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Healthcare Insurance: a Racket Exposed

Updated on November 6, 2021
DzyMsLizzy profile image

Liz's advice on finance, credit, frugal living practices, & anything monetary is from the 'school of hard knocks,' research, & experience.


Are There Comparisons? No, Not Really...

If you thought homeowners'/renters' and auto policies were complicated, you obviously haven't tried to shop for health insurance recently. My household and auto insurance policies are each a few pages long.

The legal-speak jargon, and diabolical exceptions, exclusions, denials, double-talk, ifs-ands-or-buts, repetition, contradictions and just plain nonsense included in health insurance policies on the other hand, have expanded to fill an entire booklet nearly an inch thick!

Extra Charges Several Times Over

Not only will many polices subject you to 'deductibles' (an annual minimum of medical expenses you must pay out-of-pocket before your coverage kicks in), but they also charge you an additional fee called a "co-pay." It amounts to a secondary deductible.

Now, a "co-anything" usually indicates the involvement of a third party, such as a co-signer when taking out a loan. They will be responsible to take over payment of the full amount of the loan if the main party should default or become unable to pay.

An insurance "co-pay," on the other hand, is quite different. Instead of assigning the full responsibility of the cost to a third party, it indicates only the presence of such a party. Usually this is an employer, who pays a part of the insurance bill on behalf of his employees. The remainder of the bill is paid by means of a deduction from the employee's paycheck. Sometimes the amounts match; more and more often, though, they do not, and the worker is expected to pay an ever-increasing proportion.As if that were not bad enough, there is yet another 'co-pay' expected when you show up for an appointment, sometimes more than one!

 The amounts vary, but it is an unforgivable practice. It is even worse for the self-employed, who must carry the full cost of the bills all by themselves. In this case, there is no 'co' party. The so-called 'co-pay,' then, is also borne by the patient when they seek care. It can quickly escalate to ridiculous heights.

Say you visit your doctor for what seems like a minor complaint. You are charged a co-pay at the desk before you are seen. Then, suppose the doctor sends you for blood work and an x-ray. You are then hit with 2 more co-pays, one at each department.

This is on top of the monthly bills you have already paid for supposed coverage. In such a scenario, it can easily cost you over $50 in co-pays for a single day's doctor visit. It gets worse. Suppose you have one of those nasty policies with an annual deductible, say $500 before the insurance pays anything at all. Now, your 'co-pay' at your visit will be the full cost the doctor charges, and the same at the lab and x-ray department. You can easily and rapidly find yourself above the $200 mark.

Truly Unaffordable For Many

A friend of mine, whose name I shall not mention to protect her privacy, told me of this scenario at her last job, in her words:

"The last three years of my previous job was the first job that offered insurance in a format I could afford. The two jobs I had before offered - but was too expensive. The only reason I could afford (but not really) was because the company paid for half.

However- even with the primo package.... The amount of dollars that came out-of-pocket were ridiculous! I would have been better off keeping the half I paid and sticking it into a savings account and using that to pay for the sh** when needed.... I would have still come out ahead!"

This an all-too common complaint. It is worse if there are children who also must be covered: another acquaintance of mine has 3 small children, and must temporarily also cover her hsuband who recently became unemployed. She pays out over half of her entire salary for health coverage--yet, she is considered to "make too much money" to qualify for any assistance programs!! Between mortgage, car payments and insurance coverage, it is a wonder people have any money left over for such apparently "unimportant incidentals" as groceries!

Why Is It So Expensive?

Unfortunately, the overriding motive is nothing more than pure corporate greed. Other factors that come into play simply amount to more greed--this time on the part of providers of services and supplies. Remember way back, the exposé of the $500 toilet seats and overpriced hammers sold to our government? This is a similar problem. The suppliers overcharge for small items for no better reason than to rack up charges to the patients’ bill.

I recall one such instance many years ago: I had to have a small cyst removed from my finger. (It was benign, and I would have ignored it, but for the fact that it was where my pen rested, and caused discomfort when writing.) Removal took all of about 5 minutes in the doctor’s office.

The ‘dressing’ for the resulting wound was an ordinary band-aid. When I got my bill, I was astounded and outraged to discover I’d been charged $5. for a single band-aid! I could have gone to the drugstore or supermarket and purchased an entire box of the things for less! I called and gave them a piece of my mind, telling them that if I ever had to undergo any other such simple procedure, I’d bring my own damned band-aid!


