The Myths and Realities of Healthcare Insurance: Why You Might Be Paying More Than You Should

Myth 1: "My cost for a service will always be lower if I use my health insurance than if I pay my doctor directly."

Reality: This is often not the case. While insurance can help with significant medical expenses for things like catastrophic injuries, it doesn't always guarantee the lowest price for routine or predictable care. Due to deductibles, co-pays, and negotiated rates, you might find that paying out-of-pocket for neuropsychological assessment could be the same or cheaper than using your insurance.

Myth 2: "Doctors on insurance networks are more qualified than doctors not on insurance networks."

Reality: A doctor's network participation has little to do with their qualifications. In fact, apart from verifying that a doctor is licensed to practice their profession in their state, there is virtually no vetting or quality control surrounding the doctors who join insurance networks. Many highly skilled and experienced doctors choose to stay out-of-network for various reasons, including greater control over patient care and less administrative burden. Insurance companies keep their insurance networks of specialists, like neuropsychology, small so that their members are funneled toward providers insurance companies who accept a low fee. This results in outrageous wait times, doctors spending less time with patients, and poorer patient care.

Myth 3: "Paying for healthcare services out of pocket is incredibly expensive, and only for wealthy people."

Reality: While major medical emergencies can be costly, many routine healthcare services are surprisingly affordable when paid for directly, even specialties like neuropsychology. Many clinics and providers offer transparent pricing for common procedures, allowing you to compare costs and potentially save time, money, and stress by bypassing insurance altogether. Additionally, working directly with a doctor's office to determine cost allows them to offer you discounts, pre-payment, payment plans, or sliding fee scales. A health insurance company will NEVER negotiate with you or work with you to make sure that a healthcare service is within your financial means.

Myth 4: "Having health insurance means I don't have to worry about healthcare costs."

Reality: Even with insurance, healthcare costs can be a significant burden. Over 50% of health insurance holders have a deductible in excess of $1,000. That means that you have to pay at least $1,000 out of pocket before your insurance covers anything. Patients with high-deductible plans may find that their costs working directly with a doctor to pay for healthcare is actually lower than what their deductible would have cost them.

Myth 5: "My insurance company always has my best interests in mind."

Reality: Insurance companies are businesses, and their primary goal is to generate profit, not necessarily improve health and wellness. It's important to remember that their interests may not always align with yours, and that to an insurance company, you are risk that must be managed using algorithms and legal maneuvers. In fact, author Jay Feinman wrote a book on the most common methods by which insurance companies (not just in healthcare) extract profit at the expense of their members called "Delay, Deny, Defend" which can be purchased online:

• Delay - Insurance companies take weeks or months to resolve even routine basic claims.
• Deny - Insurance companies only turn a profit by collecting premiums and refusing to pay for some or all of a claim
• Defend - Insurance companies aggressively defend denials using dedicated teams of lawyers and analysts that most regular people are simply unable to compete with

These strategies are what allow insurance companies to reap enormous profits. For example, in 2023, United Healthcare CEO Andrew Witty earned $23,5234,936 (https://www.fiercehealthcare.com/payers/unitedhealth-ceo-andrew-witty-was-2023s-highest-paid-payer-ceo-heres-what-his-peers-earned), Elevance Health (which includes Anthem/Blue Cross Blue Shield) CEO Gail Boudreaux earned $21,889,039, and Cigna Group CEO David Cordani earned $21,047,255.

It is ironic that we complain about the rising cost of healthcare, but are willing to participate in a healthcare system that funnels the proceeds of these rising costs to corporate healthcare executives and administrators!

Myth 6: I can simply call the number on the back of may card and ask if a service will be covered and how much I will have to pay.

Reality: While doctors are required by law (the "No Surprises Act") to provide transparent pricing to their patients, insurance companies are under no such obligation. Patients are rarely aware of what their out of pocket cost for an insurance/covered service will be until they receive their explanation of benefits (EOB) after their claim is processed. Unfortunately, calling the number on your card and asking a customer service representative what your cost will be will oftentimes result in inaccurate information being relayed. For example, they may tell you that you will owe a $25 copay for a service, but when you get your EOB they demand you pay $1500 toward your deductible. So much for no surprises!

How these myths perpetuate rising healthcare costs and enrich healthcare insurance companies:

• Reduced price transparency: Insurance companies withhold up-front pricing information for various services from patients, and hope that you will assume that paying out of pocket for services is too expensive. Healthcare providers who provide direct care to patients are required by law to disclose costs to patients up-front. When working with a healthcare provider outside of your insurance company, be sure to ask for a "Good Faith Estimate," for your anticipated costs. Follow this link for more detail: https://www.cms.gov/medical-bill-rights/help/guides/good-faith-estimate
• Overreliance on insurance: The belief that insurance always provides the best price discourages consumers from seeking out-of-network options or negotiating directly with providers, limiting competition and allowing them to increase premiums while decreasing coverage.
• Increased administrative burden: Complex insurance policies and billing procedures create a significant administrative overhead for both providers and patients, adding to the overall cost of healthcare.
• Limited patient choice: The focus on in-network providers restricts patient choice and can lead to accepting higher prices or less desirable care options.

What can you do?

• Be an informed consumer: Ask for transparent pricing information, compare costs, and work with direct pay doctors for routine services.
• Don't be afraid to negotiate: Many providers (including at STLCCH) are willing to offer discounts or payment plans for patients who pay directly.
• Shop around. Ask multiple doctors what their out of pocket price for a service will be.

By understanding the realities of healthcare insurance and taking an active role in your healthcare decisions, you can potentially save money, access better care, and avoid contributing to the rising costs of healthcare.