I should probably be careful
what I say about this.
I mean honestly,
it's one of the biggest companies in the U.S. of A.
I would like, for a minute, though,
to consider how this company
with all its many offices and millions of employees
is symbolic of one of the biggest scams
in the world :
the fundamental emasculation
of the AMA --
and all its many,
But the AMA, of course,
would never let that happen, so
they fight back, and
who gets screwed,
and who has to pay?
You guessed it.
Now, how does this work, you wonder?
It's easy --
witness this statement
from a "provider" to me.
Yes, you are correct --
the provider had something to do with x-ays,
at her tender quattro-centerian age,
is having a little trouble
with her knee.
Nothing major, mind you --
I can still kick,
and I can still
but sometimes, it hurts.
So I went for a knee x-ray.
I have a standard medical insurance policy,
and the x-ray provider submitted their bill
to my insurance company.
When I was in the office for the x-ray, I had offered to pay the "co-pay"
because I knew I had to pay one, and the receptionist said:
"Oh, let's wait and see what your insurance pays."
(For those of you
outside of the U.S. of A.,
let me please explain:
with most standard health insurance policies here,
the patient is required to pay a "co-payment"
for nearly every doctor's visit and procedure
(along with paying huge monthly payments
for the insurance itself.
In my case, my standard co-payment
but it can be higher in some situations.)
Had I paid the co-payment,
I would have never had the opportunity to witness
how my insurance actually paid less than I did for the procedure.
As you can see from above--
The provider billed the insurance company $71.00
for my knee x-ray, which took about one minute
lying on a cold shelf below a creaking old roentgen machine;
the insurance company paid $11.71;
the provider adjusted the bill by $37.29,
and then I was billed the
Yes, that's right:
when it comes down to cold,
I paid more than the insurance company did for my x-ray.
And I still don't have the results!
I wonder how many
of the average readers out there
how it could be that a bill for $71.00
can be satisfied with a payment of
(roughly half of the amount billed.)
I'm telling you:
if I sent half of the amount I owed to the gas company
I wouldn't have heat this winter;
if I paid half of my car payment,
I wouldn't have a car;
if I paid half my
department store bill,
I'd have a bigger balance,
the medical industry gets away with paying
half of their bills,
and the insurance companies
keep letting them give xrays.
Now why, one might wonder?
Of course, I'm going to try to explain this because
Once upon a time, Makropoulos worked
She actually managed a medical office.
It was sometime early in the 1980's,
and the insurance companies were just beginning
to figure out and refine
their methods for emasculating
the medical industry.
And they came up with this notion of the
UCR - "usual, customary and reasonable" payments
right around that time.
And I was kind of amazed,
even bedazzled by the puzzle the UCR provided --
and it went like this:
The insurance companies asked doctors and other medical practitioners in any given region
to take each procedure they offered
and let the insurance companies know what they charged for it;
then the insurance companies determined the average cost for any procedure,
then they determined the "Usual, Customary & Reasonable" (UCR) for a procedure,
and then they paid a percentage of that.
So, take a usual doctor's office visit.
The doctor was charging $15.00 for it.
When asked, the doctor, and every other doctor in the area,
let the insurance company know that office visits cost $15.00,
and maybe some doctors in that region charged $18.00,
and maybe some charged $12.00,
and they told the truth,
and the insurance companies averaged it all together,
and came up with the average charge of an office visit in that region.
Let's say that average was $15.75
Then, the insurance companies,
led by the Insurance Company of All Insurance Companies,
told the doctors that they would, based upon that average,
declare the "Usual, Customary & Reasonable" charge for an office visit,
which tended to be around 80%.
The UCR for an office visit was then, around $13.00.
The insurance companies,
led by the Mother of All Insurance Companies,
declared that they would pay up to the UCR,
but not more than that.
In fact, most insurance companies then declared that they would only pay
80% of the UCR, and the patient,
or a supplemental insurance,
would be responsible for the difference between the actual insurance payment
and the UCR.
I hope you can follow this --
it's really quite elegant,
and also very convoluted.
Because that was when it really began --
So, guess what happened?
who really needed $15.00 for each office visit,
were suddenly only getting around $11.00,
if they were lucky,
and they had to decide if they wanted to ask their patients
to pay the difference.
Some of them did.
Some of them also found,
with their older patients who,
up to that point always had had health insurance that paid everything,
those older patients couldn't afford to pay the $4 difference,
so the doctors started doing something called
which fundamentally meant that they would accept what the insurance company paid,
and write off the rest for certain patients.
