My out-of-pocket charge for a kidney transplant: $100.00. That is all it will be.
Appointments and MRIs scans ordered by various doctors to clear me to be on the transplant list: $830.00 and counting.
The out-of-pocket charges that are irking me most are those for MRIs. If I go to the ER and have them as an in patient, I pay the co-pay of $100.00. Having a scheduled appointment / referral from a doctor has cost me $160.00, $186.00, and $159.00.
Sometimes I go to the doctor and there isn’t a co-pay. Sometimes there is. Sometimes they say there isn’t, then bill me a month later. When I pay, even though the majority of the bills are from the same hospital system, I cannot pay through one billing site.
Suffice it to day, it’s all been very frustrating (on top of the whole failing body thing I have going on)
My out of pocket for a DaVinci hysterectomy, 2 days hospital stay in a private room [night prior and night after], head of gyn oncolgy, head of anesthesia, medications, pre and post imaging, pre and post lab work, oncology lab work, 1 week, 2 week, 6 week and 6 month followups and my out of pocket at Yale - New Haven was $600. [I brought my own daily meds, I refuse to not follow my very specific scheduling, and I consulted with the anesthetist and my surgeon for the pre and post medication schedules for taper off and back onto my assorted meds.] I saw the billing sent to Tri-Care, and it was $35 000. Given what went on I don’t think there was much padding going on with the billing.
The 20 years mrAru did as career Navy is worth it simply for the overall cost of medications and surgery over the past 25 years to keep my sorry ass alive and more or less functional.
As a physician, here’s the problem. You are not allowed to discuss rates with other physicians (for antitrust reasons?). Every insurance plan pays a different rate. It is almost impossible to figure out what each insurance is paying given different copays and deductible for different versions of different plans (I participate with 13 or 14 insureres but there are hundreds of different plans). The insurance pays you the lesser of their agreed fee or what you charge. Therefore, in order to get full payment you have to make sure that you are charging more than the allowable cost of the best-paying plan.
Here’s an example (numbers not real):
I charge $80 for an office visit
Medicare allows $50 so pays $40 with a 20% copay
Blue Cross #1 pays 110% of Medicare with a flat $20 copay so they allow $55 but pay me $35
Blue Cross #2 pays 120% of Medicare but the paient has a $3000 deductible so they allow $60 but pay me nothing
Blue Cross #3 pays a contracted rate of $75 but the patient has a $200 deductible of which $15 is outstanding and and the patient has a $15 copay so they allow $75 and pay $45.
Excellent plan #1 pays $80 with a $20 copay so allows $80 and pays $60.
Excellent plan #2 pays twice medicare but the patient pays 50% so they allow $100 but would pay $50 but because my rate is only $80 they only pay $40.
Meanwhile, excellent plan #1 raises its payment by $5 so they next visit they allow $85 so they would pay $65 but because I only charged $80 I only receive $60. However, this plan doesn’t actually tell me that they have raised their rates. They simply send me a notice that some of their rates may have been adjusted and I am free to peruse the hyndreds of pages on their website to figure out which of their hundreds of plans I actually am seeing patients under and the current payment for the codes I use most often under those particular plans.
The other alternative is to just charge everybody $150 and hope that this is higher than my best payor.
Yeah, market forces can’t keep normal medical costs down for two big reasons. The market hasn’t yet found the price where I would refuse to have myself or my child treated for a life threatening condition, they can charge anything they want and I’ll pay it. And, as others have pointed out, the costs are cleverly hidden so it is impossible for even a health person with free time to figure what they will have to pay. We all throw our hands in the air and hold our wallets out because the alternative is to stay sick.
Elective surgery is a wonderful example of the market at work. I could get laser surgery on my eyes or boob implants or a tummy tuck for a fraction of what my insurance paid for my broken pinky finger. And it’s a pretty sure bet that those cosmetic doctors couldn’t botch the job as badly as my orthopedic doctor because they would lose business if word got out.
My wife spent a few months with a PICC line in her arm where she was receiving nutrition. This is something that they insert in the hospital using x-ray equipment.
One fine day she felt the adhesive come loose and the line slipped out about an inch. Now, I understand why we couldn’t just shove the line back in: the portion that came out was now contaminated, and the far end of the line is dangerously close to the heart.
Her home care nurse said “Go to the ER and they’ll put in a new one.” So we went.
They admitted her almost immediately (almost unheard of) and put her in a room for the night, saying “The PICC line team won’t be here until tomorrow.”
