Emergency Room Visit -- HDHP

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Emergency Room Visit -- HDHP

Postby runnergirl » Wed May 15, 2013 10:47 pm

This is my first year with an HDHP. Prior to this, we paid very little for health care costs because of a generous insurance plan. The other day someone in the family ended up at the ER. I am very nervous as to the bill. Haven't received it yet. Does the insurer negotiate a good rate for customers who have a high deductible ($3000)? Or am I treated as a cash customer and will end up with a large bill? It seems to me the insurance company will not have an incentive to negotiate a good rate on my behalf because I have to pay such a high deductible. When I get the bill, can I negotiate with the hospital?
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Re: Emergency Room Visit -- HDHP

Postby livesoft » Wed May 15, 2013 10:49 pm

The rate has been pre-negotiated and should be in your plan documents or online. Also these HDHP all have toll-free numbers for questions.

I would guess the incentive for them to have pre-negotiated is the chance that you have already met your deductible through other health incidents and that they would end up paying the entire bill.
Last edited by livesoft on Wed May 15, 2013 10:53 pm, edited 1 time in total.
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Re: Emergency Room Visit -- HDHP

Postby LadyGeek » Wed May 15, 2013 10:53 pm

This thread is now in the Personal Finance (Not Investing) forum (insurance).
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Re: Emergency Room Visit -- HDHP

Postby CaliJim » Wed May 15, 2013 11:02 pm

Not specifically to your question - but next time my little one breaks a finger - I'm going to the Urgent Care clinic instead of the ER. IMHO ER's are expensive.
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Re: Emergency Room Visit -- HDHP

Postby livesoft » Wed May 15, 2013 11:07 pm

But the doc-in-a-box will likely do nothing for the broken finger and tell you to make an appointment with your orthopedist. So one can skip the trip and just make the appointment yourself.

My last visit to the ER resulted in three full-anesthesia orthopedic surgeries, but I had to walk out after 9 hours of no treatment. The good side was they didn't send a bill to either me or my insurance company, so those first X-rays were absolutely free except for the excess pain.
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Re: Emergency Room Visit -- HDHP

Postby ddunca1944 » Thu May 16, 2013 12:11 am

How mich is your deductible?
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Re: Emergency Room Visit -- HDHP

Postby EmergDoc » Thu May 16, 2013 1:47 am

livesoft wrote:But the doc-in-a-box will likely do nothing for the broken finger and tell you to make an appointment with your orthopedist. So one can skip the trip and just make the appointment yourself.

My last visit to the ER resulted in three full-anesthesia orthopedic surgeries, but I had to walk out after 9 hours of no treatment. The good side was they didn't send a bill to either me or my insurance company, so those first X-rays were absolutely free except for the excess pain.


Although there are exceptions, neither the doc in a box, the emergency room or the orthopedist is likely to do much of anything about your broken finger. Unless the bone is sticking out of the skin, I fail to see how a broken finger qualifies as an emergency.

Why can't you go to your primary doctor with a broken finger? Tape it to a popsicle stick until his office opens on Monday and take some tylenol and ice it. Google "broken finger treatment."

Here's another tip: If you've been there 9 hours, and you're not dead yet, it might not be an emergency. I'm just kidding of course, but it's usually a good sign when you're stuck in the back of an emergency department and ignored for a while. Do you really want to be the guy in the room with two doctors, two techs, three nurses, the x-ray guy, and the lab guy while the chaplain ushers your family into the consultation room? Nobody is ignoring him. I'd rather be sitting in the back wondering if that doctor is ever going to come back and give me my results.

If you want to pretend you have an emergency, I'll pretend it's an emergency too....and bill you for it (and if you think my bill is bad, wait until you get the one from the hospital). Of course ERs are expensive. Why would you expect them to be cheap? Walk into the place and look around. Does anyone or anything there look inexpensive to you? It's like going into a financial advisor's office and sitting on $15K leather couches in the waiting room. You know who's paying for that stuff. If you don't HAVE to be there, don't go. If you're not sure if you have to be there, you probably don't have to be. You can always call your doctor's office, even after hours. Someone is usually on call. If there isn't, get a new doctor.

I'm continually surprised at the inability of the lay public to properly determine a medical emergency. I had a guy come in today with a two month old ankle sprain that he had reinjured twisting it today. Across the hall was a guy with a blood pressure of 50/30, an 85 year old with chest pain who had a pacer/defibrillator placed the day before (luckily it was working to get him out of what would otherwise have been a fatal rhythm), and a guy with shortness of breath who had so little lung left from all his smoking that you could barely see any lung tissue at all on the CT scan. You want to pretend your ankle is an emergency? I will too. But don't expect the $100 bill you'd get at the doc in the box or the $50 you'd get from your primary doc. We've got to be educated, trained, equipped and staffed to manage those other three patients...at the same time.

The sign out front doesn't say "Convenience" in bright red lights. It says "Emergency".

Rant over. Could you tell it was a long evening? :) Have a nice day.

OP- The insurer will negotiate the bill, but don't be surprised if it is still $1-2K from the hospital and a few hundred from the doc. Here's a link to what Medicare pays emergency docs:

http://www.ebixinc.com/uploads/JanED11.pdf

Basically $59-163 per visit. Expect double that for your private insurance rates. Procedures are additional. But the hospital bill might be 3-10 times that. You might also get a bill from the radiologist and pathologist.
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Re: Emergency Room Visit -- HDHP

Postby stlutz » Thu May 16, 2013 1:57 am

You will pay the rate negotiated by your insurer. You should not pay the bill until you get the EOB from your insurer. That will confirm you are paying the correct amount. Depending on how the hospital is setup, you may get multiple bills--the hospital and the doctors often bill separately.
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Re: Emergency Room Visit -- HDHP

