRACTION of what we do on medical services..It's just a huge transfer of wealth...
Age today: 68. Married, 6', 215 pounds, active, no health issues.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA at age 66 9.0 DRE "normal", BPH, Finesteride. (Proscar)
PSA at age 67 4.5 DRE "normal" second biopsy, negative.
PSA at age 67.5 5.6, DRE "normal" U-doc worried..
PSA at age 68, 7.0, third biopsy positive for cancer in 4 cores, 3 cores Gleason 6, one core Gleason 9. Finesteride discontinued, still no urinary symptoms, never had any..From age 55 to 65 I had no health insurance.

I have a date with the robo surgeon on Sept 3 but I'm keeping my options open. I'm also looking at seeds combined with IGRT which seems to be having good results with high-risk patients..

Worried Guy
Veteran Member

Date Joined Jul 2009
Total Posts : 3742
   Posted 8/1/2010 3:56 PM (GMT -6)   
Is there anyone who doesn't think the system is broken now? (Sorry. Guys like Cleve Killingsworth, chairman and chief executive of Blue Cross and Blue Shield of Massachusetts, who received 3.5 million and 4.8 for 2008 and 2009 can't reply. We know they think everything is fine. ) Remember there are CEOs for every state and some states like NY get multiples - lucky us. Also there are the VPs, the Asst VPs, the CFOs, their cousins ... Heck, even fired execs like Mike Unhjem, N Dakota, collect $2.2 million. How many billions per year is that? And not one nickel of it goes to actual health care.
We've tried this system for so many years and look how it morphed into a get rich scheme for a few very powerful individuals. Isn't it time to at least look at something different?

Another thing that bothers me is the varying price for the exact same work done in the same lab depending upon the insurer. We are not in Korea or Italy where it is expected that everything is negotiable. There should be set prices.

Just sayin'...

By the way, just for fun, .check out the top dog's salary in your own state. Unless he's your son, the numbers will make you sick.

Post Edited (Worried Guy) : 8/3/2010 1:38:23 AM (GMT-6)

Regular Member

Date Joined Feb 2010
Total Posts : 385
   Posted 8/1/2010 4:46 PM (GMT -6)   
From the point of view of the patient (us), the best system is Medicare. They set the price. Most hospitals and doctors chose to take what they pay ("take Medicare assignment")--it's too big a part of the health insurance pie for them not to. Medicare pays for most medical care with little need for "gatekeepers". The administrative costs are far far less than commercial insurance. The cost of Medicare funded health care, per item, is substantially less that that funded by commercial insurance. My health insurance is from my state, so it has some, but not all, of the good features of Medicare. I'm counting on getting Medicare in a few years.

If we had Medicare for all (AKA "single payor"), hospitals, doctors, pharmaceutical companies would all take some financial hit. The insurance industry industry would go bankrupt, out of business, gone. That's why there was fierce lobbying against any expansion of Medicare to cover more people, and that's why the health care reform bill was so imperfect--it was either an imperfect bill or no bill. However, as the US budget deficit grows, we'll be faced with a choice of doing single payor, or raising taxes substantially.

Forum Moderator

Date Joined Jan 2010
Total Posts : 7084
   Posted 8/2/2010 11:55 PM (GMT -6)   
My GP does not accept Medicare, so all things remaining the same, I would have to find a new doctor at age 66. Wonderful.

Veteran Member

Date Joined Jul 2009
Total Posts : 504
   Posted 8/3/2010 6:51 AM (GMT -6)   
That $100k diff that the Dr and facility was shortchanged on is guess what ,,,a tax write off

Now imagine how large the write-off is when most patients generate more write-off than what the Dr was actually paid

I used to wonder why they bothered billing so high when they knew they would only get less, well the taxman says its better for their business to claim they lost on the surgery
Age: 52, PSA (2008)=1.9
Biopsy on 01/09/09, Gleason Score = 3+3
One (1) out of twelve (12) cores was positive, plus external nodule found
Surgery (Da Vinci, robotic prostatectomy): 4/7/09
Post Op Path 3+3
Removed Catheter: 04/19/09
100% bladder control - Pad free 7/09
PSA 7/09 undetectable, <0.01 - 3 months post-op
PSA 1/10 undetectable, <0.01 - 9 months post-op
Trimix provides 100% erectile function

Worried Guy
Veteran Member

Date Joined Jul 2009
Total Posts : 3742
   Posted 8/3/2010 8:14 AM (GMT -6)   
So we simply end up paying one way or the other -some to the hospital, some to the doctor, some to taxes, and some to the insurance companies. The only one of the four that I can ever hope to reduce or eliminate are the insurance companies.
Sure they tout that they might be more efficient than the government but when I see that the wages of the top dog and his minions are 10x the wages of the president of the US. Something is out of whack. Why must there be multiple TDs in so many states? Because they can. There should only be a single top dog, an STD if you will. And his pay should be less than the president's pay. Don't worry about the myth of attracting and retaining top talent. The only talent they show is the ability to grab funds and benefits for themselves. If it takes more than that to keep them, then good riddance.

I see that on June 10 "Vermont regulators ordered Blue Cross and Blue Shield of Vermont to refund $3 million to its subscribers following an investigation into a $7 million retirement package given to former CEO William Milnes.
Paulette Thabault, commissioner of the state Department of Banking, Insurance, Securities and Health Care Administration, says Blue Cross has agreed to make the premium refunds to end the state's probe into excessive compensation given to Milnes.
Milnes retired in 2008.
Officials eventually determined that Milnes had been paid substantially more than he should have been, given the size of the company."

