B [CB] S

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.

BCBS

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,

wealthy,

members.

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.

mrstrusz

*/*

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,

and Makropoulos,

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

run,

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

is $25.00, 

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

$25.00 co-pay.

Yes, that's right:

when it comes down to cold,

hard

cash,

I paid more than the insurance company did for my x-ray.

And I still don't have the results!

xraymachiness

I wonder how many

of the average readers out there

truly understand 

how it could be that a bill for $71.00

can be satisfied with a payment of 

$36.00?

(roughly half of the amount billed.)

I'm telling you:

if I sent half of the amount I owed to the gas company

every month,

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,

with interest,

next month.

But miraculously,

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

in medicine.

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.

(123Rf.com)

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?

The doctors, 

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

"accepting assignment,"

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.

Ultimately, 

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.

Thus,

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.

~ ~ ~

Now honestly,

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!).

Every year,

I would have to pay the first $2,000.00.

The monthly cost of this policy would be cheaper

for me and my employer,

they said. 

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,

every year.

In the informational meeting about this policy,

I was promised that during that time

every year

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 

"use"

my insurance,

unless I got really sick.

I have a feeling that,

annually,

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

making money.

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

of insurance.

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.

(rippdemeup)