They did nothing to her overnight, just basic monitoring. They didn’t even touch the line that was there, leaving it hanging out.
The next day, a single specialist appeared with a machine and inserted a fresh line in about 5 minutes.
The hospital attempted to charge our insurance company $45,000 for this overnight stay with 5 minutes of a very special specialist’s time.
The insurance company allowed about $3,000 (more in line with what I expected)
We paid a couple of hundred dollars.
My problem with this is that I don’t see where anyone would pay the $45,000 for such a procedure. If we were uninsured, we would certainly settle for a lower amount.
I do not see this charge as being in good faith: the hospital is planning on profiting from insurance companies that don’t question bills, people who don’t review their bills closely, and making the poor uninsured person happily pay $10,000 for the procedure, gladly accepting the huge discount over the original 45K.
The “free market” concept is based on sellers trying to maximize price while buyers try to minimize price. But the American healthcare system doesn’t work that way. Buyers are insurance companiesand want to maximize prices. Oh sure, they’ll seek to minimize in the short-term but, in the long-term their revenue will be proportional to total costs; the higher the total paid for health care the more total profit for the health insurance industry.
Despite this, you Americans have The Best Healthcare In The World™ and the rest of us are envious. I have the worst of worlds where I live: Socialized medicine for which I, a foreigner, am ineligible. I’ve had to pay $8 for an EKG and $40 for a CAT scan all totally out of my own pocket: I don’t have insurance.
Or you could just charge $80 and balance bill the patient for the portion not covered byinsurance. No?
Or is it part of your agreement with the insurance companies to not do that?
And if it is part of your agreement, then once again the good doctors have the power to correct the issue by collectively refusing to accept certain insurance. If no doctor will accept my insurance plan, I as a patient will find another they WILL accept.
As for the OP: Yes, the bills for nearly any medical service or product have very little to do with reality. The number essentially means, “Give me as much as you will.” This is fine when an insurer is handling the bill through a contract, but it makes being uninsured a potentially devastating position to be in because YOU have to negotiate the rate with someone who can say, Nope–that’s the price. Which is not such a problem when you can shop around for an elective surgery, but when you’re in the ER bleeding out, on morphine and at the mercy of whatever emergency protocol applies to you, you’re going to be financially date raped.
You are, strictly speaking, allowed to discuss rates with other physicians. Nothing prevents you from calling Dr. X down the street and asking his billing staff what they charge for an outpatient widgetectomy. What you can’t to is agree to charge the same rate for a service; that would make you a cartel.
There’s no reason for hospitals to use outside vendors. They can restrict use of their theaters to contracted physicians if they want to. They don’t, because… well, I don’t know. I presume it looks good for them to have lots of local physicians affiliated, but I can’t imagine it makes that much of a difference.
Most hospitals can’t provide enough business to support a salaried radiology/anaesthesiology/oncology etc. group practice. That’s the major reason for using outside vendors.
I got laid off in Dec 2011 with benefits ending at the end of February 2012. I was using BCBS. I received paperwork clearly stating that all medical/dental coverage would end at the end of Feb unless we signed up for COBRA. I did not sign up for Cobra and I got moved onto my husband’s insurance. Blue Cross called me at the end of November 2012 to say that I owe them money for coverage from March through October.
I kept telling them that I didn’t sign up for any additional coverage (in fact some doctors didn’t update their records and billed to BCCS and it got rejected as it should have done) AND they rejected any claims made during that time. I don’t see any way for them to say that I owe them money. As a favor they said that I just owe them for prescription coverage (WTF?) for that time period. Again we weren’t using them and didn’t affirmatively sign up for them. I’ve asked BCBS to show me paperwork saying that I signed up for it and they threatened me with going to collections. BCBS was completely unhelpful and refused to even look at the paperwork; they just kept repeating that I owe them money. By the end of our conversations, they were using collections as a threat and basically said that regardless of whether I really owed them money or not, it’d be better to pay than to have it go to collections.
It went to collections last month. I had a very nice call with a collections agent who asked whether I had paperwork cancelling my coverage. I pointed to the paperwork from my company and BCBS saying that my coverage was terminated effective 02/2012. I said that I hadn’t signed anything else indicating that I wanted extra coverage and they had, in fact, denied erroneous claims made during that period. I also said that it was very nice of BCBS to contact me AFTER my “supposed” coverage had already ended to say that I owed them money. The collections agent laughed, told me that it happened all the time and said that he was cancelling it with the explanation that I provided.
