I’ve known about this issue for some time. I know a woman who used to be a private practitioner in the mental health care field and she often talked about how what she “billed” got nicked away by the insurance carriers and how that ultimately impacted the actual amount that appeared in her and other health care providers’ initial billings.
I never really extended that concept to medications and other medical items that have a more defined cost trail – until now.
My recent TRICARE summary stated that I had purchased $751.30 in prescribed medications during the period – the month of March. I was billed and paid only $30.10 for those medications. TRICARE did not pay anything. Neither did Medicare. My pharmacy billed the insurance company $751.30 and I was only charged $30.20, which I paid – and all because the insurance company said that was all it would allow the pharmacy to charge me.
I wonder who is taking the apparent loss of $721.20. Indeed, was there a loss? Did the pharmacy merely mark up the cost of the medications by – say 25 percent – which would be fairly normal for a retail sale business? If so, did the pharmacy then lose around $530 on these transactions? Or was the real cost much lower? Did the pharmacy mark up its medications to ensure that the retail price was greater than all of the various “allowed amounts” of all of the insurance carriers it has to deal with?
Or, perhaps it is the pharmaceutical companies that are marking up their products excessively – leaving the pharmacies in their networks to take the hit. Are those “losses” even booked? Perhaps the “invoice” sent to the insurance companies is bogus! In that case the “real invoices” might have been way less – maybe even around $30. Perhaps the pharmaceuticals include a “suggested retail price” with their products but bill the retailer only a much lower and fairer wholesale amount.
Who is taking the losses?
One has to wonder how the “healthcare system” in this country became so really twisted away from reality. Why must such shenanigans be undertaken just to work within the various healthcare “networks”?
Moreover, it looks like the Affordable Care Act has not fixed it.
And still I wonder…Before the Affordable care Act, what did someone like me who had no insurance have to pay for these medications?
Would they have had to pay the full $750, the real $30, or somewhere in-between?
Who, exactly, is taking the losses?
Are there really any losses?
Perhaps everything but the $30.10 is merely a part of a big publicity stunt to further convince us that we need “health insurance” including coverage of medications in order to be able to afford “health care”?
I mean – look what TRICARE did to hold down my medications expenses; and it didn’t cost them a penny!
But…who took the loss?
This commentary was originally published June 05 2014 in the print edition of the Winona Daily News under the headline: Billing issues make health care even murkier