Why Isn't This Fraud?

Having a medical condition that has forced me to delve into the recesses of the health care system has left me perplexed.

I have to wonder why the insurance companies, hospitals, medical device providers, and pharmaceutical companies, aren't all being charged with massive fraud.

"Free market" I guess is the answer, but if so, it is a sucky one and one that I do not accept. Because what is going on in the system in this country is, to be perfectly frank, wrong.

I am going to give you two examples from my own recent history.

In September, I received a CT Scan at one of the local hospitals. My insurance was billed $10,582.80 by the hospital for the procedure (this did not include ER or other tests, this was the CT scan only). The insurance company "allowed" $3,472.13, and that is what they paid as I had already met my out-of-pocket deductibles. (For my readers outside of the US, that is a cap the insurance companies place on policies. Once you pay X amount out of your pocket, then the insurance pays 100 percent of its allowable costs. It's very confusing.)

In April I had another CT scan at an affiliated satellite location with the same hospital. The charge for that scan was $7,949.00. The insurance company "allowed" $2,276.48, and I had to pay 20 percent of that "allowable" cost because I had not yet met my out-of-pocket deductible for this year.

When I go to my insurance company's website and look at their "estimate the costs" link for procedures, the cost for a CT scan of the abdomen with and without contrast (which is what I had), is less than $1,000. Good thing I wasn't depending on that to be right, huh?

How is this possible, you ask? Here's my understanding of it. The hospital "contracts" with the insurance companies and they make agreements about what is acceptable. You and I have no say in this matter. Neither does the government, except with government-paid policies (Medicare/Medicaid).

Obviously the hospital can afford to do a CT Scan for $2,276, the lowest price my insurance company "allowed," and not $10,582, the highest price the health care facility billed.

Read the comments on this website about the costs of CT Scans. One commenter claims to have been charged $252,000 for a CT Scan! Public bilking, anyone?

Here's the second example:

My doctor prescribed a TENS unit to help me with pain and so that I am not taking so many pain killers. A TENS unit sends electrical shocks into your muscles to trick your brain into thinking the spasms and pain aren't there. It helps.

The bill for the TENS was $795.00. The insurance company "allowed" $185, and I will have to pay 20 percent of that amount. The rest of the cost vanishes into thin air.

Last week I received a notice from the TENS unit company that it was time to get new electrodes (little pads that attach to your skin so that the electric current can go into your body). My insurance supposedly will pay 80 percent of the "allowable cost" for these supplies. This is my first time ordering them.

However, because of the "contract" with the company, and what may or may not be allowed, no one can tell me what my cost will be. I will be paying 20 percent of whatever the insurance company allows, as I understand it.

So I could be paying $2 or $200.

The company that sells the electrodes told me over the phone that they could sell them to me at the "out of pocket" cost (i.e., the cost without going through insurance), for $21.60 a pack. A pack, by the way, should last me 10 days. That is a lot of money.

What do you bet they charge the insurance company about three times that amount? And then the insurance company "allows" so much - but will it be less than $21.60 or more? I don't know.

So I asked my physical therapist today if they sell the electrodes by the pack. Why sure they do! For $9 a pack.

Will my 20 percent share on my insurance be more or less than $9 a pack? I don't know.

How am I supposed to make any kind of an informed decision about purchasing these items? How do you work that kind of thing into your budget when you don't know the amounts?

Tell me, somebody please, how all of this - this making up amounts and back-door dealing - isn't one great big fraud being perpetuated upon the American public. We Americans think we have the greatest health care system in the world when it really ranks 38th, right under the health care of Costa Rica and just slightly better than that of Slovenia! Slovenia, for Christ's sake. We are not number one. That would be France. Yes, France.

Health care should be regulated. Free market my ass. F--k capitalism and the so-called Free Market. This is nothing but a rape of the sick, who generally are too ill to fight and advocate for themselves. The greedy shysters in the industry know they can easily take sick people's savings, cars, homes, and lives. What a distasteful and immoral system we have, one that allows such devils to prey upon the weak. Blood sucking leeches, every last one of them, and they all should be behind bars serving time in jail.

This is why we need real health care reform, one with regulations, checks and balances, and oversight that keeps people who are ill from having to grow even sicker trying to figure out how to keep food on the table and the lights on.

Unfortunately, fraud is legal in US health care, where only dollar bills count and people are just so much chum in the ocean filled with sharks.