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Medical Forum / General / General / August 2004Health insurances in the US - how do they work?
Hi there, I'm a foreigner and I still don't understand how the healthcare works in the US. A few questions: If I get an insurance with $30 co-payment or the like, can I go to specialists also, as many times as I want, and pay just $30? Can I choose a different specialist each time by my own? Can I do it without first going to a generic doctor? What if I go to a specialist to hear a second opinion on a cronic illness that I have (a pre-existing condition): would I "anyway pay just $30 since it's just an office visit", or it would be "not covered, since it's pre-existing" and I would have to pay 100% of the specialist's visit out of my pocket? How does it work with the prescriptions here? The patient pays a co-payment for the office visit and then another co-payment for the prescription and then a % on the actual cost of the medicines, is this correct? TIA Please read the previous questions as referred to PPOs, thanks. > Hi there, > I'm a foreigner and I still don't understand how the healthcare works > in the US. Good luck. Most Americans don't understand how it works either. There is no single answer to *any* of your questions. In fact, almost every question you asked could be answered "It depends", because the precise answer will vary depending upon the *type* of insurance plan in effect. There are as many different variations as there are insurance plans. However, there are some common threads, and I will attempt to answer your question with some basic assumptions. > If I get an insurance with $30 co-payment or the like, can I go to > specialists also, as many times as I want, and pay just $30? First of all, in order to have health insurance at all, you must pay a monthly premium. For a typical family, this may be in excess of $800/month. Fortunately, many employers (read: companies) subsidize health insurance for their employees, so your monthy out-of-pocket cost will probably be much lower. However, you'll probably have to pay *something* apart from what your employer gives you if your family is to be covered, and under some plans, you may have to pay something out-of-pocket to have yourself covered, buy your employer will pay the difference. It just depends. As far as copayments are concerned, you may have to pay a copayment of say, $25 to see your primary care physician, $35 for a specialist, $75 for an emergency room visit, etc. You'll have to pay this amount each time you're seen. Sound like a bargain? Well, it is...but you'd be surprised at how many people think it's not. > Can I choose a different specialist each time by my own? It depends. First of all, why would you? Second of all, many insurance companies require that you see doctors who participate with your insurance, which wil limit your options. Many require referral from your primary care physician. PPO plans give you more flexibility to choose a doctor or to self-refer to a specialist, but many specialists require a referral from a primary care doctor (apart from what your insurance company may require) in order to cut down on the bullshit visits. > Can I do it without first going to a generic doctor? I don't know what you mean by a "generic doctor." If you mean a primary care doctor, see above. > What if I go to a specialist to hear a second opinion on a cronic > illness that I have (a pre-existing condition): would I "anyway pay > just $30 since it's just an office visit", or it would be "not covered, > since it's pre-existing" and I would have to pay 100% of the > specialist's visit out of my pocket? Huh? "Pre-existing" is insurance company doubletalk for an illness that you had before you took out the policy, and typically one that they won't cover. In these cases, you won't be reimbursed for any charges related to the non-covered ("pre-existing") condition(s). In most other cases, you'll have no trouble obtaining a second opinion, but the copay situation won't be any different than it would be any other time. > How does it work with the prescriptions here? The patient pays a > co-payment for the office visit and then another co-payment for the > prescription and then a % on the actual cost of the medicines, is this > correct? Again, it depends. Most pharmacy benefits plans emply a tiered co-payment scheme, whereby low-cost generic drugs carry a copayment of, say, $10, while second-tier (brand-name) drugs carry a co-payment of, say, $20, and third-tier (read: expensive) drugs may carry a co-payment of, say, $35. There are an infinite number of variations on this theme, and they change all the time. Confused? Join the club. >Hi there, >I'm a foreigner and I still don't understand how the healthcare works in >the US. >A few questions: >If I get an insurance with $30 co-payment or the like, can I go to >specialists also, as many times as I want, and pay just $30? Can I >choose a different specialist each time by my own? Can I do it without >first going to a generic doctor? I think they prefer the term "PCP" or "Primary Care Physician". It depends on the plan. Some