Postby stan1 » Thu May 16, 2013 4:54 am

The negotiated rates will be the same whether or not you've met your deductible, so there is still incentive for the insurance company to negotiate a lower rate for their customers. Also, I do know that my insurer uses the same negotiated rates for their PPO and HDHP plans (but that would be entirely dependent upon what your insurer's business practices are -- you'd probably have to call and ask a few times until you got the right person who could answer a question like that).
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Re: Emergency Room Visit -- HDHP

Postby chipperd » Thu May 16, 2013 6:20 am

Well said, erdoc. Well said.
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Re: Emergency Room Visit -- HDHP

Postby nisiprius » Thu May 16, 2013 6:37 am

EmergDoc wrote:...Although there are exceptions, neither the doc in a box, the emergency room or the orthopedist is likely to do much of anything about your broken finger. Unless the bone is sticking out of the skin, I fail to see how a broken finger qualifies as an emergency. Why can't you go to your primary doctor with a broken finger? Tape it to a popsicle stick until his office opens on Monday and take some tylenol and ice it. Google "broken finger treatment." ...Here's another tip: If you've been there 9 hours, and you're not dead yet, it might not be an emergency. I'm just kidding of course, but it's usually a good sign when you're stuck in the back of an emergency department and ignored for a while. Do you really want to be the guy in the room with two doctors, two techs, three nurses, the x-ray guy, and the lab guy while the chaplain ushers your family into the consultation room? Nobody is ignoring him.
It's a problem, EmergDoc, and it's not all that simple, although I'm sure you are going to berate me when I tell my story. But to address your last concern, yes, I'm happy to be the guy that waits a long time in the emergency room, I "get" it. (And I must say that the time my wife had a kidney stone, they didn't make her wait long before they had her in an exam room and got some morphine and Toradol into her).

Here is why it is complicated. In this millennium, anyway, and in my "market," if you call a doctor after hours, what usually happens is that you get referred to someone who's covering, who then usually does NOT tell you "take two aspirins and call me in the morning" (catchphrase from a few decades ago), or does not tell you to improvise a splint. They usually tell you to go to the ER.

I think most of the middle-class insured patients you see in your ER will have called their PCP's office first because they're afraid the insurance won't pay if they don't. They are people who've been told by a doc to go to the ER. So when a doc tells me that, what do I say? "Thank you for your professional advice, but I think I will ignore it?"

OK, the story. My wife is working. We cut down to one car in semiretirement and she has the car. I'm cutting an onion. An unusually big, tough onion, and I'm using the good kitchen knife. I don't feel a thing, but suddenly notice that there's an awful lot of blood all over everything. So I wrap a paper towel tight around my fingertip and hold, hard, and the blood soaks through the paper towel and continues to spread on the counter. I open the freezer with my other hand, grab an ice cube, and jam it down on top of the bloodsoaked wad of paper towel, and the bleeding continues.

It's about 7 p.m. I don't have a car. I live a 1/2 mile walk from an ER. There are no CVS "minute clinics" within ten miles or so. There is an independent "urgent care" center about 2 miles away but I've never been there and they close at 8 and they happen to be on the other side of a four-lane highway with few good places for a pedestrian to get across.

I know I am not going to die from a cut finger, but I also believe that there could be a meaningful difference in the tip of that finger for perhaps a lifetime if someone treats it within the next hour or so, versus waiting overnight. So, weighing the various alternatives, I grab a fresh wad of paper towels, rubber-band them around my finger, put a Baggie around that so that I'm not going to shock people or gross them out, stick my hand in my jacket pocket to hide it, and walk to the ER.

I don't remember at what point I called the PCP's office on my cell phone--I might have done it ex post facto when I was sitting in the waiting room--but at some point I did call, and was told "go to the ER."

So, there you have it. Yes. I went to the ER for a cut fingertip. It took me about 2 hours to get in and out. The waiting room wasn't empty, but it wasn't full of gurneys and cops and and people in pain and white-faced friends accompanying them, so I don't feel too guilty about getting in anyone else's way. Maybe half an hour to see the triage nurse, half an hour before I was in the exam room, and half an hour before I was actually treated. And yes, yes, yes, the finger had pretty much stopped bleeding, it was just a cut to the bone with a flap of meat that was still attached. Another twenty minutes at whom with paper towels and ice probably would fixed it. Surprisingly hard to do a good home first-aid job one-handed, though).

Here's the point. There really isn't a good provision for "urgent care" in my part of the world. Maybe it's changing, but not yet.

Did I make the wrong decision? Yes, I am a spoiled middle-class person with insurance and in this particular case I went to the ER for nothing, nothing, nothing at all. But the patient can't be perfectly accurate about making medical judgements any more than a doctor can. And this layperson has been lectured often enough by docs saying "why didn't you come to me earlier with these symptoms" to be reasonably sure that my errors are in both directions.

P.S. Sure, they "pretended it was an emergency." The total was about $600 billed. (Cheap for an ER visit). I don't remember how much the insurance paid. I didn't pay a dime myself. Shrug.
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Re: Emergency Room Visit -- HDHP

Postby slowandsteadyone » Thu May 16, 2013 7:19 am

This year is my first year with a HDHP as well. Long story short, I recently had a severe puncture wound to my foot. I went to urgent care who looked at it for 2 seconds, prescribed me antibiotics and sent me on my way along with a $230 bill.

The next day I was not able to walk and just felt terrible. Discovered I had a 103 temperature so I called the urgent care place again and they said, "GET TO THE EMERGENCY ROOM". I went there, they warned me that people were waiting from 5 to 24 hours to be seen by someone. While waiting one guy drove himself in and said that his back suddenly started hurting on his drive home from work. I'm guessing he was in the "24 hour wait" camp.

