Case Scenario

Case Scenario

I mentioned that my mother is my inspiration for forming an Insurance Advocate line of business. She experienced health challenges for many years. It was her diagnosis of End Stage Renal Disease (ESRD) requiring hemodialysis three times a week that we both realized she would require more assistance.

2018 brought more health challenges than normal. Physical therapy for mobility. Wound care for small sores that would not heal. Two falls in one week started the journey of hospitalization, inpatient rehabilitation, and skilled nursing care for short-term rehab. An infection and low blood pressure initiated an Emergency Room visit and admittance to the ICU. While my mother surprised her doctors yet again with her determination, we came to the realization that dialysis would no longer benefit my mother. At that point we transitioned to the comfort care plan agreed upon by our family.

Reviewing the final hospital admittance, the following services were provided for my mother's medical care:

Emergency transportLevel 5 ER

  • Chest X Ray
  • Blood tests
  • Ultrasound
ICU - 9 days
  • CT Scan
  • CT Angiography
  • Ultrasound
  • Chest X-Ray
Renal inpatient - 2 daysEndoscopyHemodialysisNonemergency TransportPalliative Care

Date of ServiceReasonTotal Charges
6/22/2018Emergency Transport$629.08
6/22/201871045 - X-ray$57.00
6/22/201871045 - X-ray$57.00
6/22/2018ER Visit Level 5$1,396.50
6/22/2018Ultrasound Guidance$116.85
6/22/2018Venipuncture$76.95
6/23/201870450 - CT Scan Head W/Out Contrast$243.00
6/23/201871275 - CT Angiography Chest$501.00
6/23/201893970 - Doppler Study Venous$196.00
6/23/201871045 - X-ray$57.00
6/25/201876700 - Ultrasound-Abdomen Complete$223.00
6/25/2018Initial Hospital Care$315.00
6/26/2018Initial Hospital Care$334.00
6/26/2018Egd Diagnostic Brush Wash$671.00
6/26/201847534 - Internal-External Biliary$1,330.00
6/26/201874183 - MRI-Abdomen W & W/O Contrast$506.00
6/26/201871045 - X-ray$57.00
6/26/2018Anesthesia Services for endoscopy$1,845.00
6/27/2018Subsequent Hospital Care$123.00
6/27/201899231 - Subsequent Hospital Care$137.00
6/27/201870450 - CT Scan Head W/Out Contrast$243.00
6/27/201871045 - X-ray$57.00
6/27/201874018 - X-Ray Abdomen$52.00
6/28/2018Subsequent Hospital Care$123.00
6/28/201871045 - X-ray$57.00
6/29/201890935 - Hemodialysis - One Eval$390.00
6/30/201874018 - X-Ray Abdomen$52.00
6/30/201874018 - X-Ray Abdomen$52.00
6/30/201890961 - ESRD Related Services 2-3+$900.00
6/30/201899231 - Subsequent Hospital Care$95.00
7/1/201899232 - Subsequent Hospital Care$172.00
7/2/201871045 - X-ray$57.00
7/2/201871045 - X-ray$57.00
7/2/201890935 - Hemodialysis - One Eval$390.00
7/3/201899232 - Subsequent Hospital Care$172.00
7/3/201899497 - Advance Care Planning 1$205.98
7/3/2018Subsequent Hospital Care$256.00
7/4/2018Nonemergency Transport$426.37
7/4/2018Hospital Services - 6/22 - 7/4$133,408.80
7/4/2018Palliative Care$1,663.89
Total$147,701.42


Being over 65, my mother received Medicare benefits. The role of Medicare is to manage healthcare costs by negotiating submitted claims. In other words, when a provider submits proof of services rendered Medicare responds with an amount they will reimburse for that service. The provider is required to accept Medicare's reimbursement rate.