allow you to go directly to the specialist: others require a referral from a PCP. In most cases the PCP and the specialist have to be "in" your plan and if they're not that $30 goes up considerably...unless it's an emergency...or other travel-related reasons...or...there's lots of exceptions and restrictions. Read the plan. BTW $30 as a co-payment sounds high, many are $10, and then there are ones that are $0 but you have to see a specific MD...it's all in the plan. >What if I go to a specialist to hear a second opinion on a cronic >illness that I have (a pre-existing condition): would I "anyway pay just >$30 since it's just an office visit", or it would be "not covered, since >it's pre-existing" and I would have to pay 100% of the specialist's >visit out of my pocket? Normally there's a period of open enrollment most often when you're first employed at this job and then once a year for a month (yeah, yeah: check the plan). If you sign up during these times pre-existing conditions don't count: otherwise you have to convince the MD to put a diagnosis code that doesn't indicate a pre-existing condition...or pay the full cost (sometimes less: check the plan <g>). >How does it work with the prescriptions here? The patient pays a >co-payment for the office visit and then another co-payment for the >prescription and then a % on the actual cost of the medicines, is this >correct? Depends on the plan. Some don't even cover drugs at all; others cover 100% especially for chronic illnesses like diabetes. A reasonable plan might charge you a flat fee for a month's supply (or three if you go to their mail-order pharmacy). The fee might be $50 for brand-name and $25 for generic. BTW getting a look at the plan documents is about as easy as seeing the battle plans for the next country the US is going to invade. They're both closely guarded secrets. You'll have to console yourself with some publicity blurbs but because your questions are simple the blurbs will probably answer most of them. Thanks for the good replies A few more questions: - How much does a doctor's office visit cost in US on average (both for Primary Care Physician and a Specialist please) if I don't have an insurance? - If at the visit it turns out that I didn't actually have anything (that would be diagnosed as "hypocondriasis" I suppose), will the insurance deny the payment for the visit claiming that it was "not medically necessary"? - Suppose this situation: I have an insurance and I go to a doctor of the PPO. At the visit it turns out that I have to pay the full cost of the visit because it's precondition or not medically necessary or anyway not covered by the insurance. In this case will the visit be the same price as not having the insurance at all, or it will be discounted (and by how much % ?) because the doctor belonged to the PPO so they have anyway agreed on a reduced price? TIA! >Thanks for the good replies > >A few more questions: What is the context of you asking? If you have insurance, e.g. through your employer, the only answer that matters is the one from that insurer. Ask them. If are trying to choose among plans, ask each one. It is common that you may be able to choose among plans. Paying more gives you more coverage. bob > - How much does a doctor's office visit cost in US on average (both for > Primary Care Physician and a Specialist please) if I don't have an > insurance? A huge "it depends." The fee will vary depending on geographic region, type of physician, and length and complexity of the office visit. Many physicians will offer discounts off their regular fee schedule for patients who pay cash, or at least may "downcode" to make it more affordable. Generally, we're probably talking somewhere between $30 and $150, not including any lab work, x-rays, procedures, etc. > - If at the visit it turns out that I didn't actually have anything > (that would be diagnosed as "hypocondriasis" I suppose), will the > insurance deny the payment for the visit claiming that it was "not > medically necessary"? Nobody would code "hypochondriasis." They'd code symptoms, and the insurance company would likely cover the visit. > - Suppose this situation: I have an insurance and I go to a doctor of > the PPO. At the visit it turns out that I have to pay the full cost of [quoted text clipped - 4 lines] > because the doctor belonged to the PPO so they have anyway agreed on a > reduced price? You'd have to ask the doctor in question. If it's a hypothetical question, there's no answer...sorry. >> - Suppose this situation: I have an insurance and I go to a doctor of >> the PPO. At the visit it turns out that I have to pay the full cost of [quoted text clipped - 7 lines] > You'd have to ask the doctor in question. If it's a hypothetical > question, there's no answer...sorry. OK, wait a sec...I think I understand now. Generally, a physician's office has one fee schedule. When they contract with an insurance carrier, they are contractually obligated to accept the insurance carrier's fees, even if they're less than the physician's published fee schedule (and they almost always are). However, in cases where a service is not