They took me back in about 45 minutes. Again to shorten the story I ended up admitted to the hospital and spent 3 nights there on intravenous antibiotics. The hospital bill alone was $24,000 with about a $21,300 negotiated discount. The whole thing with doctor bills and all cost about $3,800. I was honestly floored by how low the figure was considering I had an emergency room visit, 4 days and 3 nights in the hospital, an MRI, an operation and follow-up care.
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Re: Emergency Room Visit -- HDHP

Postby frugaltype » Thu May 16, 2013 7:49 am

nisiprius wrote:Here is why it is complicated. In this millennium, anyway, and in my "market," if you call a doctor after hours, what usually happens is that you get referred to someone who's covering, who then usually does NOT tell you "take two aspirins and call me in the morning" (catchphrase from a few decades ago), or does not tell you to improvise a splint. They usually tell you to go to the ER.
...
Here's the point. There really isn't a good provision for "urgent care" in my part of the world. Maybe it's changing, but not yet.
.


In my area there is no urgent care place from 5 pm Friday until 8 am Monday.
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Re: Emergency Room Visit -- HDHP

Postby deanbrew » Thu May 16, 2013 8:13 am

While I appreciate emergdoc's rant, he needs to understand that he is far, far better able to evaluate what is and is not an emergency, because he works in an ER!

For the average person who is not an ER doc or nurse, a sudden-onset malady or injury causes a great deal of concern. If it's your kid and it's at midnight, the concern ratchets up enormously. So, have some empathy forgive all of the uninformed, panic-stricken patients who make the mistake of going to a hospital in the middle of the night or on the weekend for treatment.

Now, I realize there are people who use the ER when they get a cold or have flu symptoms. We're not talking about that. And besides, they don't care how much an ER visit costs, because they're not paying for any of it.
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Re: Emergency Room Visit -- HDHP

Postby BolderBoy » Thu May 16, 2013 9:33 am

stlutz wrote:You will pay the rate negotiated by your insurer. You should not pay the bill until you get the EOB from your insurer. That will confirm you are paying the correct amount. Depending on how the hospital is setup, you may get multiple bills--the hospital and the doctors often bill separately.

Let me reinforce this - wait for the EOB. You may get a bill BEFORE you see the EOB. Wait for the EOB. Read the bill and see when it is "due" - if you don't pay it or at least call and talk with them about it, before the due date, they may send it to collections and ding your credit score.

Your insurer is legally obligated to send an EOB.

Do you have an HSA associated with this HDHP?
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Re: Emergency Room Visit -- HDHP

Postby RobInCT » Thu May 16, 2013 9:54 am

EmergDoc wrote:I'm continually surprised at the inability of the lay public to properly determine a medical emergency.

Pardon me for not being educated enough to correctly diagnose whether I'm having an actual emergency. Next time I'll just wait at home until I'm positive I'm bad enough to be one of the people whose families the chaplain will be ushering in to see me.

Question: How many people do you see who end up dead, disabled, or much sicker than they needed to be because they really should have gone to the ER but didn't think it was an "emergency"?
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Re: Emergency Room Visit -- HDHP

Postby jimkinny » Thu May 16, 2013 10:13 am

EmergDoc wrote:
livesoft wrote:But the doc-in-a-box will likely do nothing for the broken finger and tell you to make an appointment with your orthopedist. So one can skip the trip and just make the appointment yourself.

My last visit to the ER resulted in three full-anesthesia orthopedic surgeries, but I had to walk out after 9 hours of no treatment. The good side was they didn't send a bill to either me or my insurance company, so those first X-rays were absolutely free except for the excess pain.


Although there are exceptions, neither the doc in a box, the emergency room or the orthopedist is likely to do much of anything about your broken finger. Unless the bone is sticking out of the skin, I fail to see how a broken finger qualifies as an emergency.

Why can't you go to your primary doctor with a broken finger? Tape it to a popsicle stick until his office opens on Monday and take some tylenol and ice it. Google "broken finger treatment."

Here's another tip: If you've been there 9 hours, and you're not dead yet, it might not be an emergency. I'm just kidding of course, but it's usually a good sign when you're stuck in the back of an emergency department and ignored for a while. Do you really want to be the guy in the room with two doctors, two techs, three nurses, the x-ray guy, and the lab guy while the chaplain ushers your family into the consultation room? Nobody is ignoring him. I'd rather be sitting in the back wondering if that doctor is ever going to come back and give me my results.

If you want to pretend you have an emergency, I'll pretend it's an emergency too....and bill you for it (and if you think my bill is bad, wait until you get the one from the hospital). Of course ERs are expensive. Why would you expect them to be cheap? Walk into the place and look around. Does anyone or anything there look inexpensive to you? It's like going into a financial advisor's office and sitting on $15K leather couches in the waiting room. You know who's paying for that stuff. If you don't HAVE to be there, don't go. If you're not sure if you have to be there, you probably don't have to be. You can always call your doctor's office, even after hours. Someone is usually on call. If there isn't, get a new doctor.

I'm continually surprised at the inability of the lay public to properly determine a medical emergency. I had a guy come in today with a two month old ankle sprain that he had reinjured twisting it today. Across the hall was a guy with a blood pressure of 50/30, an 85 year old with chest pain who had a pacer/defibrillator placed the day before (luckily it was working to get him out of what would otherwise have been a fatal rhythm), and a guy with shortness of breath who had so little lung left from all his smoking that you could barely see any lung tissue at all on the CT scan. You want to pretend your ankle is an emergency? I will too. But don't expect the $100 bill you'd get at the doc in the box or the $50 you'd get from your primary doc. We've got to be educated, trained, equipped and staffed to manage those other three patients...at the same time.

The sign out front doesn't say "Convenience" in bright red lights. It says "Emergency".

Rant over. Could you tell it was a long evening? :) Have a nice day.

OP- The insurer will negotiate the bill, but don't be surprised if it is still $1-2K from the hospital and a few hundred from the doc. Here's a link to what Medicare pays emergency docs:

http://www.ebixinc.com/uploads/JanED11.pdf

Basically $59-163 per visit. Expect double that for your private insurance rates. Procedures are additional. But the hospital bill might be 3-10 times that. You might also get a bill from the radiologist and pathologist.

