Yesteday I got to play hookie because my daughter had a follow-up visit with the orthopedist. Our appointment was at a different location then the original visit. Her appointment was at a suburban strip mall. There was one event that illustrates a significant problem with consumer driven medical decision making. No one knows what the bill will look like due to the vagaries of medical billing.
She was happy and excited as she told the receptionist that her broken wrist was no longer broken, and that she wanted to go on the monkey bars that afternoon. As soon as we got called in, the med tech told me that my daughter needed new comparative x-rays. I was handed a form that was an authorization for a hospital to come after me in case my insurance did not pay. This looked wierd to me. I asked the tech if this office was considered a hospital clinic. If it was a hospital clinic, I would be paying more for the X-ray as well as paying a facility charge. She did not know.
I then called a friend of mine in claims and asked for a favor.
“Sally, could you look at Site 19821, Dr. Doe, and see if there are any radiology claims in the past year with POS that is not 11 and were there facility fees?”
“Dick, you’ll owe me a coffee tomorrow… give me a minute to get the SQL written…. how is your little one …Yes, South Suburban General was running their radiology until 3/31/15 and charging a facility fee, but after that every POS indicator is 11 and all claims are in-house claims….”
That coffee that I owe her as soon as I get off my bus will have been well spent.
Sally told me that the form I was given was out of date/useless, and I would be charged normal office rates and normal office co-insurance. The forms that I was given authorized facility charges. I would have not been surprised by a big facility charge bill on Labor Day. I am an extreme outlier in my knowledge of medical billing plus my access to relevant claims data to make informed decisions. Most people would have no idea that a facility charge was possible as they signed their forms.
No one knows to ask if Room 14 is considered an in-network office location while the doors immediately to the right and left of Room 14 are out of network doors or hospital clinic doors. No one can make an informed decision, and people are stuck at getting the X-ray at the place the doctor wants the X-ray as they would still be on the hook for the full specialist visit cost even though the specialist would need a foll0w-up visit to actually read the X-ray. So the price of shopping would be a second specialist visit payment that totally destroys any costs savings from shopping.
Thankfully, it worked out, but the office staff had no clue that they were previously charging facility fees and now no longer were. They were just told to get people to sign a form before X-rays.
I lucked out, and my daughter saw the orthopedist for five minutes. He gave her the okay to do whatever she wanted and made a very helpful suggestion that taking a right at the second set of lights and following that street for half a mile would lead to an awesome playground with four sets of monkey bars. So that is where we went for two hours after the appointment and she monkeyed around for most of that time.
different-church-lady
And what’s the moral of this story? Because I’m sitting here and seething but I can’t articulate it.
Can we just come right out and say it? The American Medical Industry is like a shakedown operation, run by con artists who don’t even understand they’re con artists.
That’s a statement that doesn’t make any sense, but the hell, can anyone offer a better description?
MomSense
Yup, this is my monthly labs situation unless I drive to the hospital and wait forever and take time off work. The lab may appear to be in the same facility as my doctor but once you cross under the arch next to his door, you are magically out of network.
dr. bloor
@different-church-lady: Yeah, that’s absolutely the take away message. The office staff and PAs spend time every morning before their shifts practicing lines in which they feign ignorance about arcane, insurance-industry driven billing procedures so they can rip off patients with facility charges.
rreay
“a very helpful suggestion that taking a right at the second set of lights and following that street for half a mile would lead to an awesome playground with four sets of monkey bars.”
That’s a good orthopedist.
sharl
Has anyone with Richard’s knowledge of our Byzantine medical “care” system, combined with the necessary technical/coding chops and a sadistic sense of humor – assuming such a talented and frightening person exists – considering creating an electronic game based on all this? It would, of course, be a very difficult game, and it might have been more marketable in the pre-ACA world. But things are still sufficiently confused that there may be a market for such a game, at least as a tool for education and/or lobbying for fixing all the things that are so messed up here.
gene108
On other Internet forums, about 10 years ago, I had this same debate with right-wingers, when Bush, Jr was pushing the idea of consumer driven health care and that this would unleash the magic of the free market to control healthcare costs.
No one knows what procedures cost.
Only someone like Richard could find out, by asking the people he works with what the insurance is going to pay and even for that he owes co-workers favors.
The doctors, nurses, lab techs, etc. have no idea what an X-Ray will cost in the end, because they do not know what insurance company discounts will be applied and what charges will get finally approved.
Why this has not been a bigger issue, I do not know.
