Staphylococcus Interruptus Redux

I’m mending well according to all the MDs seen today, 10 days after my ER visit. The orthopedic surgeon removed the stitches and said to “keep it clean” but to otherwise go on with things. And the infection MD moved me from the IV administered heavy-duty bug killer to a pill which should be sufficient from here on – the RN will come by the house tomorrow and remove the PICC line.

Also, I have one more appointment today, with my regular MD, but expect mostly to be bringing him up to date so he can pick up the reins from here.

That’s the good news.

But all this comes with the revelation that, even though I thought I had “good medical insurance” that provided 100% coverage for emergencies, and even though I was diligent in selecting an ER that was “in the [insurer-approved] list”, I’m still going to be getting bills the insurance won’t cover, or at least not at the billed amount.

Apparently “100%” isn’t 100%.

Here’s how it works. The hospital has an agreement with my insurance to bill only at the “reasonable and customary rate”. And that’s what they do. The room, the medications from the hospital pharmacy, the surgical theater and all that are billed at this approved rate and, because it was an emergency, my plan gives me 100% coverage. The insurance pays 100% of the hospital’s fees.

Now, enter the physicians.

They are contracted – sub-contracted actually from the insurance company’s perspective – by the hospital. Their [sub-]contract does not require their adherence to the insurance-approved rates. The physicians, if they so choose, may charge whatever they wish for their services.

True, my insurance pays 100% – and here’s the got’cha – of the “reasonable and customary rate” to the service providers who are “in the network”. But these sub-contracted physicians charge more, sometimes quite a bit more. And worse, the unknowing [OK, I’ll say it, the ignorant] patient [me] didn’t know to challenge each and every physician to see if they take my insurance.

So imagine, if you will, the unconscious patient wheeled in to the ER – with good insurance, mind you. At the presumably good judgment of the hospital and attending physicians, they can, without ever waking up, run up considerable debt which is only covered in part by their insurance.

Same for the fully-awake but otherwise ignorant patient.

To the case at hand, my insurance plan from Blue Cross Blue Shield of California states that I’m 100% covered for emergency care.

But that’s only for the care I receive that is covered by agreements between health providers and the insurance company. Going to an in-network facility only guarantees me that the services of that facility are covered. Sub-contracted providers such as the physicians are not bound by that agreement. They can charge whatever they wish.

The bottom line is, if you get sick and need emergency treatment, it’s gonna cost you something, maybe a lot or maybe a little. Don’t believe the insurance company’s “100% claim”. What it costs you will depend on who’s on call when you get there, and who’s on call when they, or one of the sub-contractors, decide you need some other sub-contracted specialist.

The “old boy” physician network is, surprise, alive and well.

Today, the medical and the insurance industries are one-up’ing each other in this tit-for-tat game. And it is the lowly consumer, you and me, that are ultimately footing the bill.

BEWARE: As negative as I’ve made this sound, please do understand it’ll be worse with Obama’s plan. Wait times will go up as providers are paid less but more and more seek attention. Instead of “playing it safe”, future providers may take a “wait and see” approach before prescribing (note the prefix “pre” in that word) antibiotics.

In the current system, I *did* get immediate attention – virtually no wait whatsoever – in the ER.

And in the current system, I did receive the needed surgery by the “on call” specialist appropriate to my needs (an orthopedic surgeon). Surgery took place within a couple of hours of my walking through the ER door and saying, “I’ve got this funny bump on my finger that keeps coming back. Do you have someone that could take a look at it?”

And when the culture from that surgery said “Staph infection, could be MRSA”, I did get the appropriate medication including a PICC line, a ticket home, medicines delivered to the door and an RN who has made three visits (with one more to go) to my home.

I’m on the mend with no complications (knock on wood).

I did receive top-notch care, thank you very much.

But when the insurance says “100%”, don’t you believe it.

I don’t like being the pawn.

Back to Bullseye – I’ll be in the backyard tomorrow morning throwing pellets 10 Meters. The range opens at 6:00AM.

10s and Xs!