Exactly. They don’t need to know every single billing code and how much every single coverage provider will pay. What they do need to know is that Blue Cross will pay more than Medicare will pay more than workers comp. They need to know that they can bill every single patient for a band-aid if they put one on and they could justify that, even if ethically they might not be able to. They need to know that they can put a charge on there for tests that, while not absolutely necessary, could possibly be useful, maybe, and what the hell, the insurance will cover most of it.
My son has had wheezing issues since he was a baby, always brought on by a cold. My pediatrician referred him to an asthma specialist, just to see if we needed to have a care plan for him and to get a better idea of what was going on. The asthma specialist tested him for all sorts of different allergens, even though every time he wheezes, it’s in conjunction with a virus. The tests consisted of applying a whole bunch of different allergens to his skin, waiting 15 minutes or so, and having the doctor see if there was any irritation. Was this protocol? I’m sure. Could the doctor have given me a good idea what was going on without it? I’m pretty sure he could have (especially since what he said was, basically, yeah, he has viral induced wheezing; he’ll probably grow out of it). Charges for the tests? $400. My insurance happens to suck, so we had to pay a good chunk of that. The doctor, though, knows he can give the same sort of basic allergy test to every single patient who walks through his door, whether it’s really relevant or not.
Knowing the cost depends on the physician and the type of practice that they have. There are the fixed costs and the variable costs to deal with, along with repayment timing and paperwork hassles.
Example: Radiologist.
Medicare: He could afford to have up to 35% of his patients be on Medicare. The reimbursement was not enough to keep the lights on, but a Medicare patient was better than no patient. He had to pay his techs, staff, and office costs regardless. Once the percent of Medicare patients broke 50%, he shut down his operation.
Mammograms: He could afford to run Mammograms when it was OK to use film. Once everyone insisted on the new digital machines, he could not afford to do mammos. The reimbursement was low, the equipment was expensive, and the only way to pay for it was to have a patient always in getting a mammo.
I lecture for a Health Care MBA program. The room is 1/3 docs trying to figure out how to run a business, now that logic no longer works. I know people that ONLY teach physician’s groups how to code charges - since the same procedure can often be coded 3 different ways with each different insurance company. These people specialize in knowing the best codes and code combos to use for both higher reimbursements and more timely reimbursements.
A physician might know the reimbursement for an office visit, but once you get a tray out and start doing things it gets tough to remember. “Hmmm, Blue Cross, PPO, In-Network but NOT HMO, lancing a boil - is this $35 before I charge for the disposable lance and disinfectant?”
As a lifelong asthmatic and allergy sufferer, I’d say the testing will probably prove worthwhile. I had broadly similar symptoms as a littl’un, and instead of actually testing me for allergies, the paediatrician diagnosed me with a milk allergy- resulting in four years of no chocolate, cheese, cow’s milk, ice cream, etc. for no good reason.
My parents are physicians and this still happened. It was wayyyy outside of their specialty, so they simply followed the other guy’s advice. It wasn’t until my mother decided to switch from anesthesiology to general practice (and took some immunology courses) that it got sorted out and I was able to eat sweet sweet chocolate again.
Yes. You should have received an explanation of benefits from Medicare for every service billed and every provider paid or rejected. (Providing she had Medicare and not a Medicare replacement. They all handle issues differently.)
I don’t know if you are aware or not but you have just focused on a completely different issue. Good doctors don’t pad their bill or do unnecessary tests. If you feel yours is like that, I suggest you change.
HOWEVER, in this climate of lawsuits and medical board complaints, there is a CYA mentality throughout the medical community. “In my opinion, it is being caused by a virus but if I document that and they get a dog that ends up harming the child, I am screwed”.
“I don’t think the patient needs an MRI of the spine for his back pain because the symptoms indicate a sprain, but if he has a herniated disc, he is going to sue me in the long run.”
I’ve been talking to my buds at work. Some examples —
Bud1. Ski accident. $2500 billed to him. Insurance company, and hospital said it was paid. He is free and clear.
6 months later he gets a summons for court. They are suing him for lack of payment unless he sends them $2500 today. No bills. No notice. Nothing.
Bud2. A few sports related injuries. Not too serious. Some checks are sent to him, some to his doctors. Like me, no checks match the bills. Since he can’t match anything up, he deposits them and pays bills as they come.
