Need some insurance advice

Following up last week’s post about insurance ridiculous, I spent some time poking around for different plans and found a hospital plan that “covers your hospital needs-and the hospital needs of your covered dependents-even when you are far away from home.” Well visited are covered too, and It’s significantly cheaper than our current plan and a better insurer. You pay out-of-pocket for non-hospital visits, but then hospital stuff is covered. That would work for us.

Here’s the question though: they say they only cover expenses billed by the hospital, so if the surgeon isn’t on the staff, their work wouldn’t be covered. I have no hospital experience and so my question for those in the know: is it common for hospital doctors to be hospital staff? Or are they usually not? What I don’t want is an accident that sends me to the ER, like a car crash, and I have some emergency surgery and after the fact discover the surgeon isn’t a hospital employee. And then be on the hook for $300,000 in bills or something. Anyone with experience, please chime in!

18 thoughts on “Need some insurance advice

  1. In my experience it depends on the hospital. My wife delivered our second child last year via emergency c-section (ambulance arrival, cord prolapse) and the baby spent a week in the NICU of a hospital we had not “preregistered” for or done any sort of in-network/out-of-network research on, and we were lucky that their “hospitalists” (OB & pediatrician) were hospital staff rather than out of network contractors. However, it is my experience that almost all labwork/pathology and anesthesiology is billed separately and not part of hospital staff (even if it is in-network). Still, to pay the hospital bill and the doctors, we first had to meet our deductibles and out-of-pocket maximum. Our $45K hospital bill ended up being our out-of-pocket max of $1500. I’d be wary of any plan that has a very high out-of-pocket max.
    Our first child was also a C-section, with the surgery provided by my wife’s OB so the surgery bill came from her office. Same for our pre-selected pediatrician to visit the hospital. About ten separate bills on that birth. It’s my understanding that this is the more common model–every one bills separately.
    (Another note: a common and annoying practice these days is “balance billing” where you get bills directly for things that your insurance should cover. This happens to us on about every third bill.

  2. When I had some minor out patient surgery, the doctor was on staff, but the anesthesiologist was not. So we received one bill from the hospital (which included the doctor) and one from the anesthesiologist. When I had my daughter, we got three bills – one from the anesthesiologist, one from the doctor, and one from the hospital.
    Have you used an independent insurance agent for any of this? in my experience, they’re here to answer just these kinds of questions, and they don’t represent a single company, so they can usually help find something that fits your needs?

  3. I use and they show all the available plans and have talked to them so yeah, that’s helped. I just wanted a sense of what it might be like. I did speak with someone this morning at the insurance company and she said about 50% of the doctors fees tended to be through hospital. But also in the car accident example, all the hospital services are covered, only the surgeon and anesthesiologist might not be. So even if total bill was $300,000, most of that would be covered stuff. And since the plan is significantly cheaper than our current plan, the money I’d save each year could be put aside for such fees, if/when they came due.

  4. Also, keep in mind that all preventative care (well baby visits) now has to be covered under the Affordable Care act. My annual exam/mammogram are my biggest expenses most years, so when I had to get private insurance (thanks layoff) I got a high-deductible plan. For me that was the biggest difference from the last time I had crap insurance.
    I don’t know about the hospital-specific info though. I’m way out here in the sticks so I did check that my local clinic and the three closest hospitals (including 2 in Billings, 90 miles away) were in-network.

  5. In general, the more specialized the provider, the less likely they are to be on staff. ER docs, general surgeons, Primary Care doctors within the hospital (and of course nurses, support staff, etc…) are usually on staff. Specialized surgeons, pediatricians, anesthesiologists are usually not on staff.
    The answer is definitely very dependent on the location and the type of hospital. A for-profit in Texas will have a much different mix than a non-profit teaching hospital in Boston.

  6. @Charlotte Yeah, that’s what makes this plan actually seem reasonable, because all well visits are covered at 100%, kids and adults. So we only pay for sick visits and then the non hospital expenses. Seems like dollar for dollar, the money we save on not paying higher monthly fee makes this work out.

  7. Last year my husband went to the ER with chest pains. [He wasn’t admitted.] I can echo what others said: the doctors and lab work were not billed by hospital. This was at a non-profit teaching hospital in Houston, FWIW.
    Ambulances are also billed separately, and more expensive than you can imagine. I’m not trying to sway you one way or the other, of course; it was just a marvel to me.
    As you probably know, you only have to spend something like 7.5% of your AGI on medical expenses to claim them on an itemized tax return. We’ve gotten close to that number before even with good, employer-sponsored health insurance. I don’t know how premiums figure into that 7.5% though.

  8. This insurance business seems absolutely crazy. I don’t know much about the American healthcare system (I’m from the UK – and ours certainly isn’t perfect!) but there must be a better way…

  9. @Katie, et al- Our health care system is crazy! That is the reason our legislators eventually passed a watered-down health care bill last year. The sad thing is that it doesn’t go nearly far enough. However, it all may be moot if the current congress gets its way. Health care in the U.S. is an absolute nightmare!

  10. Personally, I would be worried about insurance covering treatments for a long term illness. Yes, hospitalization is expensive, but so are cancer treatments. A friend of mine was recently diagnosed with ovarian cancer and is getting chemo infusions. All her treatments are at an outpatient infusion center. Something to consider.