Nice rant and can not agree more. Too bad there is not a direct relationship in cost and receipt of service.

Jim
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Re: Emergency Room Visit -- HDHP

Postby Aptenodytes » Thu May 16, 2013 10:20 am

I have been in the same position as you. I ended up with a bill for $2300. I tried to negotiate the bill down because we were paying out of pocket, but had absolutely no luck.

The HDHP world is a very different world than what we lived in before.
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Re: Emergency Room Visit -- HDHP

Postby Kosmo » Thu May 16, 2013 10:39 am

I was going to go on a rant about a previous rant, but that's not useful. I'll say this though, there's a reason that any person on the street can't sign off on the structural integrity of a building. It's the same reason they can't determine a medical emergency.

In college, I had 2 separate friends who had "normal" injuries from playing rugby. Both thought nothing of it at the time, they didn't feel any different than previous bumps and bruises. Both ended up going to the ER in the middle of the night from intense pain. Both had to have emergency surgery, one for a ruptured spleen and one for some type of leg injury (I have no idea what the issue was, but now he has a 1" wide scar running the length of his thigh). Determining that those were medical emergencies could only have been done by a doctor, seeing as my friends didn't realize something was wrong until the pain was significantly increasing hours later.

Part of the issue is that there is no "non-emergency room". If it's past normal business hours and you have a medical issue, going to the emergency room is really the only option even if it's not a true medical emergency. Even if it is during normal business hours, you may not be able to be seen by a specialist or even your primary doctor immediately.
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Re: Emergency Room Visit -- HDHP

Postby EmergDoc » Thu May 16, 2013 11:12 am

deanbrew wrote:While I appreciate emergdoc's rant, he needs to understand that he is far, far better able to evaluate what is and is not an emergency, because he works in an ER!

For the average person who is not an ER doc or nurse, a sudden-onset malady or injury causes a great deal of concern. If it's your kid and it's at midnight, the concern ratchets up enormously. So, have some empathy forgive all of the uninformed, panic-stricken patients who make the mistake of going to a hospital in the middle of the night or on the weekend for treatment.

Now, I realize there are people who use the ER when they get a cold or have flu symptoms. We're not talking about that. And besides, they don't care how much an ER visit costs, because they're not paying for any of it.


You're absolutely right. And I never said that I minded seeing people who weren't sure if they had an emergency or not. I see that as part of my job- either take care of your emergency or tell you you're not having one. But the bill reflects the "emergency" price, whether it is or isn't. I love having non-emergencies come in. You want to see me for your sprained ankle? Great! You want me to put 3 stitches in your finger? No problem.

And Nisiprius- Keep in mind that 20 miles in a taxi is a whole lot cheaper than an hour on a gurney.
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Re: Emergency Room Visit -- HDHP

Postby EmergDoc » Thu May 16, 2013 11:12 am

RobInCT wrote:
EmergDoc wrote:I'm continually surprised at the inability of the lay public to properly determine a medical emergency.

Pardon me for not being educated enough to correctly diagnose whether I'm having an actual emergency. Next time I'll just wait at home until I'm positive I'm bad enough to be one of the people whose families the chaplain will be ushering in to see me.

Question: How many people do you see who end up dead, disabled, or much sicker than they needed to be because they really should have gone to the ER but didn't think it was an "emergency"?


Believe it or not, it's surprisingly rare. It does happen though.
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Re: Emergency Room Visit -- HDHP

Postby EmergDoc » Thu May 16, 2013 11:14 am

jimkinny wrote:Nice rant and can not agree more. Too bad there is not a direct relationship in cost and receipt of service.

Jim


There are plenty of other issues with health care billing and provision. No doubt it's complicated. And perhaps emergency care should be a little cheaper than it is. But my point is that it's NEVER going to be cheap. It's just an expensive thing to do.
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Re: Emergency Room Visit -- HDHP

Postby EmergDoc » Thu May 16, 2013 11:26 am

Kosmo wrote:I was going to go on a rant about a previous rant, but that's not useful. I'll say this though, there's a reason that any person on the street can't sign off on the structural integrity of a building. It's the same reason they can't determine a medical emergency.

In college, I had 2 separate friends who had "normal" injuries from playing rugby. Both thought nothing of it at the time, they didn't feel any different than previous bumps and bruises. Both ended up going to the ER in the middle of the night from intense pain. Both had to have emergency surgery, one for a ruptured spleen and one for some type of leg injury (I have no idea what the issue was, but now he has a 1" wide scar running the length of his thigh). Determining that those were medical emergencies could only have been done by a doctor, seeing as my friends didn't realize something was wrong until the pain was significantly increasing hours later.

Part of the issue is that there is no "non-emergency room". If it's past normal business hours and you have a medical issue, going to the emergency room is really the only option even if it's not a true medical emergency. Even if it is during normal business hours, you may not be able to be seen by a specialist or even your primary doctor immediately.


First of all, your friends had severe, increasing pain that tipped them off that they were having an emergency. So they went to the hospital and had it taken care of. I'm sure it was expensive but worth it. If they'd gone in immediately after the game, the doctor might not have done anything except warn them to come back if they had "severe or increasing pain."

Second, you're absolutely right that no one is running an all-night "convenience care." I'm willing to do so. I have no problem at all rechecking your abnormal lab work, refilling your blood pressure meds, numbing up your broken tooth to get you out of pain until your dentist opens in the morning, or x-raying and splinting your finger. But I'm going to charge prices that are very similar to what I charge for running all-night "emergency care." If someone wants to step in and cut me off from that market, they're welcome to do so, but in my area, the people who want to do that only stay open until 10 pm and call themselves "urgent care" or "quick clinic" and they only take people who are willing to pay them. It's apparently either not much fun or not very profitable for them to stay open all night (and not profitable at all to take care of people without insurance.) Imagine that! Staying up to provide medical care at 3 am isn't very fun or profitable! Who'd have thought?

