Fictionalized medical bills and provider proliferation

So a few years back, I needed a nebulizer. Went with an in-network DME provider. The unit I wanted went for about 200 dollars retail. The DME provider collected 20% of their in-network fee (of about 150 dollars). Then submitted a bill to the insurer for 6 hundred dollars. Yes, this was quite literally triple what the same machine would have cost if I’d gone down to DME’R’Us with a prescription in hand and no coverage.

I got a CPAP mask replacement recently. Cost me about 17 dollars out of pocket, for a mask that retails for about 127 dollars. The bill to the insurer? five hundred dollars. This was marked down to the in-network rate of about 100 bucks.

Every other medical procedure (beyond routine office visit) has a “rack rate” of at least 4-5 times, sometimes 10 or more times, the negotiated rate. What the fuck is that all about? I mean, I understand negotiated rates but why are the rack rates THAT much higher? It smacks of fraud, to me.

So I’m pitting the providers for jacking up their listed rates to such a fucking INSANE degree that it’s impossible to tell what a procedure really costs.

(and the funny part about the nebulizer: I don’t think they ever got paid. The claim showed up in my insurer’s files as “out of network” and posted against my OON deductible… I tried appealing it because the DME provider was in-network. They never came after me for any money).

Related: Every time you have anything done, you get bills from:

  • The doctor
  • The facility
  • The anesthesiologist
  • The pathologist
  • The radiologist
  • The pathology lab
  • The pathologists drinking buddies…
  • The doctor’s babysitter’s gardener…

OK, I have yet to get anything that was obviously identified as the babysitter’s gardener… yet. But seriously, no wonder the US medical system is so messed up - nobody knows who’s gonna be hitting them up for money next when they have anything go wrong.

Yes, my latest procedures involved both a pathology lab and a pathologist (who as far as I can tell isn’t even physically located within a thousand miles of here). Prior to that it was just the pathology lab who, I guess, was competent to read their own reports. I guess the local gut docs decided that this didn’t make them enough money so they “hired” this pathologist I’ve never met.

I friend of mine got a “Bone Growth Stimulator” to help heal an injury and she was told directly that if she got it through insurance it would cost $2000 of which she would pay a $200 copay, or she could buy it directly for $200 without involving insurance.

U.S. medical billing is a real crap shoot.

I have a hard time blaming the doctor, because I think the prices are part of a package negotiated with each insurance company, and the “rack rate” may not be the same for each insurance company.

My current experience with insurance is insanely frustrating. You go do the doctor, and nobody knows what anything is supposed to cost. How much is X procedure, they have no idea, talk to the insurance company. You call the insurance company, and you’re trying to relay ideas to an operator, without having a person who actually knows what’s going on with you, and knows about medicine, to help.

I recently had a vasectomy, and despite the fact that I asked over and over again about the costs and what was included/wasn’t included, I wound up with an additional bill for pathology on the removed tissue. You need a fecking itemized list of procedures to read over the phone, just to know what your out of pocket costs are going to be. No wonder our costs are so high, I spent probably 3x as much time discussing the costs of the procedure with the office staff / insurance company than the doctor spent working on my crotch, and I was still surprised by the bill.

We took my daughter to the emergency room a couple of weeks ago and two different people took our insurance information. On our way out I asked if I needed to pay the $150 copay and they said they would send us a bill. Since we had rushed in at 3 a.m. and it was almost 6 a.m. and I was exhausted I just figured that was good enough and we left. Two weeks later I got a bill in the mail for more than $1000 for the emergency room fee alone. I called and asked why they never billed our insurance and their response was, “Oh, nevermind that then. We will go ahead and bill your insurance.” Are they incompetent? Are they trying to scam us into paying and then billing our insurance too? I guess we will never know.

At the last place I worked, one of the benefits was payment to employees if the employee discovered medical providers double-billing or the insurance company overpaying. Employees were encouraged to go over their benefit statements with a fine tooth comb. If a mistake was discovered, the employee was paid a percentage of the mistake. I don’t remember the percentage, but it was high enough that some employees received hundreds of dollars.