Of course, that’s just a single indicator of far worse inflated charges. You must be on your guard. Ask everyone you know who has ever had to spend time actually in a hospital, or recall any such experience of your own. If you ask folks who were actually paying attention, you will probably discover that is it quite “normal” for them to have discovered several such instances of over-charging, say a few dollars for a single aspirin tablet.

Multiply these "small" overcharges by hundreds of thousands of patients per year, and it adds up to a tidy sum.

Other Costs

I hope you never need an ambulance ride. Oh, my goodness, the charges for that, even for a short trip of say only 6 miles or less, are exorbitant! It can easily amount to over $3,000. It would be cheaper to hire a limousine, and pay extra for the ticket the driver might get for speeding and running red lights!

Yes, I know, they have all that specialized equipment and trained medical technicians aboard the ambulance, but you get my point. Even with that accounted for, the charges are pretty excessive. Many insurers limit the amount they will pay toward an ambulance ride, and others, such as “free” county services, refuse to cover ambulance transportation at all.

When you consider the many conditions and treatment options that are routinely excluded from coverage, it should mean more money is available for the remaining costs, but this money disappears into some corporate black hole.


Another Nasty Trick

There is yet another money-skimming scheme going on behind the scenes. It may not be illegal or fraudulent per se, but it is most certainly highly unethical. You may think you have adequate insurance, only to be stunned by a "supplemental billing" for charges not covered.

Typically, any given insurance policy pays only a percentage of the cost, usually between 70% and 80%. That leaves 20% - 30% for you to pay out-of-pocket after your deductible and co-pays have already been covered and paid!

This is the 'coverage gap,' between what the insurance company has decided they will pay and the actual charge for the service or treatment, and is responsible for the booming business in "Medi-gap" coverage policies, to cover the difference between what Medicare pays for and the actual costs.

It works like this. The insurers have some secret formula they apply to determine what they think the charge for any given covered item should be. Then, they pay their percentage based upon that rate chart instead of on the actual charges made. This means you are left with an even higher percentage of the cost out-of-pocket than the wording of the policy would lead you to believe.

This is deceit! The policy booklet might tell you this, but not in any kind of clear and easily understood terms, and certainly not up-front. It will be well-buried.

For Your Basic Health and Safety

Ask, ask, ask! Make a nuisance of yourself. Become a “pill” before you take a pill. When you see the nurse approaching with medicine, here are some questions you need to ask when you or a loved one is hospitalized:

  • What is that medication?
  • What is its purpose?
  • What are any possible side-effects?
  • How often must I take this?
  • For how long must I take this?
  • Who prescribed/ordered this medicine? (If it was not ordered or prescribed by my regular doctor, I do not want to take it until I speak with him/her. (or, I do not want it given to my [insert name/relationship of patient] until I [or s/he] speaks with the regular physician.)
  • Did the prescribing physician consult with my [their] regualr doctor about this?

Demand to know the name of each and every medication, dosing schedule and any and all diagnostic and/or surgical procedures performed.


Outright Fraud

Many, many “errors” are made on a daily basis. I place “errors” in quotes because only some are true errors. Particularly in the case of the elderly, where the insurer is Medicare, countless instances of bogus billings for medications never administered have been uncovered. Most people don’t ask enough questions, or, if they are too ill to ask, then their family members or caregivers are not asking.

Ultimately, we are responsible for our own care, and that of our loved ones. It is your (or their) health at stake, and your wallet on the line, however you slice it. Whether you pay directly for insurance, or whether you are under Medicare, for which you have paid (and continue to pay with taxes), it is your money being spent.

Write down what you are told according to the questions in the previous section. It is YOUR medical record, and you have every legal right to know what is contained therein. Likewise for primary caregivers. Use your notes to compare against any and all subsequent bills and/or “information sheets” stating what was paid by any private insurer or the Medicare system.

Anything that does not match up is bill-padding. It happens all too often. and that, ladies and gentlemen, is fraud. If you find such bogus charges, report them to the insurer or Medicare!