It’s a flat out crazy system when the provider wouldn’t even explain what the amount owed was for! I spent hours on the phone trying to get something sorted out that was a mistake (or deliberate) on their part.
I’m pretty sure it’s part of the agreement. By agreeing to take the insurance, you agree to take their pricing “$XX or your rate, whichever is lower, of which we pay $YY and you get the remainder from the patient”.
The trick is that you can’t just ask the doctor for his rate, because it all depends on what the rate is for the insurer. If you’re uninsured, you have to pay a bargaining game, because his book rate is basically the highest rate allowed by the insurers he accepts.
Since insurance is usually tied to employment, it’s generally a game of finding a doctor who will accept my insurance, instead of finding an insurer that my doctor accepts.
But are their partners also working solely at the same hospital? That’s why I said group practice - you need a fairly decent-sized group to have adequate coverage for sick times, vacations, and weekend call. Some hospitals are large enough to support that (mine is), but many are not.
This is my point. The 45,000 is a number that the hospital knows is totally fictional. It’s bullshit, they know it, and the insurers know it. Otherwise the markdowns would not be 90% or more. An in-network agreement should get you a bit of a discount… like if the procedure was truly worth 45,000, then you shouldn’t be accepting a discount below, say, 40,000 - otherwise you’re scammers.
When I have an office visit, the rack rate is, say, 150.00. The negotiated rate is 100.00. I pay my 20, the insurer pays 80. That’s a little more reasonable. But any kind of procedure or other test is fucking insane. I’ve had lab bills marked down from 200 dollars to 10.00.
Oh - and it’s not like you can price-compare. There aren’t any “colonoscopies-r-us” sites where you can comparison shop. Durable Medical Equipment is one of the rare places where you can explicitly point and say “see - that 600 bucks is a fucking FRAUD”.
The balkanization of the various specialities and billing contributes. One horror story I heard was when someone’s baby was in a NICU. The hospital was in-network. The neonatology practice - the ONLY such practice at the hospital - was not. Oh, I suppose they could have just moved the baby to another hospital… the whole “dying en route” angle was surely overplayed a bit…
Scott Adams calls these kinds of systems “Confusopolies”. Another example is phone service, where none of the plans are the same and none of the features are the same. Anything where you cannot easily do a one to one comparison to tell what the costs are for the same features. It’s not that the companies are in collusion (monopoly) to set prices, they just have such a scramble of options that you cannot make sense of what a fair cost is.
Possibly, but look at the other side of the coin. It’s reimbursement to them for the costs of doing business with the insurance agency. By the time they get through fighting with the company, it’s 4-6 months later and the doc still hasn’t been paid.
It’s not like medicine is the only industry that uses a lot of subcontractors. But I can’t think of any other industry where it’s common for the client to pay all the subcontractors individually, or where the general contractor can’t give even rough estimates.
It doesn’t seem like an inevitable law of nature so I have to assume the medical/insurance industries in the states like it that way.
This is cynical beyond belief, so I hesitate to even throw it out there but:
Default medical bill for a service is $1 million
Health Insurance Companies execute contacts with providers to pay $75 - $100 for that service.
Consumers must now decide: do I incur $1 million in bills I hope I can negotiate down to a reasonable level, or do I buy health insurance? Clearly, health insurance is an attractive product.
Health Insurance Company wins a new customer, doctors win guaranteed payment and informally directed business (if you have insurance, why would you knowingly select an ‘out-of-network’ provider?).
Why is the system set up like this as opposed to how you go about getting home & car repairs done? Because, no matter how badly damaged your house or car is, you can make a few calls and in 30 minutes at least narrow down who you want to work with. Medical situations are notably different in that they often contain an emergency element where decisions are being made for you, or you are being directed where to go for which procedures by Your Doctor. Your Doctor wouldn’t steer you wrong, in fact a good one will steer you to an in-network provider for that CT or MRI. Price availability depends on your market area I think, but I know I’ve done phone surveys to find out how much something like a knee MRI costs at various locations. You will get all kinds of numbers depending on who’s paying, there’s even a cash price. Hospitals offer cash discounts (which evaporate when they find out there is a car insurance claim pending) of up to 50% in a lot of places if you simply say, “How much to settle this bill if I pay it in cash right now?”
I dearly love doctors and the work they do, and I have the deepest respect for their knowledge, but when so many don’t even know what they charge for a service they really deserve a good portion of blame for runaway healthcare costs.