Some of the doctors also found
that it was getting harder to keep their lights on
and pay the costs of the increasingly expensive and refined equipment,
so the doctors in any given region
all got together and said:
"let's start charging $25.00 for an office visit."
And they did.
And then when the big insurance companies again, after a year or so,
did an average of the cost of office visits,
they found their average went up,
and the UCR went up,
and the doctors got the $15.00
that they really wanted for their office visits.
Well, they actually got around $18.00,
but there's inflation, isn't there?
And so the cycle began:
doctors increasing prices regularly to nearly double what they really needed;
insurance companies using complex equations and cogitations
to tell them they would only get a certain amount of that,
which tended to be
about half of what the doctors charged.
At a certain point,
it got ridiculous,
because patients were being asked to pay the difference between
a $75.00 bill for an office visit,
and the $30.00 the insurance company agreed to pay for it,
and more and more patients were asking their doctors
to accept assignment on them.
about the time I decided I had to get out of that industry,
the insurance companies started pressuring all doctors to accept assignment
on all patients,
and ultimately the doctors gave in,
knowing damned well that they could not ethically expect anyone
to pay $75.00,
or even $65.00,
for an office visit that lasted
about three minutes.
Thus, we get a statement like the one I received above,
with one caveat--
in the past 15 years or so,
the industry has produced this thing called the "co-payment,"
which means the patient must pay a little bit for every service rendered.
It started out very small,
but it has been continually increasing.
This co-payment makes it possible for the insurance companies
to pay less for a service, and leave it up to the patient
to pay the difference between what they want to pay
and the U.C.R.
Fundamentally, the insurance companies are willing to let the patients pay
what they demanded the doctors stop charging.
the statement above --
let me explain it again:
The $71 is what this Radiology Provider has set as the going rate for a knee xray;
the UCR is actually $36.71, and the provider has
"accepted assignment" - ie: written off the difference between
the UCR as set by the insurance companies and their charge.
Now, how do I know the UCR is $36.71?
Add together the remaining amounts:
my $25.00 copayment
and the insurance company's $11.71 payment.
The insurance company paid a percentage of the UCR,
and I was left to pay the difference.
Oh, in case you're wondering what I pay for insurance:
this is a "benefit" for me --
according to my paystub,
my employer pays $210.43 twice a month for my insurance;
I also get $52.61 deducted, twice a month, from my gross pay,
to help pay for my insurance. (I'll let you figure the monthly cost out.)
For that, I get an insurance policy that requires I pay co-payments,
and I end up having to pay more than my insurance company has to pay
for an x-ray.
~ ~ ~
I know I've been known to write
some very confusing blog entries,
and they came out of my weary,
427 year old, overactive brain.
This blog entry,
with its convoluted formulas
may have taxed the best of my readers,
and I have to make it very clear:
I didn't even make this stuff up!!!
This is how the insurance industry works in the U.S. of A.,
and it's getting worse :
the other policy my company offered me
was one that required I pay the first $2,000.00 every year myself.
Once I did that,
then the company would offer the same coverage
as my current insurance (with copayments!).
I would have to pay the first $2,000.00.
The monthly cost of this policy would be cheaper
for me and my employer,
If I opted to take this coverage,
I would get counseling on how to create
a Medical Savings Account,
to help me pay that first $2,000.00,
In the informational meeting about this policy,
I was promised that during that time
that I was paying the $2,000.00,
I would only have to pay
the Usual, Customary & Reasonable
for any service.
Now, how about that?
In my case, that would mean that I would never actually
unless I got really sick.
I have a feeling that,
so far in my life,
with perhaps the exception of one year,
I don't cost my insurance company $2,000.00 a year.
It strikes me that under this scenario,
the patient is being asked to pay even more of the bill,
and the insurance company keeps simply
It gets even more confusing when the patient is retired.
I won't go into that.
You know, I actually have some good friends
who work in the health insurance industry,
and they work very hard.
They take good care of their families,
and they try to live
the American Dream.
And it's just so sad
that their industry is one of the industries responsible for making the American Dream
so impossible for the average person.
What I think is actually happening in America
is that the insurance companies are developing ways to
continue taking money out of the average worker's salary
while also getting that average healthy worker
to simultaneously carry the brunt of the bill
for their health care.
In this scenario,
only the very sickest
and the very wealthiest,
and the very wealthiest and sickest
actually reap the benefits
Everyone else pays for it.
And it's a real nightmare if you have no insurance at all,
because, you lucky stiff,
you have to pay the original amount
that the medical providers charge the insurance companies.
That's right --
you're the one who has to pay
$71.00 for a knee xray.