Our current health insurance policy will pay for 80% of $400 of routine
physical exams and lab tests and innoculations per calendar year, at a
'network' institution, which means U of Michigan or one of two doctors in
Saline (both affiliated with St. Joe's but the exams have to be done in Saline
in order to be network).  U of M charges $199, and one of the Saline doctors
charges $152 for a routine physical.  They can then order tests.  After three
days of phone calls to the insurance company, U of M, St. Joes, PPOM etc.,
I think I have figured out that the tests have to be done by U of M (where
they are twice as expensive as at St. Joe's - for instance PAS screening test
for prostate cancer is $35 at St. Joe's, $69 a U of M, some thyroid screen
test $100-230 at U of M, $35-120 at St. Joe's).  Anyway, assuming that the
Saline doctor will want to bother having tests done at U of M instead of St.
Joe's (which I think just means that we have to take ourselves to U of M to
draw blood), we will have $250 of the $400 left to spend on tests (only $200
if the exams need to be done at U of M).

Various people at various phone numbers (U of M billing, St. Joe's billing,
one helpful nurse, the insurance agent) have recommended almost entirely
different tests.  One person says to get a complete blood count ($21-110),
another says they usuall do BAS (basic blood test for various minerals - $78)
and CMP (comprehensive liver test - $73).  There is some thyroid screening
test that detects heart problems ($100-230).  A cholesterol test is $73.

We are certain that we don't want our cholesterol tested.  We eat almost no
cholesterol and little fat and are not obese and have no concern about heart
problems.  Jim tested his cholesterol with a kit from Red Cross (free when
he gave blood one year) and it was 125 the second time (it was below the chart
the first time but they said to try again).  This was before he started eating
vegan.  We both have blood pressure about 110/65.  

What tests have other grexers had done and what are they supposed to detect?
What three tests (or maybe two tests) totalling about $200 would you
recommend.  (If any further tests were necessary they could be done at half
price at St. Joe's since the insurance won't pay for them anyway).  Probably
Jim would do PSA, and I might get a tetanus shot (which he already had last
time he cut himself and it got infected) so probably we have about $130 left
for maybe two tests.  What does CBC look for?  CMP?  TSH?  

A doctor friend suggested a routine sigmoidoscopy (they stick some flexible
tube inside you to look around).  I have not found out what it costs because
they keep transferring me to some other number, but the facility charge is
$528.  A colonoscopy is $1400-1600.  These are therefore ruled out.
An gynecological exam is about $150 plus some unknown amount for a PAP smear
- which implies it would cost no more to bypass the insurance and pay $75 at
Planned Parenthood.  (The insurance pays only 80% - so a $300 exam would cost
me $60).  
What really strikes me is that nobody who orders the tests has any idea what
it will cost the patient.  I was at least able to find out the cost of the
exam.

10 responses total.

The basic blood tests you've mentioned will tend to show if something is
wrong but not much else.  They aren't targeting specific problems, except
maybe the PSA.  Bang for buck, the CBCP, Basic Profile and a PSA is what
I'd buy first.  I'd also get a hemacult test of fecal material if routine
sigmoidoscopy isn't possible.  A skin check during a physical would
also be important.  And a baseline, healthy, EKG would be nice to have
for future reference. 

Many thanks.  What does a Basic Profile test for?  Is CBCP the same as
complete blood count and if so, what are they looking for there?  I think the
insurance may only cover about two tests each, if they also charge for drawing
blood at what seem to be the usual U of M prices.  

Jim wonders what a mysterious red rash (turning a bit flaky) that appeared
on his wrist shortly after he pulled up a lot of weeds using gloves might be.
He had me look up ringworm.  I think poison ivy - I have seen it in the yard.
If it does not clear up in a month he will have something to tell the doctor
about.  

I will check out Northfield and Plymouth - perhaps they have some lab not
affiliated with U of M.  A bit early in the season for a bike camping trip.

A CBCP is a complete blood count including platelets.  It literally is a
tally and microscopic look at the cells and fluid that makes up blood. 
Leukemias, anemias, acute vs. chronic infections, etc. - the bell gets
rung with a CBC.

