American health insurance fine print: wait one extra day for surgery after an accident and price goes up dramatically

Here’s a fun story on the health insurance system that America’s most brilliant technocrats have created…

Woman falls on Christmas (Tuesday) morning and breaks her collarbone. Blue Cross pays 100 percent of the cost of emergency care following an accident. $0 deductible. ED doc says will likely heal on its own. First available consult with an orthopedic specialist is Thursday morning. After a bit of deliberation, it is decided that surgery to insert a plate may be helpful. This will cost the insurer $30,942 ($35,080 “rack rate”). Had it been completed within 72 hours of the emergency visit, it would have been covered completely. Due in part to the holiday and a question about whether the break could heal adequately on its own, the surgery was not done until the following Monday, outside of the 72-hour window (one business day beyond, or maybe not even that if we subtract out Christmas).

Although the procedure is exactly the same, now the insurance customer must pay 15 percent of the total: nearly $5,000!

So the insurance company that you might think would want to encourage patients to step back and consider whether an offered intervention is useful instead gives them a huge financial incentive to sign up for whatever physicians put on the menu during the first 72 hours!

(The good news is that any customer who memorizes the 165-page 2018 benefits document would be well aware of this 72-hour cliff (don’t forget to read the 176-page PDF for 2019, though!).)


  • “A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills” (Vox), in which the government-run hospital tries to get $24,074 for a $3,831 (market price) visit because “the hospital’s focus is on serving those with public health coverage — even if that means offsetting those costs with high bills for the privately insured. … ‘Our mission is to serve people who are underserved because of their financial needs.'” (the woman involved in the bike accident never had a choice to go to a hospital that was in-network for her Blue Cross)

4 thoughts on “American health insurance fine print: wait one extra day for surgery after an accident and price goes up dramatically

  1. Let’s see. None of my sister in law’s specialist visits for dementia or arthritis were covered by her Medicare supplement. We are beginning to wonder why we renewed it for her. Last year it covered stuff. Maybe a new pattern to change program parameters to punish people who just renew? My mother’s portable oxygen generator is not covered by her Medicare replacement plan, ironically the AARP one and these are supposed to be the people who advocate for seniors? Next in both my mother in law’s and my father in law’s deaths, the hospital was very quick to recommend hospice as the solution. Hospice is basically “going home to die” with some help from nurses. Which also ironically is just an hour or two a day until they are about a week from dying. In fact, in my father in law’s case, he was in the hospital exactly three days, when they started asking us to “find a place to put him”. I’m a huge skeptic that doctors and hospitals are actually helping most of the population. Yes, some surgeries are necessary and save lives. Yes, people need to be cared for. But the system is very broken. I’m not sure what the solution is, maybe some quality-based competition, maybe educating the public better on their choices, but things do have to change. Some rural parts of the country have no doctors at all due to the fact that medical and nursing schools limit attendance severely in order to keep the supply of US doctors low.

  2. I had a similar issue back when in my small town. I fell on the ice on a rock and broke my elbow. I thought is was OK at first so I did not go to the ER. When the pain did not ease I went to the doctor three days later. He said it is broken and I needed to have surgery. He said he could schedule it at the hospital tomorrow if my insurance will approve. My insurance said it is only partially covered and patient will have to pay 20% or about $4K of $20K bill. If I had gone to ER the surgery would have been covered 100%.. I ask for options and my doctor said we can do your surgery at my Surgery Center as out patient. It will be cheaper than the hospital and the same exact procedure. So he did the same surgery at his out patient clinic for $6K (1/3 cost) and my part was $1200. It was a win win.

    So I learned to shop around for better medical pricing. I avoid the ER as they are crazy expensive. I go to Urgent Care for a ear ache or a sore throat instead of waiting days or weeks to see my GP. I go to Lab Corp for blood tests. These places are cheaper and my deductibles are less. So I save $$$. I do the same for a Colonoscopy test. The price is $2K instead of $5k at the local hospital. I do the same thing for xray and MRI tests.

    My brother in law and his wife both go to annual “wellness medical testing days” sponsored by their insurance. It costs them $100 to get a ton of tests run and a doctor to read the results all in one day. They say it saves them a bunch in deductibles and it is a lot more convenient to get it all done in one day.

    I agree the insurance companies are killing medicine. But there are some things you can do to fight back…

    By the way. It is way worse in Scotland or England. There you might wait 2-3 years and become a drug addict on pain pills before you get surgery if it is not an emergency.

    Good Luck.

  3. I live in California and have Kaiser-Permanente coverage. It appears that they pay for all of my care: Emergency room, ambulance, hospitals and surgery. A few things they don’t do in San Diego, they contract out. They are an HMO, so they lose money whenever they see me. They have been doing this for 50 years. Seems to work fine.

  4. Nothing is more profitable than getting people to pay for the illusion of service. Fine print and recursive exceptions are the hallmark of a thriving, free market. No one can know all the rules, and you only realize how absurd they are after you’ve been had.

Comments are closed.