The Prostate Papers—Chapter 8: Healthcare Billing Insanity

Gary returns with an episode about receiving an insane EOB (Explanation of Benefits) from United HealthCare.

Today, it’s a rant, but I promise to make it a short tirade. The trigger? My latest EOB statement from my healthcare insurance company. To be honest, I seldom download and open these statements. I’m a big fan of Medicare and have a really good Advantage plan thanks to my late wife’s retirement program. Until this year, I have had the good fortune of being relatively healthy—no major illnesses or chronic medical issues. I typically incur few medical expenses, and it never costs me more than a small copayment for any procedure. My healthcare insurance company? UnitedHealthCare. Yes, the purported Darth Vader of the healthcare insurance evil empire.

Really? A Quarter of a Million Dollars?

On to my rant. So, I opened this new statement and was blown away by the year-to-date numbers it presented. The top line was enormous. My providers—the labs, imaging facilities, clinics, and doctors who delivered services—billed UnitedHealthcare over $256,000 from January to October. I know I was diagnosed and treated for prostate cancer, which isn’t cheap, but a quarter of a million dollars? I might add that I did not spend one night in a hospital or have an operation in a surgical facility. Now, the relevant numbers were the actual payments to the providers and my share of the costs. UnitedHealthCare paid a bit under $33,00, 13% of the billed amount. My out-of-pocket share was an incredibly small $521.

This begs the question about what kind of screwed-up system, knowingly and with a straight face, bills anywhere from five to eighty times the negotiated cost of a medical procedure? Every provider knew precisely what they would get paid by my Medicare insurance company before they submitted the claims. These are pre-authorized payments, yet they still billed these egregious amounts. Why did a urologist bill over $23,000 for a 15-minute, in-office procedure, knowing they would get paid $279?

But Who Pays the Balance?

As I noted, I have the good fortune to have a decent Medicare Advantage plan that pays for almost everything. My concern is for the poor patient who sees an enormous unpaid balance and wonders if they will be required to cover it. Sure, there’s a note in the EOB saying you should not be billed for the balance, followed by another notation that the patient may need to pay a copayment, coinsurance, or deductible. So, am I on the hook or not? No wonder there is so much anxiety today around medical treatment and its costs.

In my humble opinion, the medical-industrial complex of healthcare providers and insurance companies maintains this evil pricing charade to take advantage of the disadvantaged. These obscenely inflated prices are the starting point for unfortunate patients who may be underinsured or even uninsured. How many families have lost homes or gone bankrupt based on their inability to pay these fantastical prices?

Explaining the complexities of the healthcare payment system is way above my pay grade. Still, these thoroughly confusing payment practices can partially explain the anti-healthcare sentiment rampant in our country. And we haven’t even touched on the burden of self-advocacy placed on patients dealing with complex medical issues. Or the simple frustration of just trying to ask their healthcare provider a simple question. Leave a MyChart message? No response. Call the office? Listen to a long phone tree before being sent to voicemail. Leave a voicemail message? Ignored. As you can probably tell, I’ve dealt with a few challenges over the last nine months.

A Costly Bureaucracy

My tirade was triggered by a stunning Explanati