Medical billing: any better with Kaiser or similar, than with other medical plans (for Senior)?

In My Humble Opinion
1

Being over 65, I have Medicare parts A and B (and D, but that’s not an issue), and a 3rd party supplementary “gap” coverage plan which they call Part F. If I have any kind of outpatient procedure beyond a routine doctor’s office visit, it is very difficult to keep track of what the charges were for that procedure, what insurance paid, and what I’m responsible for. On no particular schedule, Medicare will send a summary, that may include more than one date or procedure; the insurance company will send a summary that also may include more than one date or procedure; for the procedure, the facility and every single participant not directly paid by the facility (i.e. doctor, anesthetist, some technicians) sends their own bill. To further complicate matters, the amounts paid or agreed to by Medicare and the insurance may change, never to my benefit it seems, so after I think everything is paid for, I get another bill.

Does any medical insurer or medical care provider give the patient a final breakdown for an outpatient procedure of all this stuff in one place, where I don’t have to be a CPA to figure it out? I thought maybe Kaiser would be better, since (if I understand correctly) everything is integrated as long as you stay within their system.

2

I have no clear idea how the actual cost of being a Kaiserite compares with other medical plans. But a big part of their business model, from the “customer”'s point of view, they have it very simplified.

Kaiser is very much a “one-stop shopping” deal, both for getting their services, and for the way their billing works.

Almost all of their services are “in-house”, so for lab work, various kinds of procedures, treatments, you don’t have to run all around town to different facilities to get it done. Your providers all give lab orders, write prescriptions, referrals to specialists, almost all in-house.

(Note that “in-house” doesn’t necessarily mean all literally at one physical location. Kaiser may have various of their own offices scattered at places around town.)

Their billing is similar. You get a monthly bill for your monthly “membership” which is on top of your Medicate Part B payment (which is probably deducted from your Social Security before you ever see it).

Co-pays for various procedures are paid on the spot at the time of service, usually. Sometimes the service will include more stuff than originally intended, and you will get a separate bill for that sometime later. That is where the “unpleasant surprises” can sometimes show up.

They send an EOB (Explanation of Benefits) several weeks after the end of every month in which you used any of their services. It looks like a rather detailed bill, except that it’s not a bill. It gives a line-item by line-item list of everything that happened, including the total cost billed by the provider, the cost approved by the Plan, the amount paid by you, and any amounts paid by third parties. Also includes totals for the month and year-to-date totals.

All pharmacy bills are separate. You get a separate, but similar EOB for that. The plan seems to cover a bit under 50% of your prescription expenses. I don’t know how that plays if you have some really expensive prescription costs – I have a feeling it’s not a great deal. But I have no idea how it compares with the Part D plans you see advertised all over the place.

Kaiser definitely has the “one-stop shopping” part of their business model in place, including the more-or-less “one-stop billing”. At least it’s convenient.

All the billing and paying can be done on-line or by telephone, including re-ordering your prescription refills. It’s very automated and mostly works well.

3

My parents have Kaiser.Yes, I believe it is all integrated. If you have ready access to a Kaiser facility, it’s worth exploring. My parents have been very happy. I would recommend getting the highest level plan you can afford.

4

Note that the bills, as shown on those EOB’s, may still be quite complicated and require a medically-knowledgeable CPA to understand, if you really want to understand it.

The advantage is that you get one EOB detailing everything, instead of a blizzard of bills in the mail from a whole bunch of providers you never heard of, for services you didn’t even know you got.

There’s still whole bunches of items on those EOB’s, from named in-house providers you never heard of for services you didn’t know you got. But much of that is at little or no separate cost to you, and it’s all documented there in one place.

For instance, your PCP may order some kind of X-rays. Then you’ll see separate items on your EOB for your PCP’s time, and for the use of the X-ray facility, and the technician who did the X-rays, and the radiologist who read and interpreted the X-rays – all names of people you don’t even know. But often, the entire co-pay for all that stuff will be bundled together into one of those line-items, with a $0 co-pay for all the others.

5

Kaiser does out-source some limited amount of their services, but not much.

One useful is a limited our-sourcing of pharmacy services. They strongly push you to get your re-fills by mail-order (I do, and it works well). For long-term meds, they want you to get re-fills for 90 days at a time, and if you do that by mail-order, you can get three months pills for two months co-pay.

For first-time prescriptions, they usually want you to get that done in person at the pharmacy so you can have a (usually useless) consult with a real live pharmacist.

For this, they also contract with several of the major big-chain pharmacies, so you can get your first fills from certain local drug stores, if the nearest Kaiser pharmacy is too far away.

6

Specifically, about billing, I get EOB’s from my insurance company too. They are very detailed. But they are not organized in a way that is useful to me. Maybe every two months, I get one of those listing everything that happened during that time, if a claim has been submitted by a provider and if it has been resolved by the insurance company.

For example: recently I have had some heart problems. As a result, I visited a cardiologist for the first time and had an EKG, a few days later had an echo cardiogram, a couple of weeks after that I had two outpatient procedures under light anesthetic, and a few days after that a follow-up visit with another EKG. Next week I have another visit for another echo cardiogram and some kind of heartbeat-recording patch to be installed. Two weeks later the patch will be removed, and sent to be “read” by someone. If I want to know what each of those things cost, I have to take the EOBs and make a spreadsheet with divisions for each event and each procedure.

What I would like to find is an insurer who already provides the information in a format like that. Now I’m realizing that probably doesn’t exist, probably EOB’s are required by law to be presented in precisely the format I’ve been getting them in, because some set of lawmakers decided it was a good idea. May I say, I don’t agree with them.

Well, never mind. Thanks for the information, but I’m not going to Kaiser if for no other reason than that I don’t like being restricted and regimented, with very little recourse if I don’t like it.

7

I have Kaiser, and it’s been really easy to deal with when I retired and moved into the Medicare sphere. I have my supplemental, and it’s really great coverage. But it’s been pretty transparent, and there’s not a ton of paperwork.

8

Seems to me, the Kaiser EOB’s are already in a format something like this. Each event, procedure, or encounter is listed, with the costs for each.