You say this as if those two questions are opposite of each other.

The high billing amounts seem to be the hospital/office saying, “Let’s see how much will stick.”

My health insurance has an HRA (reimbursement account) that is partially funded by the company. Last year, I found that one particularly large procedure had been double billed, and both bills were deducted from my HRA. If I hadn’t noticed, I would have had to eventually pay that additional amount for further bills accrued after the account was depleted.

Well, yes. All those are separate entities, and all of them expect to get paid for the work they do.

Bingo! And it makes for a very frustrating situation for everybody. Unless we go single-payer, though, I don’t see an easy way out, unfortunately.

Yet somehow my grocery store manages to figure out the cost of a loaf of bread before I buy it, and out of that sticker price, they pay

The cashier
The stock person
The manager
The manager’s manager
They guy who mops the floor
The electric company
The gas company
The light bulb changer
The guy that plays the piano up front (I’m not making that up.)
The bakery that actually made the bread

But there’s no way to get that in medicine with the way care is currently structured. It will take some sort of single-payer setup to replicate that in medicine. And getting that in place is going to be hard, as there are a lot of vested interests who will fight that change.

Exactly. *That *is the problem, not the fact that there are many people involved in getting the product (bread/healthcare) to the consumer/patient who all want to be paid.

Okay, let’s go with single payer then.

Oh and in your example, WhyNot, nearly everyone you mentioned is an actual employee of the grocery store. In the example MamaZappa gave, none of the four doctors involved are likely to be salaried employees of the hospital or clinic (which is why they are billing separately). That makes for a more complicated billing situation. (The more expensive comes from other factors, touched on by Cheesesteak’s post.)

Of course. But Mamma Zappa’s post was implying there was something hinky (if not downright fraudulent) about all those separate bills, which is why I replied the way I did. She’s not being ripped off; those providers did perform services, and under our current fee-for-service model directly billing the patient for those services is how they get paid for their work.

I count half.

I don’t think her point as that there was anything “hinky”, but that it’s needlessly complicated for everyone involved. If that wasn’t her point, it’s still my point.

Fine by me. It’s going to be an uphill battle, though. Insurance companies have a vested interest in keeping the current system going, and they have a lot of political clout.

It’s because medical bills have no relation to the procedure in the first place.

An example given in that article is a procedure costing $99,690 at one hospital and $7,044 at another one less than 30 minutes away.

And this is why it is hysterical when anyone talks about the power of the free market to bring down costs. The absolute core of the free market system is the idea that people make purchases based on the lowest cost for identical products. But if you literally cannot tell–even roughly–what things will cost until after the fact.

Interestingly enough, fertility medicine is one of the few areas of medicine where you really do have a free market: most people are at least somewhat out of pocket and you don’t have to have the product like you have to have, say, treatment for a broken arm. And so prices are very upfront compared to other types of medicine–clinics have price sheets. And it seems to me that that does drive prices down: for all that fertility treatments are not cheap, you can get a lot done for less than the cost of a broken arm at the ER.

In 2011, I had to get a procedure on my ear that only ended up costing me a $30 copay.

However, earlier this year when I went to get the same exact procedure done on my other ear, I wound up getting a bill for $180, in addition to the $30 copay I had to pay at the office.

At first I thought it may have been because I hadn’t met my deductible. But in 2011 when I had the first procedure done, I hadn’t come close to meeting my deductible either.

When I called the billing department, I couldn’t get a straight answer on why it cost me so much more this time.

And therein lies the problem. The healthcare business in this country doesn’t really function like a traditional free market in that consumers are able to look at costs and figure out what’s the best deal.

If you go to a mechanic, you’re often be able to see right when you walk in the door that, say, an oil change will cost you $19.95 or a radiator flush, $89.95. Or if they find something wrong with your car, they can tell you “all right, this will cost you $350 to fix.” And if you don’t want to pay that, you can always call around.

But, I’ve found in many cases the doctors themselves won’t even know how much the services cost, let alone how much the patient has to pay out of pocket.