A basic profile looks at eight electrolytes and metabolic byproducts in
the blood - sodium, potassium, chloride, C02, blood urea nitrogen,
creatinine, glucose and calcium. High or low levels can point to
endocrine, renal or liver problems long before there are other, obvious
signs and symptoms. 

Which of the two would you choose, having to choose just one?  If we keep this
same policy we could do the other one next year.  I have not been able to find
a cheap individual policy that lets you choose not to go to U of M doctors.
With this one ($1000/year for me, more for Jim) you pay the first $5000
(unless you have an accidental injury in which case they waive the deductible
on $300 or so and you pay only 30% of that) and then you pay 30% of the next
$5000 (in network - or 50% out of network) and if you are still alive after
that they pay the rest.  Comparing costs at U of M and St. Joe, it might be
cheaper to go out of network.  Only policies that let you go to St. Joe's
instead are HMO's with no deductible, at $250/month.  

This policy is American Community Mutual.  I keep calling and getting idiots.
I ask them if there are restrictions on where the lab tests need to be done
that go with the routine physical and they tell me they have to be done in
the doctor's office and that I have to first pay the deductible and then a
copay.  Reading the policy at them did not help.  I finally got a supervisor
who said the lab tests should be done at a lab, a network lab (call PPOM to
get a list - the list was U of M).

An HMO might make sense if we wanted an annual sigmoidoscopy, colonoscopy,
ten blood tests, etc.  I think I should wait until 65 to get sick when the
government will start paying for it.

I got a supervisor at the health insurance company.  She told me that they
paid 80% and I paid 20% not of what the doctor and lab tell me they would bill
me, but of 'usual, customary, and reasonable' charges, which she interpreted
as what they have agreed to bill the PPOM which is what the insurance company
goes through.  The PPOM has a contract with each institution or doctor and
I could find out what the 'reasonable' charge is by getting the procedure
code, the diagnosis code, and the doctor's tax code and phoning the PPOM for
more info.

Amazingly, the doctor's office managed to give me procedure codes for most
things, procedure and diagnosis for the exam, diagnosis only for PSA, and
understandably did not want to give me the doctor's social security number
(tax code).

It only took about 40 min on the phone with the PPOM (their computer was down)
to get the 'reasonable' charges.  For the doctor's exam this was $142.50 ($10
less than we would have paid cash instead of insurance), for the CPT and some
other exam normally billed $73 each it was $14.06 billed to the PPOM, and for
the BAS (basic) blood test ($78) it was $7.57.  In other words, the U of M
lab test department bills individuals (uninsured, or if they are paying off
the deductible) 5-10 times what it bills insurers.  It bills $199 for the
$142.50 exam.  Translated, this mean the U of M's charges are about 150% to
1000% of reasonable when the patient pays.  This should be illegal.

So we can afford a whole lot of $14 tests.  It is $5 to draw blood for all
the tests.  I hope I don't need to pay them $50 for a blue patient card first
(that was the difference in cost between new patient and patient who has been
there in the past three years).  

I am thinking of spending another hour on the phone to try to find out what
happens if we go $1 over the $400 - are we billed for the difference at the
patient rate (which might be $78 minus $1) or at the PPOM rate ($1).  

You would think the insurance company could arrange some way for people paying
the deductible to get PPOM rates for this (bill the PPOM, which bills the
patient) so that the deductible would take twice as long to reach and the
insurance company would not have to pay for as much.

I wish we had national health insurance.

Medicare does not pay for preventive exams or tests, said the doctor's office.

I really don't have a recommendation as to which of the basic
screening tests to have done and which to defer.  

If this laboratory work is part of a physical exam then the
doctor should be able to help you with that one.

But at $14 per test we could have around 15 tests done so no problem.
The problem is how to bike to Saline and arrive at 10:30 without having to
battle rush hour traffic on some awful roads with deep gravel at their sides
(through which I walked last time).  It is a 2 hour trip.  
Does one normally need to go back for a repeat visit to talk about the test
results?  

Ride the bus.

The diesel fumes make me sick.  
I think we could leave at 8:30 and take back streets to reach the highway moat
at around 9:00.  We will probably have to go across it on Ann-Arbor Saline
Rd., which if I recall correctly has no sideway.  

how about sars

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