It is one of the underlying reasons our healthcare system continues to be broken.
dr. bloor
@rreay:
I’ll say. He’s trying for REPEAT BUSINESS. Amirite?
Richard Mayhew
@dr. bloor: Only if he has a sideline in neurology as that playground seemed like it was tough to break a bone, but easy to to get a concusion.
:)
Richard Mayhew
@dr. bloor: No one in particular is trying to fuck people over. The system as a whole is fucking people over. That is my take-away.
MomSense
As it happens I’m on hold with my insurance company listening to a muzak version of the Hall and Oates song “Make a Wish”. Isn’t that song close enough to Muzak already?
I heard something upsetting today from a young person who has some kind of internship at an opthamalogy practice. She is worried that her dad lost his job and they may have to go on Medicaid. She said there is a stigma about Medicaid patients and they don’t get the same care as everyone else.
RSA
@rreay:
I bet he can also direct older patients to nearby skate parks, rock climbing facilities, and so forth. :-)
MattF
Some months ago, I got an incomprehensible bill from an insurance company. I know, dog bites man, but this one was special. I called the number on the form and complained; the nice rep on the line was brisk at first– then she looked at the bill on her computer screen and started laughing.
Starfish
@MomSense: She’s right. Medicaid pays less to the doctors so if the doctors can farm out the care to a nurse practitioner, they will. And if you are a saintly doctor who sees your own Medicaid patients, the patients assume that they can go to a better doctor once they are off Medicaid and have private insurance coverage.
Richard Mayhew
@RSA: My daughter is already on the rock wall, and is pretty good about it. Most days I love the fact that she has minimal fear and a lot of physical confidence in her ability to surmount challenges, but it does run up the medical bills.
Tom Levenson
Richard: thanks for this. It bears repeating every day and twice anytime a GOPster opens its mouth: the health care “market” is not an actual efficient market in the sense of the pedagogically useful lie you get taught in Ec 1. Those who call for “market driven” solutions are in the pay of the major powers — rent seekers — in the health care industry. This we all know. But the GOPsters do their best to make sure that that knowledge stays buried, and powerless.
Punchy
Please, please tell me you go by “Rich” or “Rick” or something other than “Dick”.
MomSense
@Starfish:
My private insurance plan doesn’t cover yearly eye exams or glasses. I have to pay out of pocket so I am going to go to the mall optometrist even though I have a family history of eye disease because I can’t afford what the good doctors charge. It’s messed up.
different-church-lady
@dr. bloor: Well that’s fair enough swipe long as you take my frustration-driven gobbdly-gook at its word. But that wasn’t my intent.
Maybe all I was trying to say was, “What’s with the incompetence? There’s so much of it that’s its starting to seem like it’s by design.”
peach flavored shampoo
What does this mean? Is this insurance slang of some sort? Otherwise, what’s so special about Labor Day?
MomSense
@Starfish:
Isn’t Medicaid reimbursement at Medicare levels now because of the ACA? Does this mean the same lesser treatment is also given to Medicare patients?
japa21
@MomSense: But, if the optometrist detects anything your insurance would cover an opthamologist for things beyond vision exams. Another thing that people don’t understand and why consumer driven medicine is a big bunch of hooey.
There are too many situations which fall into gaps. When does insurance cover something and when doesn’t it. Even people who work with insurance daily have to spend a lot of time figuring some of this out and they have the actual resources to do so. The average person on the street has neither the time nor the resources.
different-church-lady
@Richard Mayhew:
My additional suspicion is that nobody within the system seems to have any interest in fixing it. Not because they’re evil or because they directly benefit from individual acts of unfairness, but because they don’t really care as long as they still have a job at the end of the day.
It’s as if we’re at the end of a dystopian novel where we’re supposed to see the mask ripped off the evil, oppressive president of the broken society and instead find out there isn’t one.
pluege
the selling of “the market” as some sort of magically wise cost saving elixir has been the biggest con-BS snake oil ever. It is complete crap, almost across the board, not just the Medical Industrial Complex.
Starfish
@MomSense: Possibly, but I bet it takes a while for attitudes to change. Does this apply to states that did not take the Medicaid expansion?
Richard Mayhew
@Punchy: With Sally, I’m usually known as “Hey Asshole” as I tended to give her team big ugly projects and clean-ups, so this was a step up for her. Usually, I go by Rich at work.
Stella B
@MomSense: No. Medicaid does not reimburse at Medicare rates.
