Insurance Will Cover It

In the interest of avoiding litigation, the insurer will be referred to only as Nameless Insurance Machine - NIM

The first Explanation of Benefits was for $10,051.38 of Hospital Services

We have yet to see a bill from the hospital.  Perhaps that will explain what the individual services might be.  For now, we are looking at 8 pages with lines like these: an Amount Billed of $2,138.07 worth of generic Hospital Services with a concomitant Amount Allowed of $302.10.  Honestly, denizens, I just don't know where to start.

How about those 7 cents?  Someone somewhere spent an awful lot of time and energy coming up with that number.  Is its specificity designed to reassure me?  Would I think less of this mess if the amounts were rounded off to the nearest dollar?

There is no rhyme or reason that I can see between the Amount Billed and the Amount Allowed.  To make it simple, let's round off our numbers.  That $2100-and-change charge was reimbursed at about $300. Another Amount Billed, this one for less than $1700*was also reimbursed at about $300. There's a $27 charge that's both Billed and Allowed at $27, and $6.22 comes in in both columns, too.  It's a mystery, I tell ya, it's a mystery.

Lest I imagine that this bill comes from a heartless entity, there's a column titled Message Code.  Actually, it says Msg. Code, and it is only 4 spaces wide.  The columns which include dollar amounts are 13 spaces wide.  Those columns do not use the dollar sign.  That's 13 spaces for numbers and commas.  That's a lot of money.  We'll revisit that thought later, but, for now, it's back to my message.  Most of the rows referred me to messages 3 and 5.  Those messages contain the exact same verbiage:

This NIM participating provider will accept NIMs allowance as the basis of payment unless other coverage...is available for these expenses. 

Beyond wondering why in the world they need two different numbers to tell me exactly the same information, I have an even more basic question: What does that mean?  I'm a reasonably well-educated woman and I have no idea what they are trying to say. Basis of payment? When I hear basis I think of a starting amount.  When you sell stock, you look at the price you paid - your basis - to calculate your profit.  Am I to assume that this is merely a beginning? I don't think so.  But if they mean total payment then why not say it? Messages 3 and 5 also remind me to

review the provider information in (my) benefit booklet

I also searched the website.  There was no explanation that I could find.  The whole thing seems more than a little fishy to me..... less Pike Place Market  and more Lower East Side pushcart.

But let us continue.  We have chosen a plan with a fairly high deductible, so we are not surprised that the Amount Allowed and the Deductible amounts are identical, less the $150 the hospital collected while the patient was writhing on the bed.  That's the Emergency Room Access Fee and it has its own special column, called CoPay.  I'm not sure about the derivation of the term, but I know that it means I'm taking out the charge card before they do anything else. I knew about that fee going into the experience and it's the only part which is clear to me.

I am stuck on the Claim Totals line.  The Amount Billed by the hospital is $10,015.38.  The Amount Allowed, that which they will accept as the basis of payment (whatever that might mean), that which we will be paying out of pocket as part of our deductible, is $1,521.65.  That's a difference of $8,493.73.  And my question is, who's responsible for it?

Is the hospital lying when it pegs the cost of care for 6 hours in their Emergency Room, without including the doctors' fees, at $10,000?  If it's an accurate figure, then how in the world are they ever going to recoup their costs?  I cannot imagine that NIM's basis of payment is that much different from any other insurance conglomerate's. Could you run a business if you wrote off more than 50% of your expenses as uncollectibles? 

I am making a pledge here and now - I will become the first woman in recorded history who will be able to say, with certainty, that she understands the hospital/insurance/insured nexus.  I am going to get to the bottom of this is it's the last thing I do.  I have been listening to Jesse Kelly trying to unseat Gabrielle Giffords by blaming her for ObamaCare.  His suggestions for a solution are gibberish.  I am going to rise above the tide of political bickering and insurance company gobbledy-gook and I am going to come out on the other side with the knowledge I need to understand how and why we managed to spend upwards of $10,000 to diagnose pneumonia.

This will be an on-going series, and I'll link back to this post as I go along.  For now, I am waiting to hear from NIM and a family member who might also be able to shed some light on the subject..... he was a hospital CFO for many years.  My fear, denizens, is that I will end up no more satisfied than Jonah in Sleepless in Seattle, when he asked how much it costs to fly to New York.  The answer? "No one knows how much it costs to fly to New York."

I hope someone knows how much a CAT scan costs.

* For you control freaks, that would be $1667.66 and $303.92 to be exact