  11. @Toni I’m worried about that. I feel like I’m hanging on here until 2014 when we can buy from the exchange. I have no idea if it will be affordable and decent coverage. And no idea if it will even happen.
    @Amy Good point, thanks. This is exactly why I asked for comments here, to get some broader ideas about what I could require. Looks like this plan does cover chemo and some other outpatient treatments.

  12. In the car accident example, the at-fault patry’s auto insurance may cover the medical expenses (ie “liability” coverage if someone hit you, “medical payments” if you hit someone else). Even if you can’t pay, a subrogator will often reduce the amount down to a “negotiated rate.” In sum, the auto accident example is a situation where there may be other coverage or third-party liability for injuries, so the hospital should be informed of that upon admission to the ER.

  13. You should probably ask the hospital about doctor billing. My experience with hospitals in Indiana and North Carolina, the doctors always bill separately from the hospitals. I don’t think I’ve ever had a doctor bill through the hospital, even the pediatrician on staff when my kids were born.
    We have a high-deductible private plan with an HSA. But I opted to not have maternity coverage. Did you realize that if you pay upfront hospitals and doctors will often give you a discount?
    Also, if you’re not familiar with Aflac you should check it out. Aflac is what’s called “supplemental insurance”. They offer lots of different plans, but the accident plan is the most worthwhile (especially with kids). After an “accident” we get a check for $120 for visiting the doctor, and $35 for several follow-up visits. They also pay extra for other types of procedures that might be needed. It’s really great if you frequent the chiropractor because the definition of accident is so loose. Say you’re hanging pictures and get a kink in your neck. That counts as an accident.
    I’m not affiliated with Aflac, it’s just so awesome I try to let everyone know about it. If you go to you can search for representatives in your area.

  14. im a fellow new yorker who works as a nurse in one of the large teaching hospitals in the area. while i dont know a lot about insurance issues, since what i do is bedside care, i am familiar with many of the hosptials in the area as they typically refer to us.
    most of the hospitals in the greater NY region are teaching hospitals. (ny presbyterian has both columbia and cornell and then theres nyu, montefiore, methodist, mt sinai, st luke’s, st vincents was 🙁 one, and even the public city hospitals such as bellevue, jacobi, metropolitan, etc are all teaching hospitals. and that’s just the tip of the iceberg!) as is such, most physicians that work there are hired as professors of the associated medical schools/universities. if youre admitted to those hospitals, im sure that some fees for services (tests like ultrasound, some bloodwork, x-rays, bed occupancy which pays for nursing care, etc) are charged by the hospital itself, but im *pretty* sure the university is somewhat involved what the fees for services of the physicians, who are the ones ordering all of the labs, bloodwork, test etc. im not sure how it works as an outpatient, but most of those physicians practice as both inpatient and outpatient providers, so im sure the universities/medical schools are involved.
    i hope this didnt make things worse for you! this insurance stuff is so confusing, and i work in the health care industry! i was just hoping to provide a more local perspective. id recommend you call the hospitals you would be most likely to come in contact with and ask about their billing practices. also, see what institutions your pediatrician, obgyn/midwife and general practitioner have admitting privileges with and ask them as well. the system, as messed up as it is, is designed for you to first deal with things through your primary providers who then refer you to specialists as needed, unless there is an emergency where you need to access the system via the emergency department. see what the practices are are the institutions where you are most likely to get care, and go from there.

  15. For what it’s worth, I had emergency surgery 2 years ago. ER was covered, but ER doctor was separate because he was a contractor. The general surgeon who did the surgery was separate, as was the anesthesiologist. Blood work and abdominal scans were also separate charges. It added up fast.
    In Houston we’ve got a lot of non-profit teaching hospitals, and there doesn’t seem to be any difference on the financial side of things between those facilities and “for profit” facilities. Only difference I’ve noticed is how many doctors/students/residents appear in your room to discuss things and availability of non-standard protocols.
    Long term care can be exceptionally expensive, even with insurance. My uncle had lung cancer that had metastasized to his brain. Despite excellent insurance, within 6 months the family had to put their house on the market to cover the deductibles from his care. This in California.

  16. It is increasingly common for ER docs and anesthesiologists to be outside contractors, and specialties, like orthopods, neurosurgeons, plastic surgeons- really anything you can think of– almost certainly are members of groups that will bill separately. That’s really the reason the policy you are looking at can be cheaper– it covers a lot less.

  17. It boggles my mind reading how complicated and expensive health insurance is in the States. I live in The Netherlands where rates are going up every year but nothing like this. For this year I paid €1570 for my entire insurance, which covers almost all medication, hospital visits, doctors, ER and surgeries. Only the dentist I have to pay a percentage if I go for more than the twice a year clean up.
    I had a kidney transplant in 2009 and dialyses before that, the costs were astronomical. I never would have been able to pay for it.
    I really feel the injustice for people in countries where health insurance doesn’t work the way it is supposed to.
    I hope you manage to get a good insurance packet, quality and price wise!

  18. As Charlotte mentions above, coverage for adult and child well visits is required due to health care reform, but make sure to look at what the insurance plan will cover at a well visit. Does it include lab work if you or a family member needs to have blood drawn, or any other tests that need to be run?

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