covered by the insurance carrier (cosmetic procedures or in your example, a denied service because of a pre-existing condition), the patient will be billed based on the physician's published fee schedule. If the doctor offers a discount for cash (some do, some don't), you could potentially pay less. However, you will *not* be billed based on your insurance carrier's fee schedule, since those fees only apply to *covered* services paid by your insurer. By definition, a denied service is not covered. >carrier's fees, even if they're less than the physician's published fee >schedule (and they almost always are). However, in cases where a >service is not covered by the insurance carrier (cosmetic procedures or >in your example, a denied service because of a pre-existing condition), >the patient will be billed based on the physician's published fee >schedule. This, too is a "depends". Not covered you are generally right. If it is something that is generally covered but isn't in your case because of pre-existing conditions, it still MIGHT be billable only at the negotiated fee. Again ask the company. If the doctor offers a discount for cash (some do, some >don't), you could potentially pay less. However, you will *not* be >billed based on your insurance carrier's fee schedule, since those fees >only apply to *covered* services paid by your insurer. By definition, a >denied service is not covered. Again, this may not always be the case. If it is something that is excluded (many cosmetic procedures) then, yeah. However, if it is something that is usually covered but isn't in your case because of pre-existing conditions (say allergy shots) then they might still be required to charge you only what they would have gotten from the company. -- A moral compass needs a butt end. Whatever direction France is pointing-- from collaboration with the Nazis, acccomodation with the Communists, existentialism, Jerry Lewis or a UN resolution veto-- we can go the other way with a quiet conscience. --PJ O'Rourke > If it is something that is excluded (many cosmetic procedures) then, > yeah. However, if it is something that is usually covered but isn't in > your case because of pre-existing conditions (say allergy shots) then > they might still be required to charge you only what they would have > gotten from the company. No, and here's why. Let's say my charge for "Service X" is $25. When I negotiated a contract with "ABC Insurance Co.", I agreed to only accept $15 for this service. I also agreed not to charge patients anything above and beyond that amout for that specific covered service. This prevents what is known as "balance billing", where "ABC Insurance Co." would pay their $15, and I would charge the patient for the remaining $10 to recoup my usual fee of $25 for "Service X." With most insurance contracts, this is expressly prohibited. Again, this is for *covered services* (meaning services being reimbursed by "ABC Insurance Co." under the terms of my contract with them). So, when I see a patient who is covered by "ABC Insurance Co." and perform "Service X", I actually bill the insurance company $25...but the company only pays me $15 as per our contract. The $10 difference is "written off" as billed but not collected, and is shown on our accounting documents as a "discount". However, when the insurance company refuses to pay for the service AT ALL (meaning that it's not covered), the patient is billed $25 just like the insurance company was, except that since there is no discounted fee-for-service contract in place between the patient and the doctor, the patient is expected to pay the full amount. > So, when I see a patient who is covered by "ABC Insurance Co." and > perform "Service X", I actually bill the insurance company $25...but [quoted text clipped - 6 lines] > in place between the patient and the doctor, the patient is expected to > pay the full amount. I mentioned discounts for cash earlier. In the above scenario, most doctors would probably not offer the cash discount at this point. The reason being that the justificaton for offering discounts for cash in the first place is that the physican's office will not have to incur the overhead of billing and processing an insurance claim, and thus can accept less than the usual fee if it is paid in full up-front in cash. Since we're talking about a service that has already been billed to the insurance company, denied (and probably re-billed at least once, usually at the patient's request), and ultimately re-billed to the patient, the doctor's office has already spent a considerable amount of time (and time is money) trying to collect the bill. Thus, there is no reason to offer a discount for cash at this point. In fact, for truly miniscule dollar amounts, the doctor may have actually spent more money trying to collect the bill than the amount of the charge itself! Had the patient known in advance that the service would not be covered, they may have had the option to pay in cash and receive a discount if the doctor had such an option in place (again, not everyone does), but probably not now. |
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