First there was math, then for a while the big thing was New Math, and a few years ago it was Common Core math, so the theory behind the best way to teach math has been an evolving idea for a long while.

I get it, math can be difficult and so we try to make it easier for kids to learn and use in their everyday lives. I don’t mind it, try it and if it works, great.

Now though, I am just baffled by this new method that is going around, something called Insurance Math. I consider myself a relatively smart guy but I just can’t wrap my head around this at all.

Insurance math is taught using complex word problems, here is a sample I just encountered, see if you can figure it out:

A man goes to his doctor, let’s call him Scott.

Note, the man, who is the patient, his name is Scott, we never do learn the name of the doctor.

Anyway Scott goes to his doctor and has a number of tests related to his liver. Scott is then sent to a specialist who is part of the same hospital as Scott’s doctor but for some reason Scott’s Insurance won’t cover the full cost of Scott’s visit to the Hepatologist even though a referral was issued and the Hepatologist is in network. Scott’s insurance covers the lab work for this visit but not the doctor visit. This costs Scott $210.00 and about 20 hours of his life talking to doctor’s offices and insurance companies and anyone else that Scott can think of, but Scott can’t get the issue resolved and is forced to pay the $210.00 to avoid it going to collections.

At the same time the Hepatologist that Scott was sent to ordered an elastography MRI of Scott’s liver and was told this is a very important test. Scott, however, was afraid to call and schedule the test because it was ordered by a doctor that Scott’s insurance says is out of network, even though they are actually in network and he feared that the insurance wouldn’t pay for it. Scott couldn’t really afford the $210, he was afraid to ask how much an elastography MRI might cost him.

Eventually, about three months later, Scott got his original primary doctor to schedule the MRI and as of now it appears that it will be covered by the insurance company.

Simultaneously to all of this, Scott’s original primary doctor prescribed some medication for Scott to take that can lessen the scarring (or fibrosis) that is developing on his liver. The primary doctor tries two times to get the prescription approved by Scott’s insurance company and is denied both times.

Scott was told by his doctor that this was a very expensive medication. Scott, being the industrious guy that he is, learned about a program by the drug’s manufacturer that offered assistance to those who might not be able to afford it. The manufacturer told Scott that the prescription would cost $349 month with no insurance.

This made Scott sad becuase he could not afford $349 a month for this prescription.

Scott’s doctor thought that maybe the Hepatologist that Scott went to see might have more luck getting the prescription authorized than he did, so she tried and finally Scott’s insurance agreed, this medication would indeed help Scott and his liver issues and they approved it on his insurance.

Scott had his doctor send the prescription to his local pharmacy and being the curious guy that he is, called CVS to find out how much this would cost him. Imagine, and this is where the math gets really tricky, Scott’s surprise when he was told that his co-pay for the prescription, after the insurance company paid their part, would be $535 a month.

Scott couldn’t believe his ears, why would it be $535 a month through the insurance if it was only $349 a month without insurance. Scott did something he hated doing but felt he had no choice, he called his insurance company and asked them if this was true, and why this would be the case.

The agent assured Scott that since this was a tier 4 drug (followed by 10 minutes of unintelligible insurance jargon) that their contracted price with the pharmacy was over $1000 and that (another 10 minutes of unintelligible insurance jargon) and that indeed his copay would be $535 a month.

Scott asked the agent why he even had insurance and for the first time, the agent had no jargon or mumbo jumbo to offer him, before reminding him to stay on the line to answer the brief survey that would follow this call.

Given all the information provided above, and using the concepts of Insurance Math, please answer the following questions:

Why does Scott even have insurance?
Why does the insurance make it so difficult to approve a medication that costs more through them than buying directly?
How much does an elastography MRI cost a patient who gets it ordered by an out of network doctor who is really in network?
When Scott’s liver eventually fails, they just take that sucker out like tonsils or an appendix right?
How much does a liverectomy cost anyway, provided it is done by an in network doctor in a covered facility?

I’m stumped, how about you?