2 months later the insurance company calls him and tells him that he owes them $300 or they are going to ding his credit. They over paid.
Since we are self insured, and the second biggest employer in the county I may start making some waves about this. It’s absurd. We are hiring THEM.
Like I said, I should NOT have to put together a database to handle my insurance. As it is, 3 months after my simple surgery I have a paper file that I take back and forth to work with me.
This. You guys seem to spend an unbelievable amount of personal time on such things once you’ve had treatment. That’s a huge productivity loss right there.
If we’re not getting a Single Payer System, the least that should happen here is some simplification.
Let’s say that insurance companies, by Federal Law, boil down all their policies to 6 levels @ 6 standard premiums nationwide. The employer/employee division of these premiums could vary-- A small employer could possibly say “I’ll pick up 100% of Level 4 or below, but if you want 3, 2 or 1, you have to pay the difference yourself.” In unionized workplaces, this would still be a collective bargaining subject.
The one with the cheapest premium-- Level 6-- would cover nothing until a $5000 deductible is met; then 20% of the next $10,000 and 100% above that.
The highest-premium, Level 1, would be one of those all-inclusive, low co-pay-at-time-of-service, patient-never-sees-a-bill policies.
The other 4 would fall somewhere in between, but a Level 3 in Iowa and working for the Federal Govt. gets no better or no worse coverage than a Level 3 who’s self-employed mowing lawns in Utah and would pay no more and no less in premiums.
All care providers would know the terms and limitations of the levels–there’d be minimum time “on hold” to wait to fight with the ins. cos. and more time and effort aimed at actual patient care.
At the end of each month, the ins. cos. would file a form stating how much money they took in in standard rates plus investment income minus what they paid out to claimants. The govt. would audit the figures ASAP and send the ins. cos. checks to cover shortfalls.
Or people just pay the bills because they can’t afford the time - so in a lot of cases the clinic/doctor is getting paid twice.
My clinic regularly charges me the copay when I arrive. I can’t see the doctor without the copay. Then three or four months later, they bill me for my copay.
My copay is low, my time is pretty valuable to me - if I’m busy the two hours it normally takes to straighten this out with the bookkeeper at the clinic is worth far more to me than paying an extra $15 to make it go away. (And I can’t believe its worth the clinics time to pay someone to deal with all of the ‘I paid this copay already’ calls at two hours each - so just paying the bill must be pretty common.)
I got a bill for the whole amount. There is no due date on the bill but it also says I will incur penalties if it’s late. Terrific. It also said a copy had been sent to my insurance.
So, I’m left holding the bag. Did insurance refuse the whole thing? Are they negotiating? When is this due?
So now it’s my job to make sure the health care provider and the insurance company are talking. I’ve been put in a middle man position and have zero leverage.
I had already received random checks from the insurance company, so I deposited 3 of them and used that money to pay the bill.
Two months later the insurance company pays 80%, and I get another bill for 20%. I had already paid the whole thing.
Now, because of the basic cluster fuck that is the ‘system’ they actually owe me money. I’m out $1000 while waiting on the check.
And that’s just the beginning. I have a pre-tax savings account that is used specifically to cover my deductable. I have to fax them a copy of any charges that insurance didn’t cover and if they approve of them they send a check to me, I despite it and write another check and send it to the HCP.
More rants (I have many). My wife received 3 separate collections agency notices that were suspiciously for the same amount ($175.00 each). No references to a clinic, account, insurer, nothing but a code number. We called and investigated each one and found that for one test the insurer was rejecting the clinic’s billing continuously because of a typo on their form of my wife’s name, and every resubmittal of the claim generated a new collections agency bill. Investigating and correcting this probably took 50 hours of calling and writing over several weeks.
This is just one that we noticed and bothered to dig into, there are simply not enough hours in the day to babysit the insurers/clinics jobs for them. When people suggest that patients just “review your bills, call if there’s a problem, insurance people work for you, it’s easy!” I want to slap them silly.
The NHS is a single payer system. I mean, you can have private insurance, or pay for private care yourself, but it’s as close as you get to a single payer system.
Look it up. A single-payer system is one in which payment comes from one source. You yourself have named three sources for payment in the UK. In the article I linked to, you will find Canada and Australia mentioned as examples of a single-payer system, but not the UK.
The UK NHS is different because it directly administers most of the providers as well as paying for their services, but it’s still a single payer system.