It's a bill Leslee Botello wasn't expecting: $7,000 to treat her son's broken knuckle at Lehigh Regional Medical Center's emergency room.
Botello has insurance and was told it would cover the hospital visit because the hospital was part of her insurer's medical-care network.
While Botello's son was at the hospital for less than three hours in late April, the total bill exceeded $21,000. Her portion of that, after insurance kicked in their share of costs, was $7,000.
Part of the reason Botello's bill was so high was because while the hospital was an in-network provider, many of the doctors who worked on her son were out-of-network
As hospitals seek to lower their cost of providing emergency care they frequently contract with independent doctors to provide treatment rather than using staff physicians. Many will also use off-premises contract radiologists in other countries to read the X-ray or MRI.
These non-par providers are free to charge whatever they wish while the insurance contract will only pay reasonable & customary. Many times the gap between what the carrier pays and the providers charge is 30% or more of the bill.
The real oddity in this story follows.
"Most of our programs are geared toward the uninsured. We don't (typically) discount for insured patients," said Billie Jo Debolt, system director for business services at Lee Memorial Hospital. "But, we do have some programs, like our prompt payment discount. If the bill is paid in full within 30 days, it can be 30 percent of the balance. We have sliding-scale discounts based on a person's income. If a person falls within 300 percent of federal poverty guidelines, they may be entitled to a 40 percent discount. If they fall within 400 percent, there may be a 30 percent discount."
For those with no insurance, full charity care is available, providing the patient falls within federal poverty guidelines.
People who are uninsured receive a better break than those WITH insurance.
Most of the area hospitals also have social workers on staff who help patients enroll in Medicaid so they have coverage
Here is another interesting fact. Many times you can enroll in Medicaid AFTER you have incurred charges and have your bill covered retroactively.
So where is the incentive to take personal responsibility?