What I really wish is that someone would step in and open an all-night drunk tank and overdose evaluation facility. If you think taking care of sprained ankles and broken fingers at 3 am isn't much fun, imagine the guy spitting and swinging at you while you tie him down and sedate him. I admit I kind of enjoy the reaction I get from "normal" people while some cocaine addict fills the ED with his profanity-laced screaming. It's better than reality TV.
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Re: Emergency Room Visit -- HDHP

Postby nisiprius » Thu May 16, 2013 11:37 am

While on vacation in Utah, we saw something we'd never seen at home: big billboards right on the Interstate in which various hospitals were advertising their current emergency room waiting times. Yes, big electronic panel,

"the waiting time at our ER is currently
......[43]......
minutes."

Fortunately we had no need to find out how accurate or truthful these signs were.

Something else we had never seen at home were big billboards advertising "modest prom dresses."
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Re: Emergency Room Visit -- HDHP

Postby pochax » Thu May 16, 2013 11:42 am

runnergirl wrote:This is my first year with an HDHP. Prior to this, we paid very little for health care costs because of a generous insurance plan. The other day someone in the family ended up at the ER. I am very nervous as to the bill. Haven't received it yet. Does the insurer negotiate a good rate for customers who have a high deductible ($3000)? Or am I treated as a cash customer and will end up with a large bill? It seems to me the insurance company will not have an incentive to negotiate a good rate on my behalf because I have to pay such a high deductible. When I get the bill, can I negotiate with the hospital?

Hey runnergirl - i went thru a similar situation (except it was me in the ER) ~1.5 yrs ago. ER visit including ultrasound, CT scan, ECG, and lab work. very difficult to figure out ahead of time how much it was going to cost even with online tools. ended up paying negotiated rates to total ~$1500. i had (and still have) a HDHP. realize charges included the cardiologist who read the ECG, radiologist charges who read the imaging studies. i think online 'estimators' totalled ~$2300 (not counting radiologist/cardiologist readings) so the negotiated rates do help bring cost down, but it's clearly not inexpensive by any means. as others mentioned, maybe a call to your HDHP provider might help (i didn't do this myself - just too lazy).
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Re: Emergency Room Visit -- HDHP

Postby Sam I Am » Thu May 16, 2013 12:20 pm

EmergDoc wrote:
Kosmo wrote:I was going to go on a rant about a previous rant, but that's not useful. I'll say this though, there's a reason that any person on the street can't sign off on the structural integrity of a building. It's the same reason they can't determine a medical emergency.

In college, I had 2 separate friends who had "normal" injuries from playing rugby. Both thought nothing of it at the time, they didn't feel any different than previous bumps and bruises. Both ended up going to the ER in the middle of the night from intense pain. Both had to have emergency surgery, one for a ruptured spleen and one for some type of leg injury (I have no idea what the issue was, but now he has a 1" wide scar running the length of his thigh). Determining that those were medical emergencies could only have been done by a doctor, seeing as my friends didn't realize something was wrong until the pain was significantly increasing hours later.

Part of the issue is that there is no "non-emergency room". If it's past normal business hours and you have a medical issue, going to the emergency room is really the only option even if it's not a true medical emergency. Even if it is during normal business hours, you may not be able to be seen by a specialist or even your primary doctor immediately.


First of all, your friends had severe, increasing pain that tipped them off that they were having an emergency. So they went to the hospital and had it taken care of. I'm sure it was expensive but worth it. If they'd gone in immediately after the game, the doctor might not have done anything except warn them to come back if they had "severe or increasing pain."

Second, you're absolutely right that no one is running an all-night "convenience care." I'm willing to do so. I have no problem at all rechecking your abnormal lab work, refilling your blood pressure meds, numbing up your broken tooth to get you out of pain until your dentist opens in the morning, or x-raying and splinting your finger. But I'm going to charge prices that are very similar to what I charge for running all-night "emergency care." If someone wants to step in and cut me off from that market, they're welcome to do so, but in my area, the people who want to do that only stay open until 10 pm and call themselves "urgent care" or "quick clinic" and they only take people who are willing to pay them. It's apparently either not much fun or not very profitable for them to stay open all night (and not profitable at all to take care of people without insurance.) Imagine that! Staying up to provide medical care at 3 am isn't very fun or profitable! Who'd have thought?

What I really wish is that someone would step in and open an all-night drunk tank and overdose evaluation facility. If you think taking care of sprained ankles and broken fingers at 3 am isn't much fun, imagine the guy spitting and swinging at you while you tie him down and sedate him. I admit I kind of enjoy the reaction I get from "normal" people while some cocaine addict fills the ED with his profanity-laced screaming. It's better than reality TV.


Been there, listened to it as a patient behind the adjacent curtain! A few of the hospitals we use at least have separate waiting rooms for adults and children. That way the young ones don't see the drunks, drug addicts, stab/gunshot patients come rolling in, often with several family members/entourages.

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Re: Emergency Room Visit -- HDHP

Postby expat » Thu May 16, 2013 12:39 pm

Does the insurer negotiate a good rate for customers who have a high deductible ($3000)?

Or am I treated as a cash customer and will end up with a large bill?


It's all negotiable.

You can either take their rate and have it counted against your deductible. Or you can ask to be treated as a cash customer and get a discount. I have received a 25% discount as cash customer.

I have initially gone in to be treated as insurance customer and then asked to be treated as a cash customer.

It depends on the time of year and your current deductible as to which is the better option.
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Re: Emergency Room Visit -- HDHP

Postby deanbrew » Thu May 16, 2013 12:46 pm

expat wrote:
Does the insurer negotiate a good rate for customers who have a high deductible ($3000)?

