Sunday, November 3, 2013

Health Insurance Hell

You know what's stressful? When you have a medical procedure that costs more than what you owe on your mortgage and the INSURANCE COMPANY DENIES THE CLAIM!!!!

These are words to strike fear into one's heart (pun very much intended): "It is your responsibility to pay $224,088.32."

Yeah, who needs a restful night's sleep?

Anyway, the insurance company paid the claim from the doctor who performed the surgery so presumably they will end up paying this one as well. Unfortunately things get denied if they don't have every bit of information so this will get resubmitted and processed. But you know, until it does, one (meaning ME) does not rest easy!

But let's go back to the beginning....

CPA Boy had a pacemaker implanted in May. He has a condition called atrial fibrillation (AF). In most people this means an irregular but generally faster heartbeat. CPA Boy decided to be different and have a very slow heartbeat.

This is a problem because the procedure they use to treat AF is called cardioversion, where the doctor "shocks" the heart back into proper rhythm. So for all intents and purposes the patient's heart stops for a brief moment and then restarts, resetting the heart without atrial fibrillation. It works if you have only had the condition for a short time. If you've had AF for a longer period it won't work. We have no idea how long CPA Boy has had the condition.

(By the way, I am not a medical professional --- or amateur for that matter --- so I may not explain all this in the proper medical way but it's how I understood it from all the doctors. I do a lot of web surfing researching medical things and came across many blog entries with good information. For any newcomers who find this blog --- welcome! --- just keep in mind my non-medical status!)

Before the doctor could perform the cardioversion they were afraid that CPA Boy's heart might not restart (due to the slower heart rate) and the solution was a pacemaker. Then the pacemaker would do its job and keep the heart beating fine.

Which it did although the cardiovert itself failed, most likely because the atrial fibrillation condition has existed for quite a while.

So all was going well over the summer. With the pacemaker and some new meds we were waiting until September to see if the ejection fraction improved. CPA Boy had an echocardiogram that month to find out. (Also in September he was also having a muscle biopsy performed in hopes of determining the underlying condition causing all these health issues. A blog entry for another day!)

Before we could get to the cardiologist appointment on September 30 for the electrocardiogram results CPA Boy started having these episodes where he was almost blacking out. The first one happened as we were driving home on our wedding anniversary (September 24). So we decided to stop in the cardiologist's office after one of the biopsy follow-up appointments on September 27.

Turns out the ejection fraction hadn't changed. And the blackout incidents were something called ventricular tachycardia (VT), a condition were the heart rate speeds up. Because he had a pacemaker the nurse could upload the data from it and pinpointed the VT. CPA Boy's heart rate was going over 170 beats per minute during these episodes. They lasted for several seconds and then stopped. The fear is when they DON'T stop as cardiac arrest can result.

So the answer to all of these issues was a new pacemaker called an ICD, an implantable cardiac device that has a pacemaker as well as an internal defibrillator (an internal version of the device they use in medical TV shows where they place the two paddles on a patient's chest and yell "Clear!").

CPA Boy had this surgery on October 7. And all is well. The ICD is doing its job. He's still in the six week recovery phase but is doing fine. He still has AF and VT but the ICD and its leads to the heart are keeping them from going very far. Thank goodness for modern medical technology!

And now we are left with the medical bills. We have insurance and we have reached our large copay ($5,650) and also reached what they call out-of-pocket expenses ($5,350) so insurance should pay for everything else through 2013. (Our premiums cost about $12,000 a year so we will pay over $23,000 total this year, not counting dentist and eye doctor visits for which we have no insurance coverage.)

The Medtronic guy we talked to said the wholesale prices of pacemakers run from $4,000 to about $10,000. For the ICD the hospital billed $110,000 for the ICD and $33,000 for the two new leads. The Medtronic Revo pacemaker from the May surgery was billed for $26,125 and the lead was billed for $10,560.

I found a pricing list online for Medtronic dated May 2013. It indicates a list price of $13,000. The hospital billed us twice that. The newer Medtronic Protecta ICD was shown at a list price of $34,000.

So let's do some math! If the Revo costs Medtronic approximately $4,000 then they sell it for $13,000, more than three times its cost. The hospital turns around and doubled the price when billing us/insurance.

On the Protecta it costs approximately $10,000 for Medtronic to manufacture. They sell it for $34,000, again more than three times the cost. But this time the hospital charged $110,000, over three times its cost.

For the record, because we used a network hospital the insurance has negotiated paying a lower amount to the hospital. For the $224,088.32 they discounted the bill by a total of $166,499.31 leaving a balance of $57,589.00. That would be the maximum amount the insurance company will pay the hospital. (Interestingly, we would be on the hook for the whole amount if insurance refuses to pay.)

So it's hard to say how this works, really. If the hospital paid $34,000 for a device and they bill for that and the other costs related to an operation and overnight stay, then they are really only getting just over $23,000 to cover those expenses.

(Keep in mind that the doctor who performs the surgery bill separately; he billed $6,550 and received $2,677 from insurance.)

The $23,000 seems a reasonable amount to cover expenses. (A hospital administrator might say otherwise!) There were at least a couple of dozen different surgeries going on that same day (mostly out-patient) and if the hospital gets $23,000 a pop at say, 24 surgeries, then they are taking in over $500,000 that day as well as whatever they are getting from patients already admitted. The doctors bill separately so they are paying nursing and administrative staff as well as overhead costs.

Anyway, I realize this is less than interesting to most of you. I just really wanted to put some numbers out here for those other people scouring the Internet for information. I hope this might help someone else.


  1. To make an obvious comment, I'm glad you majored in math! Someday I want to see your spreadsheet.

    I hope that CPA Boy continues to do well with all his new hardware and software. What a funny strange thing to have. I have been wondering what was going on this summer.


    1. Hey J! Hope you are doing well. We will be glad to get a definitive diagnosis, hopefully later this month. It's all so mysterious and scary until you know the answer. More updates to follow, no doubt! Hugs!