Can we talk Medicare pricing?

[Max_S]

@doreen

Do you mean the pharmacies give the flu shots for free to anyone , or do you mean the insurance companies don’t require a copay? I just got a shingles vaccination and my choices were

1. Pay the full price at my doctor’s office. He doesn’t participate in my insurance and although I have out-of-network coverage, he cost would not count towards my deductible or be covered if I had already met it.
2. Go to a participating provider or urgent care and pay my copayment
3. Go to a participating pharmacy and pay nothing. But it wouldn’t have been free if I didn’t have insurance or if the pharmacy didn’t accept my insurance or if my insurance didn’t cover that vaccine at a pharmacy ( I had to pay for the Tdap)

Yes. Walgreens in particular offered free flu shots for the uninsured, and anybody with insurance has a zero dollar copay when getting their flu shot at an in-network pharmacy or PCP. This is actually a good thing not a bad thing - we never offered flu shots for the profit, but as a public service. But it still sucks a little when patients say they won’t bother going somewhere else for their shots - we aren’t about to order a full case of flu vaccine for a handful of patients, and ordering a single dose instead of a case somehow costs over a hundred dollars. Plus we still can’t report to the state immunization registry.

~Max

[Flyer]

@Riemann

That first “amount charged” is a fictitious massively inflated number that is typically 2X - 10X the fair price. If the provider has stated that they accept Medicare, or if the provider is in-network with your private insurer, it is meaningless. The actual charges are the Medicare rates or the rates that your insurer has pre-negotiated with the provider for the specified service.

That fictitious wildly inflated price comes into play only if you have no insurance, of you inadvertently (or because of emergency) go to an out-of-network provider. Then it’s the rip-off price that the provider will claim you must pay them. What you are actually liable to pay under these circumstances (when you have been treated without any pre-agreed price) is a complex question, but at the very least you are faced with a long and extremely stressful process trying to negotiate the bill down to something sensible, being threatened with collections, even bankruptcy.

OR you could say, “I have cash in hand to pay my bill. How much of a discount will you give me in exchange for not having to deal with the paperwork and the hassle that comes with getting reimbursement from the insurance companies?”

[Blue_Blistering_Barnacle]

@Flyer

OR you could say, “I have cash in hand to pay my bill. How much of a discount will you give me in exchange for not having to deal with the paperwork and the hassle that comes with getting reimbursement from the insurance companies?”

This is exactly how the standalone low cost imaging centers work. AIUI, they charge one price per exam-type, no matter what they do. You pay them directly. Then you collect what you can from your insurance company.

I guess they don’t have to deal with emergency conditions, which means they can demand cash on the barrelhead FIRST.

This simplifies Billing for them, decreasing costs and essentially eliminating risk of no pay.

Not covering emergencies can also lower other ancillary costs, which are difficult to account for but do exist; this is stuff like bumping/delaying scheduled patients, staff time in communicating or dealing with urgent findings.

I think standalone urgent care centers are similar (but of course they have to deal with urgent conditions and occasional real emergencies). I’m not sure how they handle payment, but I think that EMTALA* must not apply to them, permitting them to demand cash on the barrelhead as well.

• The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay, but since its enactment in 1986 has remained an unfunded mandate.

[doreen]

@Blue_Blistering_Barnacle

I think standalone urgent care centers are similar (but of course they have to deal with urgent conditions and occasional real emergencies). I’m not sure how they handle payment, but I think that EMTALA* must not apply to them, permitting them to demand cash on the barrelhead as well.

As far as I can tell,only urgent care center owned by a hospital even have the possibility of EMTALA applying. But even for those owned by a hospital, they must be licensed as an emergency dept (also known as a free-standing emergency department) , held out to the public as treating emergencies or have provided emergency treatment in 1/3 of the cases in the previous year. And I suspect most urgent care centers , even those owned by hospitals ,don’t meet those standards.