You're kidding, right?
This can't be true, can it?
No. It's true. Here's why.
Under most insurance programs in America, the cost of providing care is shared between the insured patient and the insurance company. To determine how much the patient pays, there are four different aspects to the equation.
There is a "co-pay". This is an amount paid per visit by the patient, regardless of other factors. If you make a doctor's visit, you pay a 20 dollar co-pay. The insurance company doesn't even look at that 20 dollars. At the emergency room, the co-pay is 75 dollars.
Then there is an "annual deductible". I don't know if that term is used in Europe, so I'll explain it. Basically, it means that until your expenses reach the deductible, you pay everything. My deductible is $1,000. That means I pay the first $1,000 each year of submitted costs.
Then there is the actual cost of providing care, especially procedures. A visit to the doctor is covered at 100% of the cost. However,If that doctor does anything, there's a separate charge. Example: Applying a splint to a broken finger, which is why I was in the emergency room most recently, is a procedure. Procedures are paid at 80% if you at an "in-network" provider, but 60% for an "out of network" provider.
In case those terms aren't known, I'll explain them. An insurance company contracts with some doctors who agree to charge certain fees for certain procedures. Those doctors, or other medical providers, are called "in network". It is cheaper for the insured patient to use an "in network" provider. Each insurance company has a different network, and doctors are usually in many networks.
Finally, there is an "out of pocket maximum". I pay no more than $3,000 care per year. After that, the insurance companies pick up 100% of the rest. Of course, that's for in network providers. For out of network providers, that out of pocket maximum is $6,000.
So why are two emergency rooms different in cost? Let's start with the co-pay. A co-pay comes up each time you make a visit that results in a bill. Some hospitals are organized as a single business entity. From the time you walk in the door, to the time you leave, you are dealing with one company. Others have sub-units inside them. The X-Ray and Medical Imaging Lab might be a separate business entity with its own set of books, and its own contracts. So, if you go to the emergency room, you might actually be dealing with two different businesses. That means two different co-pays.
Next, what about labs? The hospital takes your blood. They might send it to a lab for analysis. Just because the hospital is an in network facility does not mean that the lab they use is an in network facility.
And the doctor who sees you? Is he a hospital employee? Or is he an independent provider providing services to the hospital? If the latter, he has his own billing. And possibly co-pay.
So, at one hospital, I go in, everybody sees me is an employee, and all the labs are internal. That means everyone is in network and there's a lower bill. At the other hospital, there are lots of sub units, and not all of them are in network.
Of course, a doctor's office or hospital might use different labs on different days, depending on availability, for bloodwork. Some are in network, some are out of network. Depending on where they send the blood, your bill might be substantially different. I have had insurance reps explain patiently to me that as a consumer, it is my responsibility to ensure that the blood goes to an in network lab after some nurse draws it. No I am not making that up or exaggerating.
And of course, each insurance company has its own rules as to what's covered and not. A doctor might be in several networks, so when he orders a test for one patient, that patient might be fully covered, but a second patient might have coverage denied.
It's a total mess, and a nightmare of paperwork, and a major reason we spend so much more per capita than European citizens for health care.
