Northeast Wisconsin
  • Northeast Wisconsin
  • September 2017
Written by 

Who pays?

It happened at 3 a.m. and something that you never expected. But two trips to the hospital emergency room over three days and a $34,000 bill later, the question is what was more painful: the kidney stone or the bill? 

Who would have thought that going to the emergency room could cost that much?

The $34,000 bill was reduced to $19,000 by insurance discounts, but your $5,000 deductible with a $7,150 maximum out-of-pocket (MOOP) limit can put the hurt on anyone.

What should you do when pain hits? 

On the second visit when the ER urologist suggested a procedure of inserting a stent to help remove the stone, your initial reaction is to do it, but what about cost? If you knew the cost was over $30,000, would that change your decision to proceed? Years ago, when you paid less and insurance paid more, this decision would be easy, but not anymore. You want to know your cost, health care benefit and risk. Until you reach your $7,150 limit, you will pay much of the bill. 

Using this example, see what you pay and what insurance pays as follows:

Individual pays

Insurance pays



(Billed charges)

(Insurance discount)



(Approved amount)







(20% co-insurance)

(80% co-insurance)




(Balance due)



(Total you paid) 38%

(Total insurance paid) 62%

Now that you’ve reached your maximum out-of-pocket for the calendar year, your health insurance plan will pay 100 percent of approved medical charges for the rest of the year. Hopefully the kidney stone did not occur in December, because in January your deductible and MOOP start all over again. When pain hits, you want to ask questions about your options to best address the root cause of it at the best cost.

In regard to cost, you want to know your insurance out-of-pocket costs in the form of deductibles, co-insurance and co-pays. It is these costs that make up your annual MOOP limit. In the hospital, your MOOP limit can be reached very quickly. Tell your doctor or other health professional right up front that you have a higher deductible and need to know the approximate procedure’s cost, expected benefit and risk for doing a certain procedure, and on the flip side what is the cost, benefit and risk for not doing it or doing a different approach. 

Also, always ask what you can do to manage your condition better at lower cost. This is something that frustrates doctors because many people will not actually follow recommended options to manage or reverse a health condition. The kidney stone episode is a learning experience on cost, benefit and risk. 

Understanding more about your health care and insurance is more important as these costs are shifted to us, the consumer. It requires a greater awareness about all this and lots of questions to stay in control of your decisions. Once you have greater control, you can do more to help yourself improve health, lower cost and save money. 

John Ulness

John Ulness is co-owner of Ulness Health Insurance & Wellness in Appleton. He helps people in Wisconsin understand their health insurance options to control costs and enroll. He can be reached at 1-800-386-0876 or [email protected]

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