Healthcare Fraud in the News

Failure To Treat

If you are dependent upon Medicare and/or some state supplement that goes with it, such as California’s “Medi-Cal,” or worse, totally indigent, ineligible for Medicare, and dependent upon so-called free care from a county provider, you are regarded as a 3rd or 4th class citizen, not worthy of saving in the event of a life-threatening event. The Powers That Be would rather a poor patient simply die, so the funds do not have to be spent on their care. If this is not true, then their policies have done a very poor job of proving otherwise.

You can address these concerns to your state department of health, the insurance commission, and even send a copy to the governor.

Free county care does not often cover emergency transport. So, what is such a patient to do in an emergency? Drive themselves to the hospital in the middle of having a heart attack? When severely injured and bleeding? Unlikely. Have a family member, friend or relative take them? Possibly...but neither those folks nor the patient themselves have sirens or the right to speed and run red lights. And if there is a traffic jam? Too bad. The amublance can force traffic to scoot over and create a path--an option not available to a private driver. The end result is what? They die on the way? They arrive already too damaged for the doctors to save?

By now, most of us have heard of the “Golden Hour,” a term first coined by R. Adams Crowley, M.D. of the University of Maryland Shock Trauma Center. In an interview, he stated,

There is a golden hour between life and death. If you are critically injured, you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later—but something has happened in your body that is irreparable.”

This is where that ambulance or life-flight helicopter ride becomes oh-so-important! Yet, the so-called “coverage” for the indigent does not cover this very pricey transport. Therefore, the insuring agency has elected to, in effect, “play God” and decide who is worthy of treatment in a timely fashion; i.e., who lives and who dies.

Decisions In the Wrong Hands

These are not doctors making these decisions—they are heartless corporate economists and bureaucrats whose only interest is their own bottom line. It’s no skin off their nose—they can either afford the best policy money can buy, or are even self-insured, meaning they are sufficiently wealthy to pay for whatever treatments they may require without the need for insurance.

The recent case of a certain well-known computer mogul (who shall remain namelss for legal reasons), 'buying his way' up the waiting list and traveling out-of-state for a kidney transplant comes to mind as an example of the super-wealthy who feel they are better and more deserving of quality care than the rest of the populace. They are neither better, nor more deserving. They are merely guilty of snobbery, and it disgusts me. They are part of the problem.

Related To General Health

Dental and vision care are two very commonly excluded items in many policies, including and especially "free" county care and Medicare or state Medicare supplement programs. It seems they don't consider teeth and eyes part of our bodies and in need of regular care, and sometimes surgery.

Apparently, the insuring agencies have not read the studies showing a link between advanced dental disease and heart problems. To be sure, some preventative measures on the part of the patient such as regular brushing and flossing are important. But so are regular dental checkups. Some people are much more prone to dental problems due to genetic reasons that have nothing to do with personal oral hygeine or lack thereof.

Yet, the some of the free healthcare programs consider 'dental care' to consist only of the extraction of teeth. Excuse me, but a simple filling for a cavity is a much less complex procedure, and surely costs less. This is certainly the case if a crown is needed--and if you aren't covered, it costs a minimum of $2,000.!! Loss of a tooth for any reason negatively impacts the quality of a person's life. To substitute extraction for repair is nothing short of butchery.

But, the insurers don't care.

Likewise vision care is vital to general health. If someone's eyesight needs corrective lenses, and they are not available due to high cost, that person could well trip, fall and break a leg, or worse, perhaps fall down a flight of stairs and be killed. In the first case, surely a visit to the emergency room is more costly than the eye exam and glasses would have been.

This kind of false economy is what my grandparents' generation referred to as "penny wise and pound foolish," or, to bring it up to date with a modern (but much less polite) saying, "pinching pennies and sh**ing dollars."

If the second instance were to happen, as much as I detest the litigious nature of our society, and blame lawyers in large part for many of the far-too-complex rules, this would be one case where I would surely be tempted to bring a wrongful death suit against whatever insuring agency denied vision care.

What To Do?

Again, we cannot fix these problems by remaining silent, or grumbling to our neighbors. We must take positive action.

Write to your legislators, phone their offices, become that proverbial 'squeaky wheel.'

Let the lawmakers know in no uncertain terms that passing legislation to require people to purchase medical insurance does not address the underlying problem--it makes it worse! People already cannot afford insurance--how is forcing them to buy it under threat of penalty going to solve that issue?

© 2011 Liz Elias


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