Your Insurance Is Costing More

Wednesday, April 25, 2012

Seniors attend a 'Medicare Monday' seminar at the Holly Creek retirement community on December 6, 2010 in Centennial, Colorado. 80 people came to learn how federal health care reform will affect them. Seniors attend a 'Medicare Monday' seminar (John Moore/Getty)

Nina Bernstein, health care reporter for The New York Times, discusses her reporting on how the largest health insurers in the country have been calculating the price of care based on Medicare rates - a calculation which pushes prices up.

Comments [23]

Eric from Albany CA

Reply to Bob from Huntington: in reality, hospital "owned" physician practices are often separate legal entities from the hospital itself, i.e., the physician practice is a legally distinct professional corporation or partnership separate from the hospital corporation. This arrangement permits physicians in the practice to bill insurers separately from the hospital, and it also enables the physicians to effectively exclude themselves from the hospital's network for the purposes of billing a particular insurance plan. This kind of arrangement may be legally mandated in states (such as California) where the "corporate practice of medicine" (e.g., direct ownership of physician practice by a hospital) is prohibited.

Apr. 25 2012 03:07 PM

My policy changed last year upon renewal to reimburse at 140% of Medicare instead of 80% of their make-believe "usual and customary" charges. What surprised me about the recent news coverage is not that it's happening, but that the media just found out NOW. I've been struggling with this since 2011. And, separately, prior to this year my rates increased over 20% a year for 5 or 6 years -- so it's a complete farce when the insurance companies claim that they're raising rates in anticipation of the new health care act. They've been gouging us as long as they've been about to get away with it.

Apr. 25 2012 12:04 PM
John A.

I have done line-by-line analysis of several dealings with doctors and hospitals. Why is extra charges for services not received not fraud? It is routine in nearly every dealing with them. And then there is the runaround involved in trying to get estimate first. Wow such an assault on That which I consider ethical.

Apr. 25 2012 12:03 PM

@Elle from Brooklyn
that doctor is probably happy to have a certain cash flow than one that is uncertain with insurance.
Yes health insurance should be non-profit for ethical reasons. Why should an Insurance CEO make $$$ when people are denied benefits.

Apr. 25 2012 12:02 PM
bob from flushing

Why not make all billing information available to patients in advance so they can verify what will and will not be covered in advance of treatment?

Major surgery is in essence a financial transaction and an informed estimate of charges should be required by law.

There's apparently no regulation in an area that cries for regulation..

Apr. 25 2012 12:01 PM
Pina from South Plainfield, NJ

There should be no networks, everyone should have one universal coverage!

Apr. 25 2012 12:00 PM
CL from NYC

This reporter who has ostensibly researched this matter thoroughly can't answer the question about why the insurance companies aren't obliged to use the data base???? That's ridiculous and, frankly, shameful. She should know the answer to the most important question the problem raises.

Apr. 25 2012 11:58 AM
Elle from Brooklyn

I have a doctor who became so fed up with the whole insurance system that he just stopped filing any insurance claims. You go in as a patient, pay him your usual co-pay (whatever it may be), and he just accepts that as his full payment. Obviously, this only works if the doctor is in such a good position financially that he/she can afford to do this, but it is telling to me that ANYONE would consider it preferable to earn less money than to file claims.

Apr. 25 2012 11:57 AM

If anyone need help with out of network bills please call Community Health Advocates (CHA) at 1-888-614-5400 or email All services are FREE

CHA assists consumers, communities, and social service organizations in navigating New York’s healthcare systems and services. We help people understand and access Medicaid, Medicare, Child Health Plus, Family Health Plus, commercial insurance and other health care options.

Visit their website at:

Apr. 25 2012 11:56 AM
Marc from Hastings on Hudson

The profitability questions is the issue. Insurance carriers are for profit, not for health. No one has stood up to the moral/ethical question: should health care be a for profit enterprise?

Apr. 25 2012 11:56 AM
Jon Pope from Ridge, NY

I've been paying 100% of my health insurance since 2000 in both NJ and NY. I've only been able to afford HMO coverage. With the exception of Emergency room visits, I've never been given the option to go outside my network and get reimbursed one penny. What fantasy land does this outside of network HMO coverage exist in? Please let me know, I'd like to pack up and move there....

Apr. 25 2012 11:53 AM

Doctor are not to blame. Its the insurance companies and hospital admin who force charges.

