As health insurance costs skyrocket and more people turn to high-deductible policies, a key question is emerging: When you're paying out of your own pocket, what rate do you pay?

Case in point: Lisa Stamm of Kendall, Fla., had a simple earache and got slapped with a $375 bill for about 10 minutes with a nurse practitioner. If she had no insurance, she could have paid $125. If she had a no-deductible policy, her insurer might have paid about $140, and she would have paid nothing.

"This really made me mad," Stamm says. "I called the insurance commissioner's office. I called my insurance. You'd think something could be done."

But no. ER Urgent Care insists she cough up the full $375. "We as consumers have to make our choices," said Trudy Herdocia, the firm's vice president of operations. "And live by them."

High-deductible policies have been championed by the Bush administration and the Republican Congress because they think the policies lower health care costs. The theory is that if consumers are spending money out of their own pockets, they will be more intelligent users of health care.

"The theory is patients will be able to negotiate with providers," says Gail Shearer of Consumers Union in Washington. "But the theory doesn't always translate into practice. She was concerned because her ear hurt. Negotiating a rate was not at the top of her list."

Stamm, who works in real estate, is on a Cigna policy from her husband's workplace that has a $250 in-network and $500 out-of-network deductible. That's modest compared with the $2,000 and even $5,000 annual deductibles many consumers and employers have chosen in order to get affordable policies.

Last September when she had an earache, Stamm figured it could take several days to get an appointment with her primary care doctor, and she knew if she went to an emergency room, she was likely to have a long wait and a huge bill.

So, like many thoughtful consumers are doing these days, she chose one of the growing number of urgent care centers, staffed for extended hours by doctors and nurse practitioners.

At the urgent care center near her home, she showed her insurance card and made a $50 co-payment. "They didn't say anything about their rates, and it didn't occur for me to ask."

It turns out that ER Urgent Care Centers are not in the Cigna network, and the firm had paid nothing on her bill because she had not met her out-of-network deductible.

During the conversation, the billing person mentioned that if Stamm was uninsured and paid in cash at the time of her visit, she would have been charged $125.

Herdocia, the ER Urgent Care executive, says the firm offers a cut rate for the uninsured because it understands the nation has a major problem about lack of health insurance. But since Stamm had insurance, that rate didn't apply to her.

That means Stamm's bill might be an example of a new paradigm, because as Shearer at Consumers Union points out, the traditional quirk of America's health care billing is that the uninsured are charged more than others.

Santiago Leon, a Miami insurance broker who is active in several local health reform efforts, views it this way: "They see someone who's uninsured, they say, 'Oh, that's not a deep pocket. We'll take what we can get.' But since she has insurance, they figure she is a pocket. If Cigna pays, that's great. If not, the presumption is if you can afford insurance, you have money to pay."

Stamm checked with Cigna and received an explanation of benefits, one of those "THIS IS NOT A BILL" statements most Americans ignore. The EOB stated: "Billed Amount $375; Allowed Amount $375; Deductible/Co-pay $375."

When Herdocia was asked why the charge was so high for treating a simple earache, she said that each treatment is given a code, based on the complexity of service, and that automatically determines the charge.

Now Stamm's earache becomes even more interesting. The code on Stamm's bill is 99245. According to the billing codes developed by the American Medical Association, this number is for a consultation requested by another physician or source.

It involves taking "a comprehensive history, a comprehensive examination and medical decision making of high complexity," according to the AMA's Current Procedural Terminology coding manual. "Physicians typically spend 80 minutes face-to-face with the patient."

Proper coding of medical services is a long-standing war between providers and health insurers. Health plans generally think providers tend to code too high, to get more money, and they will frequently question a code or automatically downcode it to a cheaper level.

Cigna spokeswoman Karen Godlewski said members who choose in-network providers would pay the negotiated rate, even if they were paying out of their own pockets.

UnitedHealthcare, Humana and Blue Cross Blue Shield of Florida also said patients with high deductibles should be paying the negotiated rate, not the gross charge rate.

Meanwhile, Stamm appears to be stuck. "They told me if I didn't pay the full amount, they'd take action against me and report it to the credit bureau," and she doesn't want that. "I can pay this if I have to. I just don't really want to."

But in one way the new consumer-driven health care philosophy appears to be working. The next time she gets an earache, she won't go back to that center. "I'll just call my primary-care doctor."

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