Or am I treated as a cash customer and will end up with a large bill?


It's all negotiable.

You can either take their rate and have it counted against your deductible. Or you can ask to be treated as a cash customer and get a discount. I have received a 25% discount as cash customer.

I have initially gone in to be treated as insurance customer and then asked to be treated as a cash customer.

It depends on the time of year and your current deductible as to which is the better option.


That's been my experience as well. You can either accept the insurance company's negotiated rate and have your ultimate bill credited toward your annual deductible, or you can tell the provider to not submit it to insurance and negotiate your own cash payment. In most cases, you should ascertain the self-pay negotiated rate before the provider submits anything to the insurance company.

I haven't been able to negotiate lower than the insurance rate, and want the credit toward my deductible. But I have negotiated my own cash rate when the insurance company refused to cover a bill. And "cover" is used in the broadest sense, since I was still paying.
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Re: Emergency Room Visit -- HDHP

Postby TomatoTomahto » Thu May 16, 2013 12:56 pm

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Re: Emergency Room Visit -- HDHP

Postby snowman » Thu May 16, 2013 1:37 pm

runnergirl,

There has been some excellent advise, and some that does not apply in your case.

The ER rates under your HDHP are pre-negotiated by your carrier, and are outlined in your documents. In a typical plan, the rates are very high (again, if you opened your documents, you know by now what they are). Yet, that's actually a very low rate compared to Chargmaster rates that the hospital could have charged you if you had no insurance. Those rates are negotiable by design, nobody is really expected to pay them. One of the reasons you have insurance is that the rate has been pre-negotiated for you by your carrier, which is always lower or MUCH lower than the base rates. You could call the hospital once you receive the bill and argue that taking an X-Ray of your arm and giving you an Aspirin pill in your 30 minute visit to ER could not have cost them $1K, but they will not budge. They know you have and can afford insurance, and therefore you can afford to pay the bill.

I completely disagree with advise given that you walk into ER and start negotiating cash rates vs. your insurance rates! Number one, if it's not emergency and you have HDHP, you would not be there in the first place - you don't want to pay $1K or more if you could wait to see your doctor whom you know and trust next morning for $80, for example. Second, you will not negotiate lower price on your own compared to what your carrier was able to negotiate on your behalf, period. Third, they will not be able to tell you the price anyway - it will depend on many different factors, and you will only find out once you get the bill(s) in mail. And finally, are you really going to negotiate at the front desk while your kid who just suffered painful concussion in a hockey game has no clue what planet he is on?

The advise I would offer to anyone with HDHP is to carefully review the rates and charges before you sign up (or renew) the plan, especially as they relate to ER visits! They are in the documents, and should be given equal weight to monthly premiums and deductibles when selecting the right HDHP for your family.
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Re: Emergency Room Visit -- HDHP

Postby mnvalue » Thu May 16, 2013 3:21 pm

My insurance company (and the hospital chain around here, but I haven't used that one) both run free "nurse lines" where you can call in and describe your symptoms to a registered nurse. They provide a recommendation as to if or when (i.e. if you experience certain symptoms or existing symptoms last longer than X days) you should see a doctor. For things that end up not being real emergencies, you can get reassurance and recommendations for at-home treatment for free as well as faster and with less hassle than driving to urgent care/ER.

I had a case where I knew it wasn't an emergency in any way, but I had no idea if I should go in after 2 days, a week, or two weeks. If I went in too soon, I figured I'd pay for a full doctor's visit (in both money and time) just to be told to wait some more. They told me 10 days or something like that. So when I was still experiencing symptoms at day 7, I made the appointment for 3 days out.

In another case, I knew there was quite a bit one could take before it became an emergency, but this was a "worst in my life so far" sort of thing. I figured I was close to the edge of an actual emergency. I called it. I was not; the tolerance was much higher than I expected. The reassurance allowed me to focus on getting better without worrying. And at the same time, I then knew "for sure" when to go in.

If it's not an obvious emergency, but you're not sure you should do nothing (or you're not sure what to do at home), these services can be a great resource.
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Re: Emergency Room Visit -- HDHP

Postby EmergDoc » Thu May 16, 2013 3:43 pm

nisiprius wrote:While on vacation in Utah, we saw something we'd never seen at home: big billboards right on the Interstate in which various hospitals were advertising their current emergency room waiting times. Yes, big electronic panel,

"the waiting time at our ER is currently
......[43]......
minutes."

Fortunately we had no need to find out how accurate or truthful these signs were.

Something else we had never seen at home were big billboards advertising "modest prom dresses."


Welcome to my life. The downside is that the hospitals fight over patients, even emergency ones. The upside is most EDs in town have very short wait times. I'd guess our wait time to be seen by a triage nurse is < 5 minutes and you're brought straight back after that 90% of the time in our shop. Our "door to doctor" times average around 20 minutes.

You might be surprised how hard it is to find a "modest prom dress" in some parts of the country. Most people who care about that have to make their own.
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Re: Emergency Room Visit -- HDHP

Postby Crystal Ball » Thu May 16, 2013 4:56 pm

I give EmergDoc a free pass for one rant. I've spent enough time in ERs to understand what they go through.

It is difficult for us laymen to determine what is the appropriate level of urgency needed in treatment for a sudden problem. My insurance company sends magnetic cards several times a year with the number of the nurse help line. Keep it on your fridge.

Call them when the kid gets stung by a bee and his arm is swelling. They have been extremely helpful whenever I have called. It's not a perfect answer, but it is a big help for the "don't know what to do". They have also helped in non-emergency situations determining if one should get a second opinion or if a treatment plan is reasonable. And I had a friend call when his wife's doctor wanted to use an out-of-network hospital because they equipment for less invasive surgery. They worked with the doctor and got the whole thing pre-certified. She had less invasive surgery and the bill was covered.