Apr. 25 2012 11:53 AM
Elle from Brooklyn

Following delivery, a friend received a huge bill for her epidural b/c the anesthesiologist was out of network. She didn't pay, but it took her about a year to sort out. Outrageous. Are you supposed to check credentials while you're lying on the table?

Apr. 25 2012 11:53 AM
The Truth from Becky

If the Doctor's do a "switcheroo" as she is explaining, in the operating room then the bill for the difference in fees should go to the Doctor(s).

Apr. 25 2012 11:52 AM

a couple months ago i cut my finger - no insurance, so i went to the emergency room at Beth Israel. i needed 4 stitches and a tetanus booster. total bill, including doctor's charges and ER fees: $1,855.69.

the tetanus booster was $164.00. according to the CDC website (, that's a 437% markup - according to the price to the institution a medical insider i know quoted to me, they are charging me a 5,500% markup. i imagine it is hugely expensive to run a hospital in nyc, but still...

Apr. 25 2012 11:51 AM
Leah from South Harlem

Let's talk about dental. I didn't phone the insurer -- I just went for an implant, because I didn't want to shave down the two neighboring teeth in order to make way for a denture. And also implants are just better, plain and simple. So I went to a great guy, albeit expensive -- $2,900 for extraction + implant (same session, by the way; new tech) -- and the insurer covered $120!!! Outrageous! They said they don't cover implants. I think the $120 covered part of the extraction component only. Argh!

Apr. 25 2012 11:50 AM
Elle from Brooklyn

The supposedly "reasonable and customary" rates for NYC are often ridiculously low.

Apr. 25 2012 11:50 AM
The Truth from Becky

Real simple fix...I don't go out of network.

Apr. 25 2012 11:48 AM
RJ from jprospect hts

And what happened to the academic entity that is supposed to be the objective determiner of insurance/health care costs? A chunk of money was given to several universities among others to determine an *appropriate* usual and customary. Then, who's to require the companies to charge based on those costs to come?

Apr. 25 2012 11:47 AM
RJ from prospect hts

Paying more for medications also--copays have increased from $20 to $50 or $50 to $100 or $75 to $150.

Apr. 25 2012 11:45 AM
Bob from Huntington

A question for Nina:

At many large hospitals many of the surgeons are, in fact, hospital employees who receive a salary. Yet, they are often members of doctors groups that bill insurers as though the surgeons were in private practice. Consequently, you can have surgery at a hospital that is "in network," yet, have your insurer tell you the doctor is "out of network" and you are responsible for any unpaid balance.

Question: If the doctors are hospital employees on salary, shouldn't their charges be covered as part of the in-network hospital charges? This is the practice when you visit an emergency room. ER doctors are hospital employees and their services are covered by the hospitalization portion of your health insurance--for many New York State employees that's their Blue Cross/Blue Shield coverage.

Apr. 25 2012 11:19 AM
Catherine Anastasio from Brooklyn, NY

Basing usual and Customary allowances on the faulted Medicare fee schedule is costing patients high percventage of these services.

Insurers are also cxost shifting to patients for in network services with higher co-pay amounts.

The New York Physical therapy Association (NYPTA) currently has a bill pending in the NYS legislature to cap the co-pay at 20 % of the allowed fee.

Catherine Anastasio, PT
Member NYPTA
Owner of Ridge Physiacl therapy
Brooklyn, NY
(718) 745-8282

High Co-pay Senate/Assembly Bill
DeFrancisco introduced Senate same as, PT co-pay bill
S 4870 DEFRANCISCO Same as A 187 Cahill (MS)

TITLE....No policy of group accident, group health or group accident and health shall impose copayments in excess of 20 percent of total reimbursement to the provider of care


Apr. 25 2012 10:43 AM
Elizabeth Cohen from NYC

The PPO insurance plans which provide access to providers both in and out of network are essentially fraudulent. They charge higher premiums and have higher deductibles so that you have the option to go out of network if necessary, and you agree up front that you will only receive 60% reimbursement (or 70% dep on the plan). HOWEVER, you don't realize at the time that that is 60% not of the original bill, but of a lower "allowable amount," and then have to pay back the unreimbursed amount to the doctor. Why are we paying higher premiums and higher deductibles for this? I currently owe over $50,000 to a spinal surgeon who received a paltry reimbursement "because he was out of network." (After charging you more, they then blame you for going out of network.) In NYC, NONE of the major spinal surgeons are in-network. What is a patient to do?

Apr. 25 2012 09:19 AM

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