Your glasses are not covered by your insurance, but medical problems with your eyes are definitely covered by your insurance. Those are two entirely different issues.
ArchTeryx
@MomSense: Yep, she’s absolutely right. I am a Medicaid patient myself, managing multiple chronic conditions. The only people I ever see are nurse-practitioners, at least until I needed colorectal surgery.
At that point, though, I was shifted to actual doctors/surgeons. Liability does still attach if you are a Medicaid patient, and there’s only so much they can fob off on nurse practitioners.
Richard Mayhew
@MomSense: Not any more and not completely.
States set the Medicaid base reimbursement rates (managed care organizations set their own rates, but usually the private Medicaid rates are close to state rates).
For Calendar Year 2013/2014, the Federal government gave the states a big pot of money to pay primary care providers Medicare rates for a limited set of billing codes. The goal was to get more PCPs into Medicaid, or as a lesser goal to get more already enrolled in Medicaid PCPs to open up their panel and take more Medicaid patients. However that money went away on 1/1/15 and rates dropped to whatever the pre-exisiting PCP rates were for those codes as set by the 50 states. Some states previously paid above Medicare rates for some PCP codes, some states (6 I think) decided to use state money to continue the program, and most states dropped their PCP rates back to standard Medicaid rates.
Bill
We all need someone with a good legal background to come up with a form for the doctor’s office to sign indicating that the patient has been appraised of all billing related issues, and that charges that were not adequately explained beforehand will be removed from the bill.
Richard Mayhew
@peach flavored shampoo: It means nothing much, just that I know this provider has a slow billing process, so I would not expect anything in the mail until the first week of September. Another provider would have a bill in my mailbox by next Friday. Purely local and inconsequential knowledge.
boatboy_srq
@Richard Mayhew: The problem is compounded by the objectivist libertarian types, who can’t fathom a system this arcane and think that if people just paid physicians directly everything would go swimmingly. It’s still less frustrating to jump through all the insurance hoops than it is trying to discuss the problem with Randian types who refuse to understand that the simplistically individual approach they favor is completely unworkable.
@MomSense: Medicaid is a very odd creature thanks to cost controls and the requirements
inflicted on recipientsfor coverage. I’ve heard the same thing before. There are assumptions in Medicaid-covered services that have to do with poverty, abandoned persons and social ethics: just one more reason to work toward single payer IYAM.Roger Moore
@different-church-lady:
The moral of the story is that you can’t shop for medical care because even the providers can’t tell you how much it’s going to cost. That means any plan for controlling health care costs that depends on consumer choice is doomed to fail.
WereBear
@Tom Levenson: Not only that, the “magic of the free market” applies to things people either want to get, (as in most ranges of consumer goods) or has clear pricing (the cabbage at Sam’s is clearly cheaper than the cabbage at Hanniford’s, but after the first purchase, everyone knows how long it lasts in the fridge, and can shop accordingly.)
What kind of a free market conceals costs from the customers, who don’t want to be there anyway? And how can a gasping heart attack patient “shop”? And even with optional items, like some plastic surgeries, going for price… results in higher costs as you have to fix what Dr. Bargain bungled.
It’s not a free market at all, and the jerks who believe it deserves as much blame as the assholes who shovel this out.
MomSense
@Stella B:
The issue is that I can’t afford the eye exams which is how I would find out I have a medical problem.
MomSense
@Bill:
We need someone with a good legal background to provide us with some medical form “signing statements”.
Benw
@different-church-lady: there’s no evil figurehead, just a bunch of small cogs slowly, cluelessly ripping people off: it’s very 1984.
I don’t know if I agree with Richard, exactly; for-profit medical insurance definitely has a motive to make as much money as possible, and people in that industry must be aware at some level that it can and does come at the expense of patients, some of whom are ruined by debt in situations like Richard described above. If someone with a Mayhew policy comes in with a $50k emergency room bill that their policy won’t cover, how do you feel saying, sorry, no?
So, question for Richard, if it’s just “the system” that’s broken, what is the solution? Complete government coverage? I assume you would eventually go out of business in that system, but no patients would go broke. Better regulated for-profit insurance? Eventually some patients will get ripped off and enough companies will “race to the bottom” of any oversight.
I don’t mean to be to be a dick, Rich; I really appreciate your thoughtful posts. I’d really like to know how someone who works in the medical insurance field feels about it.
