Obama: US Could Go Broke Unless Healthcare Is Reformed

[Dan40]

There are basically 3 kinds of patients.
1.SELF PAY-- Those that have money to pay but choose not to be insured.
2.INSURED--Those covered by private insurance, individual or group coverage.
3.And those covered by a Government program or policy.

Lets say a surgery has to be done and the hospital/surgery center charges $20,000.00 for the surgery.
#1. is billed for $20,000.00 and must pay that.
#2. is also billed for $20,000.00 But he has 80/20 coverage, so he pays $4000.00. Does his insurance company pay the remaining $16,000.00? NO, they have a contract with the hospital where they agreed that surgery is worth $8000.00. so the patient pays 20% of RETAIL, $4000.00 and the insurance pays 80% of WHOLESALE, $6400.00.
#3. The Government has a schedule of benefits list and allows a certain sum for each treatment. The $20,000.00 Retail price means nothing to the Government. For the particular surgery they have a price of $2500.00. A person with 80/20 coverage [like Medicare] would pay $500.00 for this surgery if it was outpatient. Gov. would pay $2000. If the surgery was inpatient [patient was admitted and spent more than 24 hours in hospital] then the Government pays a flat rate for the admitting diagnosis. Patient pay a preset deductible only. No 80/20.

Does the system need overhaul? YES, YES, Does it need more Government NO, NO!!

Fix, not replace.

Your Cobra has bad plugs and wires. Replace the Cobra or get a tune up?

[fsstnotch]

Originally Posted by Dan40

There are basically 3 kinds of patients.
1.SELF PAY-- Those that have money to pay but choose not to be insured.
2.INSURED--Those covered by private insurance, individual or group coverage.
3.And those covered by a Government program or policy.

Lets say a surgery has to be done and the hospital/surgery center charges $20,000.00 for the surgery.
#1. is billed for $20,000.00 and must pay that.
#2. is also billed for $20,000.00 But he has 80/20 coverage, so he pays $4000.00. Does his insurance company pay the remaining $16,000.00? NO, they have a contract with the hospital where they agreed that surgery is worth $8000.00. so the patient pays 20% of RETAIL, $4000.00 and the insurance pays 80% of WHOLESALE, $6400.00.
#3. The Government has a schedule of benefits list and allows a certain sum for each treatment. The $20,000.00 Retail price means nothing to the Government. For the particular surgery they have a price of $2500.00. A person with 80/20 coverage [like Medicare] would pay $500.00 for this surgery if it was outpatient. Gov. would pay $2000. If the surgery was inpatient [patient was admitted and spent more than 24 hours in hospital] then the Government pays a flat rate for the admitting diagnosis. Patient pay a preset deductible only. No 80/20.

Does the system need overhaul? YES, YES, Does it need more Government NO, NO!!

Fix, not replace.

Your Cobra has bad plugs and wires. Replace the Cobra or get a tune up?

Yep, exactly! My wife had Knee surgery on halloween last year. Dr bills were around $25,000. We owe close to $4000. Her surgery was done by one of the best in the country, 1 week after diagnosis! That's the kind of healthcare I like!

[Joe Wicked]

Originally Posted by Dan40

There are basically 3 kinds of patients.
1.SELF PAY-- Those that have money to pay but choose not to be insured.
2.INSURED--Those covered by private insurance, individual or group coverage.
3.And those covered by a Government program or policy.

Lets say a surgery has to be done and the hospital/surgery center charges $20,000.00 for the surgery.
#1. is billed for $20,000.00 and must pay that.
#2. is also billed for $20,000.00 But he has 80/20 coverage, so he pays $4000.00. Does his insurance company pay the remaining $16,000.00? NO, they have a contract with the hospital where they agreed that surgery is worth $8000.00. so the patient pays 20% of RETAIL, $4000.00 and the insurance pays 80% of WHOLESALE, $6400.00.
#3. The Government has a schedule of benefits list and allows a certain sum for each treatment. The $20,000.00 Retail price means nothing to the Government. For the particular surgery they have a price of $2500.00. A person with 80/20 coverage [like Medicare] would pay $500.00 for this surgery if it was outpatient. Gov. would pay $2000. If the surgery was inpatient [patient was admitted and spent more than 24 hours in hospital] then the Government pays a flat rate for the admitting diagnosis. Patient pay a preset deductible only. No 80/20.

Does the system need overhaul? YES, YES, Does it need more Government NO, NO!!

Fix, not replace.

Your Cobra has bad plugs and wires. Replace the Cobra or get a tune up?

My insurance works very similar to what you posted as the government plan. I work for Samsung and we are Self Insured. We use the Cigna PPO network for in and out of coverage, but Cigna is not the actual insurance provider. Samsung pays Cigna an annual fee to use their services. Samsung pays all the bills and our co-pay is 10% of the agreed upon price (wholesale not retail). Just pointing out that there are variations in the 3 listed above.