Here's what my mother's hospital bills look like after Medicare was processed:
Date of ServiceReasonTotal Charges
6/22/2018Emergency Transport$629.08
6/22/201871045 - X-ray$57.00
6/22/201871045 - X-ray$57.00
6/22/2018ER Visit Level 5$1,396.50
6/22/2018Ultrasound Guidance$116.85
6/22/2018Venipuncture$76.95
6/23/201870450 - CT Scan Head W/Out Contrast$243.00
6/23/201871275 - CT Angiography Chest$501.00
6/23/201893970 - Doppler Study Venous$196.00
6/23/201871045 - X-ray$57.00
6/25/201876700 - Ultrasound-Abdomen Complete$223.00
6/25/2018Initial Hospital Care$315.00
6/26/2018Initial Hospital Care$334.00
6/26/2018Egd Diagnostic Brush Wash$671.00
6/26/201847534 - Internal-External Biliary$1,330.00
6/26/201874183 - MRI-Abdomen W & W/O Contrast$506.00
6/26/201871045 - X-ray$57.00
6/26/2018Anesthesia Services for endoscopy$1,845.00
6/27/2018Subsequent Hospital Care$123.00
6/27/201899231 - Subsequent Hospital Care$137.00
6/27/201870450 - CT Scan Head W/Out Contrast$243.00
6/27/201871045 - X-ray$57.00
6/27/201874018 - X-Ray Abdomen$52.00
6/28/2018Subsequent Hospital Care$123.00
6/28/201871045 - X-ray$57.00
6/29/201890935 - Hemodialysis - One Eval$390.00
6/30/201874018 - X-Ray Abdomen$52.00
6/30/201874018 - X-Ray Abdomen$52.00
6/30/201890961 - ESRD Related Services 2-3+$900.00
6/30/201899231 - Subsequent Hospital Care$95.00
7/1/201899232 - Subsequent Hospital Care$172.00
7/2/201871045 - X-ray$57.00
7/2/201871045 - X-ray$57.00
7/2/201890935 - Hemodialysis - One Eval$390.00
7/3/201899232 - Subsequent Hospital Care$172.00
7/3/201899497 - Advance Care Planning 1$205.98
7/3/2018Subsequent Hospital Care$256.00
7/4/2018Nonemergency Transport$426.37
7/4/2018Hospital Services - 6/22 - 7/4$133,408.80
7/4/2018Palliative Care$1,663.89
Total$147,701.42
Date of ServiceReasonTotal ChargesMedicare Pays
6/22/2018Emergency Transport$629.08 $333.65
6/22/201871045 - X-ray$57.00 $7.11
6/22/201871045 - X-ray$57.00 $7.11
6/22/2018ER Visit Level 5$1,396.50 $133.62
6/22/2018Ultrasound Guidance$116.85 $11.23
6/22/2018Venipuncture$76.95 $7.31
6/23/201870450 - CT Scan Head W/Out Contrast$243.00 $31.46
6/23/201871275 - CT Angiography Chest$501.00 $70.93
6/23/201893970 - Doppler Study Venous$196.00 $26.71
6/23/201871045 - X-ray$57.00 $7.11
6/25/201876700 - Ultrasound-Abdomen Complete$223.00 $31.54
6/25/2018Initial Hospital Care$315.00 $89.56
6/26/2018Initial Hospital Care$334.00 $153.28
6/26/2018Egd Diagnostic Brush Wash$671.00 $95.06
6/26/201847534 - Internal-External Biliary$1,330.00 $294.98
6/26/201874183 - MRI-Abdomen W & W/O Contrast$506.00 $85.66
6/26/201871045 - X-ray$57.00 $7.11
6/26/2018Anesthesia Services for endoscopy$1,845.00 $125.81
6/27/2018Subsequent Hospital Care$123.00 $55.06
6/27/201899231 - Subsequent Hospital Care$137.00 $30.24
6/27/201870450 - CT Scan Head W/Out Contrast$243.00 $33.11
6/27/201871045 - X-ray$57.00 $7.11
6/27/201874018 - X-Ray Abdomen$52.00 $7.11
6/28/2018Subsequent Hospital Care$123.00 $55.06
6/28/201871045 - X-ray$57.00 $7.11
6/29/201890935 - Hemodialysis - One Eval$390.00 $56.41
6/30/201874018 - X-Ray Abdomen$52.00 $7.11
6/30/201874018 - X-Ray Abdomen$52.00 $7.11
6/30/201890961 - ESRD Related Services 2-3+$900.00 $156.17
6/30/201899231 - Subsequent Hospital Care$95.00 $30.24
7/1/201899232 - Subsequent Hospital Care$172.00 $56.17
7/2/201871045 - X-ray$57.00 $7.11
7/2/201871045 - X-ray$57.00 $7.11
7/2/201890935 - Hemodialysis - One Eval$390.00 $56.41
7/3/201899232 - Subsequent Hospital Care$172.00 $56.17
7/3/201899497 - Advance Care Planning 1$205.98 $51.95
7/3/2018Subsequent Hospital Care$256.00 $46.79
7/4/2018Nonemergency Transport$426.37 $211.48
7/4/2018Hospital Services - 6/22 - 7/4$133,408.80 $11,590.09
7/4/2018Palliative Care$1,663.89 $1,570.31
Total$147,701.42 $15,624.67


It is recommended for individuals on Medicare to also purchase supplemental coverage. This 'supplement' assists with the out of pocket healthcare costs not covered by original Medicare. While there are numerous insurance companies throughout the country that offer Medicare Supplement coverage, these insurance companies offer standardized plans for supplemental coverage.