We don't have to be experts - we just have to know (in advance) how to call one.

I always wonder why the hospital doesn't run an "urgent care" clinic next door to the emergency room. It would have people headed in the right direction in case there is a real ER type problem and they could shuttle the non-ER cases to the PAs next door. I suspect that the "hospital" as a business likes having those expensive beds full.

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Re: Emergency Room Visit -- HDHP

Postby expat » Thu May 16, 2013 5:02 pm

I completely disagree with advise given that you walk into ER and start negotiating cash rates vs. your insurance rates! Number one, if it's not emergency and you have HDHP, you would not be there in the first place - you don't want to pay $1K or more if you could wait to see your doctor whom you know and trust next morning for $80, for example. Second, you will not negotiate lower price on your own compared to what your carrier was able to negotiate on your behalf, period. Third, they will not be able to tell you the price anyway - it will depend on many different factors, and you will only find out once you get the bill(s) in mail. And finally, are you really going to negotiate at the front desk while your kid who just suffered painful concussion in a hockey game has no clue what planet he is on?


The negotiation can _start_ at the front desk but it doesn't end until you have actually paid the bill. The HDPD allows you (not the insurance company) to decide how and when to pay the bill as well as what charges are reasonable. This gives you a lot of power to negotiate the terms of any medical bill.

The HDHP is probably not a good choice for those who do not like to negotiate.
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Re: Emergency Room Visit -- HDHP

Postby EmergDoc » Thu May 16, 2013 5:24 pm

Crystal Ball wrote:
I always wonder why the hospital doesn't run an "urgent care" clinic next door to the emergency room. It would have people headed in the right direction in case there is a real ER type problem and they could shuttle the non-ER cases to the PAs next door. I suspect that the "hospital" as a business likes having those expensive beds full.

Crystal


Bingo!

Some EDs have a built in "urgent care" or "fast-track." They do urgent care type work....for emergency care prices. Most hospitals want well-insured people with urgent care issues. It doesn't eat up a lot of resources or time and pays well. Abscesses, lacerations, colds, sinus infections, rashes, sprained ankles etc. As long as we're the business owner (and not an employee), it doesn't bother us a bit.

Look at another business, like a restaurant. Imagine if it had two parts- the cheap part and the expensive part. You walk up to the hostess and they ask whether you want to spend $12 a plate for a decent dinner, or $20 a plate for a really nice one. If you choose decent, they walk you back to the decent section and don't charge you so much. Not going to happen. It's just bad business. If you want the cheap dinner you need to go to a different restaurant.
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Re: Emergency Room Visit -- HDHP

Postby LadyGeek » Thu May 16, 2013 5:40 pm

The OP is asking about negotiating a hospital bill under a High deductible health plan. Please stay on-topic.
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Re: Emergency Room Visit -- HDHP

Postby EmergDoc » Thu May 16, 2013 6:30 pm

LadyGeek wrote:The OP is asking about negotiating a hospital bill under a High deductible health plan. Please stay on-topic.


Livesoft pretty much covered that in the second post, no? :)
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Re: Emergency Room Visit -- HDHP

Postby Easy Rhino » Thu May 16, 2013 7:03 pm

Took my wife to the ER a while back, she had x-rays, a cat scan, and an overnight stay.

The gross bill from the hospital was $20,000.

She didn't have an HDHP though, so i don't know what the insurance-negotiated price would be.
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Re: Emergency Room Visit -- HDHP

Postby tj-longterm » Thu May 16, 2013 10:25 pm

expat wrote:
Does the insurer negotiate a good rate for customers who have a high deductible ($3000)?

Or am I treated as a cash customer and will end up with a large bill?


It's all negotiable.

You can either take their rate and have it counted against your deductible. Or you can ask to be treated as a cash customer and get a discount. I have received a 25% discount as cash customer.

I have initially gone in to be treated as insurance customer and then asked to be treated as a cash customer.

It depends on the time of year and your current deductible as to which is the better option.


This used to work well for me, but recently I discovered that the 25% discount to the cash customer was still far more expensive than the insurance rate, which is often far more than 25% off the "list price"
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Re: Emergency Room Visit -- HDHP

Postby expat » Thu May 16, 2013 10:43 pm

This used to work well for me, but recently I discovered that the 25% discount to the cash customer was still far more expensive than the insurance rate, which is often far more than 25% off the "list price"


I asked for a discount on the amount they submitted to my insurance and that they withdraw the claim from my insurance.
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Re: Emergency Room Visit -- HDHP

Postby tj-longterm » Thu May 16, 2013 11:02 pm

expat wrote:
This used to work well for me, but recently I discovered that the 25% discount to the cash customer was still far more expensive than the insurance rate, which is often far more than 25% off the "list price"


I asked for a discount on the amount they submitted to my insurance and that they withdraw the claim from my insurance.


I've tried things like that and never had any success. But perhaps I'm just not as good at negotiating :-) I have heard of the hospital suddenly desperately offering huge discounts on unpaid bills after a period of time. Not sure I'm willing to do that though. It also seems a little unfair on an after the fact basis, given that I know most hospitals are barely making cost on most patients (although I'm sure others here will feel differently about that).
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Re: Emergency Room Visit -- HDHP

Postby frugaltype » Fri May 17, 2013 12:47 am

EmergDoc wrote:What I really wish is that someone would step in and open an all-night drunk tank and overdose evaluation facility. If you think taking care of sprained ankles and broken fingers at 3 am isn't much fun, imagine the guy spitting and swinging at you while you tie him down and sedate him. I admit I kind of enjoy the reaction I get from "normal" people while some cocaine addict fills the ED with his profanity-laced screaming. It's better than reality TV.