Note they did not take the money from him. They took it from BCBS and taxpayers who will no doubt make up the difference. Shameful.

"Off with their heads!" said "Leakspierre" Jeff
OK I'll stop my rant now. (No more caffeine for me!)

Veteran Member

Date Joined Aug 2009
Total Posts : 2448
   Posted 8/3/2010 8:59 AM (GMT -6)   
Today's local newspaper had an interesting article that fits right into this discussion.

A local lady had orders from her doctor for some blood work. Having no insurance she called around to find out the costs. Having something called a "Partner Card" from her doctor's hospital she called them and was told the blood work would be $800, but since she had the partner card her cost would be $400.

She called an independent lab across the street from the hospital and was told the battery of tests would cost $257.

Along the same lines. My doctor gave me a 1 year script for 5mg Cialis for rehab purposes to be taken 1 per day. Of course we all know that the insurance carriers will only approve 5 or 6 pills per month. At the time my co-pay would have been $60.

So I asked the Pharmacist what the cost would be if I filled the script without insurance. She told me a one month (30 pill supply) would cost me $118.00.

There is just no figuring anything in the world of medical and insurance billing.


Regular Member

Date Joined Oct 2009
Total Posts : 27
   Posted 8/4/2010 10:26 AM (GMT -6)   
One thing really stood out to me on this thread and that is that doctors and hospitals know they are billing more than they will get paid --- and they do that so they can take a loss on their income tax!!!!  So, do they pay tax at all? 

Post Edited (donnathewife) : 8/4/2010 10:02:20 AM (GMT-6)

Worried Guy
Veteran Member

Date Joined Jul 2009
Total Posts : 3742
   Posted 8/4/2010 3:26 PM (GMT -6)   
Good question Donna.
Hospitals and many health insurance providers claim they are Non-profit entities. That does not prevent them from paying their upper echelon those outrageous salaries. In many cases the company prepares and pays the income taxes the top dogs owe. Poor things. I also like the low or no interest loans offered by some. Yep, it's broken.


Regular Member

Date Joined Oct 2009
Total Posts : 27
   Posted 8/4/2010 4:37 PM (GMT -6)   
yep, it is a FOR profit business, another reason I am glad we left the country and had HIFU !!  How can you trust them on health when it's clear that so many of them just care about $$$, I am sure some are good, but how do we know who??

Elite Member

Date Joined Oct 2008
Total Posts : 25393
   Posted 8/4/2010 5:02 PM (GMT -6)   

and you don't think your out of the country treatment wasn't for profit? the way that most, not all, american health insurance providers negotiate with the hospitals/doctors/treatments in recent years, has actually worked in favor for the patient. ask around here, most american men here have had to pay very little out of pocket for their PC treatments, myself included. i believe that our canadian and british brothers under their systems, also pay little to nothing out of pocket. a good medical practice, i.e., urological services, still has to be ran like a tight business, and like all business, absolutely doesn't want to pay more income taxes than any other business out there, that's the american way, lol. that part, is just business, but has nothing to do with the quality of the doctors or their services.

i think HIFU like your husband had, has very good possibilities for men with low grade PC, and meeting the criteria for safe treatment. He is braver than me, I know it will be ultimately approved by our FDA, but until it is, I wouldn't have the nerve to i leave the country and undertake a primary treatment like that, that hasn't been approved yet by the FDA. Its not a right or wrong thing, in my opinion, its a preference, and all treatments have risks associated with them.

the few men here at HW that underwent HIFU, I believe, if memory serves right, have all done well. One day, of course, the number of people doing it will increase once its approval is cleared for mainstream use in the US.

i hope he continues to do well, and that it zapped the living fool out of his cancer. my best to the both of you.

david in sc
Age: 58, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, next one: Aug 3
Latest:  7/9 cath #6 - 41 days, 8/9 2nd corr surgery, 8/9 cath #7 - 38 days, mapped  9/9, 10/1 - 3rd corr. surgery - SP cath, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, Cath #10 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12 ,Cath #11 - 21 days,  Cath #12 - 41 days, 3/2- Corr Surgery #5, Cath #13 - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 31 days, Cath #17 - 39 days, 7/2 - Corr Surgery #6, Cath #18 - 13 days, Cath #19 - 17 days, Total Blockage, Cath # 20 - 7/19

Regular Member

Date Joined Jul 2009
Total Posts : 162
   Posted 8/8/2010 1:16 PM (GMT -6)   

For those currently without insurance.....................


As a result of healthcare reform, each state has a designated insurance fund provided to those who cannot get health insurance because of pre-existing conditions. In PA, the cost of this insurance is roughly $250/month with a $1,000 deductible and it covers everything including drugs. The special fund is effective through 12/31/2013, at which point no insurance company can turn you down. In order to qualify for your state's special insurance fund, you just need to be uninsured for the preceding six months.

Age -57; Diagnosed 10/05 PSA 13.4 GS 7 (4+3) Organ confined (T2B)
Cryoablation 4/06 Allegheny Hosp-Dr Ralph Miller (Cohen/Miller)
Post Cryo Nadir 8/06 0.2
Rising steadily to 0.7 4/09 :-(
Steady at 0.7 (7/09)
Doubled to 1.5 (2/10) YUCH!
Hoping to qualify for salvage cryo or radiation
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