While these supplemental plans are not required, a 'Part D' plan is required, where the 'D' represents Drug Plan. Every person eligible for Medicare coverage is required to also enroll in a Part D plan; however, most plans have little to zero cost.

Instead of purchasing supplemental coverage, my mother received supplemental healthcare coverage as a benefit to her retirement as a teacher. Her retirement coverage also qualified as her Part D coverage because it included prescription benefits.

Returning to my mother's healthcare services received and after applying her retirement healthcare plan, we have a clearer picture of what is owed for my mother's care.

Date of ServiceReasonTotal ChargesMedicareNC State Employee RetirementPatient Responsible
6/22/2018Emergency Transport$629.08 $333.65 $59.58 $25.53
6/22/201871045 - X-ray$57.00 $7.11 $1.27 $0.55
6/22/201871045 - X-ray$57.00 $7.11 $1.27 $0.55
6/22/2018ER Visit Level 5$1,396.50 $133.62 $23.86 $10.23
6/22/2018Ultrasound Guidance$116.85 $11.23 $2.00 $0.86
6/22/2018Venipuncture$76.95 $7.31 $0.00 $1.87
6/23/201870450 - CT Scan Head W/Out Contrast$243.00 $31.46 $5.62 $2.41
6/23/201871275 - CT Angiography Chest$501.00 $70.93 $12.67 $5.43
6/23/201893970 - Doppler Study Venous$196.00 $26.71 $4.77 $2.04
6/23/201871045 - X-ray$57.00 $7.11 $1.27 $0.55
6/25/201876700 - Ultrasound-Abdomen Complete$223.00 $31.54 $5.63 $2.41
6/25/2018Initial Hospital Care$315.00 $89.56 $15.99 $6.86
6/26/2018Initial Hospital Care$334.00 $153.28 $39.10 $11.73
6/26/2018Egd Diagnostic Brush Wash$671.00 $95.06 $24.25 $7.28
6/26/201847534 - Internal-External Biliary$1,330.00 $294.98 $52.67 $22.58
6/26/201874183 - MRI-Abdomen W & W/O Contrast$506.00 $85.66 $15.29 $6.56
6/26/201871045 - X-ray$57.00 $7.11 $1.27 $0.55
6/26/2018Anesthesia Services for endoscopy$1,845.00 $125.81 $9.63
6/27/2018Subsequent Hospital Care$123.00 $55.06 $9.83 $4.21
6/27/201899231 - Subsequent Hospital Care$137.00 $30.24 $5.40 $2.32
6/27/201870450 - CT Scan Head W/Out Contrast$243.00 $33.11 $5.91 $2.54
6/27/201871045 - X-ray$57.00 $7.11 $1.27 $0.55
6/27/201874018 - X-Ray Abdomen$52.00 $7.11 $1.27 $0.55
6/28/2018Subsequent Hospital Care$123.00 $55.06 $9.83 $4.21
6/28/201871045 - X-ray$57.00 $7.11 $1.27 $0.55
6/29/201890935 - Hemodialysis - One Eval$390.00 $56.41 $10.07 $4.32
6/30/201874018 - X-Ray Abdomen$52.00 $7.11 $1.27 $0.55
6/30/201874018 - X-Ray Abdomen$52.00 $7.11 $1.27 $0.55
6/30/201890961 - ESRD Related Services 2-3+$900.00 $156.17 $27.89 $11.95
6/30/201899231 - Subsequent Hospital Care$95.00 $30.24 $5.40 $2.32
7/1/201899232 - Subsequent Hospital Care$172.00 $56.17 $10.03 $4.30
7/2/201871045 - X-ray$57.00 $7.11 $1.27 $0.55
7/2/201871045 - X-ray$57.00 $7.11 $1.27 $0.55
7/2/201890935 - Hemodialysis - One Eval$390.00 $56.41 $10.07 $4.32
7/3/201899232 - Subsequent Hospital Care$172.00 $56.17 $10.03 $4.30
7/3/201899497 - Advance Care Planning 1$205.98 $51.95 $9.27 $3.98
7/3/2018Subsequent Hospital Care$256.00 $46.79 $8.36 $8.36
7/4/2018Nonemergency Transport$426.37 $211.48 $37.76 $16.19
7/4/2018Hospital Services - 6/22 - 7/4$133,408.80 $11,590.09 $22.47 $9.63
7/4/2018Palliative Care$1,663.89 $1,570.31 $0.00 $0.00
Total$147,701.42 $15,624.67 $457.72 $204.42


Remember, my mother received more healthcare services in 2018 than she did at the same time the year before. While my mother met all of her deductibles in June 2018, she had not met all of her deductibles in June 2017. If these same services occurred in 2017, my mother’s financial responsibility would be different.

The ultimate takeaway is the importance of healthcare coverage.