Somewhat of a lack of empathy there. Some "normal person" worried sick about what is wrong with himself, does not need a lunatic creating a disturbance on top of it, as amusing as it might be to the staff. But then there seems to be a lack of empathy in general towards patients who are worried enough to get to the ER in the middle of the night.
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Re: Emergency Room Visit -- HDHP

Postby frugaltype » Fri May 17, 2013 12:49 am

EmergDoc wrote:Here's another tip: If you've been there 9 hours, and you're not dead yet, it might not be an emergency. I'm just kidding of course, but it's usually a good sign when you're stuck in the back of an emergency department and ignored for a while.


How about my neighbor, in such pain from kidney stones that she was vomiting, who didn't get seen at the ER even though she and her husband waited there all night? Not an emergency?
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Re: Emergency Room Visit -- HDHP

Postby livesoft » Fri May 17, 2013 7:30 am

If one has a HDHP and negotiates and pays instead of submitting the bill to their insurance, doesn't that mean that the expense does NOT apply to their deductible? If one keeps doing that then they essentially don't have health insurance at all because their deductible will never be met and they will always be paing out of pocket.
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Re: Emergency Room Visit -- HDHP

Postby 6miths » Fri May 17, 2013 7:43 am

chipperd wrote:Well said, erdoc. Well said.


Ditto! :happy
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Re: Emergency Room Visit -- HDHP

Postby deanbrew » Fri May 17, 2013 7:51 am

livesoft wrote:If one has a HDHP and negotiates and pays instead of submitting the bill to their insurance, doesn't that mean that the expense does NOT apply to their deductible? If one keeps doing that then they essentially don't have health insurance at all because their deductible will never be met and they will always be paing out of pocket.


Yes, and yes. If you want it to apply to your deductible, it needs to be processed through your insurance, whereby the provider agrees to accept the negotiated insurance rate, but you pay the bill until you hit your annual deductible.

I see just two times I would negotiate for a lower rate: 1) it's a procedure that is not covered by insurance; and 2) if it's approaching year end and I'm certain I won't hit my deductible, AND I can negotiate a lower cash rate than my insurance company's rate. The problem, which has been mentioned on other threads, is that it ranges from difficult to impossible to ascertain the final cost of a procedure in advance. I've received checks back from providers twice within the past year after medical issues because either the procedure was less than originally billed, or the insurance company paid more than expected. It's all about codes and rates and eye of newt.
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Re: Emergency Room Visit -- HDHP

Postby expat » Wed May 22, 2013 1:55 pm

livesoft wrote:If one has a HDHP and negotiates and pays instead of submitting the bill to their insurance, doesn't that mean that the expense does NOT apply to their deductible? If one keeps doing that then they essentially don't have health insurance at all because their deductible will never be met and they will always be paing out of pocket.


According to my insurance company, if I submit documentation (receipt etc) that shows payment, they will include the amount against the deductible.

So it's possible to negotiate a lower amount and have it included against the deductible.
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Re: Emergency Room Visit -- HDHP

Postby mikep » Wed May 22, 2013 2:23 pm

expat wrote:
livesoft wrote:If one has a HDHP and negotiates and pays instead of submitting the bill to their insurance, doesn't that mean that the expense does NOT apply to their deductible? If one keeps doing that then they essentially don't have health insurance at all because their deductible will never be met and they will always be paing out of pocket.


According to my insurance company, if I submit documentation (receipt etc) that shows payment, they will include the amount against the deductible.

So it's possible to negotiate a lower amount and have it included against the deductible.


I tried that and it was counted as "out of network" since the rule is all in network claims must be paid at the insurance contract price. So only the "reasonable & customary" amount of the "out of network" price counts toward deductible.. even though the in-network amount is higher :annoyed ... so this strategy may backfire as you could end up paying more.
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Re: Emergency Room Visit -- HDHP

Postby RabbMD » Wed May 22, 2013 2:33 pm

mikep wrote:
expat wrote:
livesoft wrote:If one has a HDHP and negotiates and pays instead of submitting the bill to their insurance, doesn't that mean that the expense does NOT apply to their deductible? If one keeps doing that then they essentially don't have health insurance at all because their deductible will never be met and they will always be paing out of pocket.


According to my insurance company, if I submit documentation (receipt etc) that shows payment, they will include the amount against the deductible.

So it's possible to negotiate a lower amount and have it included against the deductible.


I tried that and it was counted as "out of network" since the rule is all in network claims must be paid at the insurance contract price. So only the "reasonable & customary" amount of the "out of network" price counts toward deductible.. even though the in-network amount is higher :annoyed ... so this strategy may backfire as you could end up paying more.


See the bolded part here, the out of network rate an insurer tries to pay is LOWER than the negotiated rate. So now you see why often doctors do not participate with insurers. If I could not participate with medicare/medicaid I would not in a new york second, but that is pretty much impossible as a hospital-based physician. As a result our medicare rates average 65-75% less than our participating insurance rates, isn't government fiat grand? I am so sure they would be a benevolent monopoly right :oops: :confused ?
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Re: Emergency Room Visit -- HDHP

Postby staythecourse » Wed May 22, 2013 3:05 pm

I'm a doc too and from a long line of docs and will say everything ERdoc said is technically correct, BUT it doesn't matter. Since we live in a consumer driven world where regular folks make the decisions (i.e. is this an emergency or not) then you will get all sorts of elective stuff in an ER. Just like I am a specialist and get some of the DUMBEST consults from folks who just look me up and not referred by another physician.

What I don't get (not saying this in reference to the OP) is folks complaining after they get the treatment they sought they decide to later complain about the charges?? Does anyone go to McDondald's eat a burger and then go up and say "boy I don't think I should have had to pay full price".

Consumers get the power to be consumers and thus have the onus to PAY for the charges they ELECT to receive. If one doesn't like it then feel free to drive/fly to an outside country for their care. BTW, that is the point of HDHP the thought is if one has to pay out of pocket they will be more judicious with its use.

Good luck.
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