WereBear
@Stella B: And that doesn’t make any sense either. Glasses are a medical device needed by people with a wide range of medical conditions.
pseudonymous in nc
The American Way of Healthcare in a nutshell. Nobody knows who performs a service, nobody knows what it costs, but everybody knows that the meatpuppets have to sign a form so that it’ll be them that are charged when everybody else has taken their cut.
Botsplainer
@rreay:
That would be like me executing wills for a young couple and mentioning in passing that there’s a strip club that offers specials on lap dances for couples two blocks away…
pseudonymous in nc
@Benw:
Very tight sandbox with very high walls where private insurers can make money. Works in large parts of the developed world. The basic point there is that there’s political skin in the game to make changes to the regulatory system. Doesn’t have to go to shit.
Roger Moore
@Stella B:
But they aren’t entirely different issues because the main time people are tested for medical problems with their eyes is when they go to the optometrist. If you try to save money on your eye exam, the optometrist may wind up skimping on the tests for other eye problems, and you won’t find out about them. And if you’re doing that, you probably can’t afford the copay to go to the ophthalmologist every year to get the more extensive tests. It’s another example of the way that treating some parts of our bodies (eyes, teeth, mind) as totally different specialties that don’t need to be covered by medical insurance leaves dangerous gaps in coverage.
MPAVictoria
This is literally insane. For Christ sake I bet if Americans could actually comeup and experience the Canadian system they would demand change. I have a number of ongoing medical problems. I have never seen a bill, a complex form or had to worry about whether I was covered. Why the hell would anyone prefer this insanity?
Roger Moore
@Benw:
That sounds more like Brazil than 1984.
Roger Moore
@MPAVictoria:
Because they’re profiting from it. Those people then lie through their teeth to the rubes and tell them that any kind of government-run healthcare will be a Kafkaesque nightmare even worse than the current system, and the rubes go along because they don’t know better.
Ruckus
@Richard Mayhew:
I’m sure that someone some where is.
Maybe because it is so byzantine a system they are barely noticeable as being devious but someone somewhere is gaming the system.
japa21
@WereBear: Of course the same applies to dental issues. Most dental is not covered under normal insurance, even Medicare. So one must have appropriate dental coverage just to get cleanings, fillings, etc. Yet poor dental health can lead to major medical complications up to and including death.
For that reason alone, regular dental hygiene should be covered under insurance plans as preventative care. Under dental plans, regular at least yearly cleanings are paid in full, as are at least one set of x-rays. But those plans are paid for in addition to regular health insurance.
I would like to see a study made of the medical costs paid out by regular insurance for treatment of conditions resulting from poor dental health and accidents, etc., resulting from poor vision where a person can’t afford glasses.
cat
@dr. bloor:
Because nobody ever in the history of their practice has called and complained about their bill so they are just in complete ignorance of what this whole ‘medical insurance’ thing or the forms just magically appear one morning?
Bull-fucking Shit. They just shrug their shoulders and go its not my problem like every other cog in [place your industry here] business.
Richard Mayhew
@Benw: From my point of view, there are a couple of ways to make a mostly (post PPACA instead of completely pre-PPACA) broken system a whole lot better. If you can convince me that any of these paths forward are plausible, I am fairly path indifferent. And yes, most of those paths will put me out of a job after a while, and I am okay with that.
a) Single payer
b) Regional single payer (say New England, or Great Lakes States minus New York etc)
c) Consolidated Federal program single payer (instead of CHIP, Medicaid, Medicare, there is just Federal Medical Insurance) with serious negoatiating authority
d) Regulated utility model of private health insurers (Swiss like)
e) Regulated utility model of private health insurers with significant health improvement quality bonuses so the core competency/profit center for insurers is no longer avoiding costs while collecting premiums, but getting people better
Benw
@Roger Moore: pick your favorite totalitarian dystopia! You were my favorite Bond, btw.
WereBear
@japa21: Absolutely. Why doesn’t health insurance treat the entire person? It’s as absurd as going, “Oh, we’ll only cover you below the waist” so OB-GYN visits and urology are good to go but spinal injuries require an extra policy.
cahuenga
I found out (the hard way) that orthopedists are sometimes invested in local imaging and diagnostics labs, thereby setting up somewhat adverse incentive to order piles of x rays or MRIs of dubious necessity
CONGRATULATIONS!
@MomSense: If you’re a Costco member, go there. They usually have really good ones. My Costco’s eye doc is a for-real ophthalmologist (not optometrist), graduated from UC system, and has been at that store since they opened – at least 15 years.
I have to pay extra for the eye insurance and it’s virtually useless, so I go to Costco instead.
CONGRATULATIONS!
@Bill: The doctors can’t do that. They don’t know the specifics of YOUR insurance plan, and literally every single patient they see will have different coverages.
Catch-22, for them and you.
MomSense
@CONGRATULATIONS!:
We don’t have one in my state. :(
Eric S.
@Richard Mayhew: Slow billing seems endemic to the industry. I assume on some level this is caused by whatever bureaucracy is inherent in medical care providers submitting bills and getting paid by the insurance company before sending the remaining charges on to the actual patient. I’ve been in therapy twice for a repaired rotator cuff since February. Just last week I received a bill covering all the therapy up to April 23rd.
Chris
@gene108:
Exactly. It’s a fucking nightmare that makes me terrified of going to the hospital or seeing a doctor at all – I won’t know until months later what the hell happened, and the “in-network/out-of-network” labyrinth balkanizes the medical industry to the point that you start to wonder what insurance is even for.
Nothing this serious has ever happened to me before, but what am I supposed to do if I collapse and have a seizure, and some well-meaning guy across the street sees it happen and calls an ambulance that rushes me to the nearest hospital… and then I find out that one wasn’t “in-network?” Pay the full price because I was hospitalized in the wrong place, even though I couldn’t possibly have had any control over where I was being sent?
It’s fucking insane.
Mnemosyne (tablet)
@dr. bloor:
Like it or not, when a patient finds out that the lab their doctor sent them to is out of network, they’re going to blame the doctor, not the insurance company. And that feeling is only going to be doubled if we find out that the doctor has a financial interest in that OON lab.
You, personally, may be scrupulous and honest about such things, but there are enough doctors out there who are not that patients are now on their guard about additional charges generated to make a profit for the doctor.
Chris
@WereBear:
Exactly. It’s like going grocery shopping with no price tags attached to anything, and a bill that won’t come for months, but that you will still totally be expected to pay when it comes. And of course you’d still go grocery shopping; you need the food to live. You’d just have to set a big pot of money aside for when the bill does come, and in the meantime do your shopping while wildly guesstimating what everything’s going to cost. Ah, but there’s a catch: depending on the arrangements the store has with its food suppliers and exactly where these lima beans were supplied from, they could cost either three bucks, or four hundred and fifty.
Mnemosyne (tablet)
@MomSense:
It looks like there are three LensCrafters locations in Maine. If you’re a AAA member, you may get a discount on your eye exam and glasses when you show your card, but check with the actual location first.
If they’re not close enough, I’ve actually heard good things about the optical departments at Wal-Mart and Sam’s Club. You can call ahead and ask them what the cash price would be for an eye exam. It will usually be lower than a private optometrist. Other big box options can be Sears or JC Penney, depending on your area.
Central Planning
So Richard, did you get the x-rays for your daughter? I can’t tell from what you wrote.
When my daughter broke her foot a few years ago (slight fracture from twisting it in a hole on the playground), they did x-rays to show the (minuscule) fracture and gave her a boot to wear; I don’t think they even casted it. Anyway, we went back at 6 weeks, daughter was feeling fine with no effects of the break, and they said it was good.
And they wanted to do x-rays again. “Why?” I asked. There was no good answer for that besides “that’s what we always do.” I passed. They couldn’t believe it. Her foot is still fine. If she were limping or acting like it hadn’t healed at 6 weeks I probably would have done the x-rays again.
MomSense
@Mnemosyne (tablet):
Thanks. I’ll probably end up going to Wallyworld. I haven’t been to one in years.
Snarki, child of Loki
@sharl:
It should be fairly simple expansion pack to a FPS.
RaflW
@Roger Moore:
Yep. Just signed a form this morning that I acknowledge that the cardiac unit I visited doesn’t know the cost of care in advance. It was just an echocardiogram, so it’ll probably ‘retail’ for something like $1-2K with radiologist review, but then provider contribution will kick in, etc. Who knows?
What I do know, from my previous health plan with a higher deductible and different payment structure was, when I needed a CT years ago, thank FSM I had insurance. I had to pay the whole bill, but it was $4K reduced to $800 after provider reduction. Had I been an uninsured ‘cash customer’ I’d be on the hook for 4K.
piratedan
@Chris: It can be extremely chancy if you have anything that gets outsourced or is outsourced, say for example anesthesiology or biopsy requests. While you’re at the hospital, the hospital no longer does those things that a hospital used to do because people have parceled those specifics out because it wasn’t “cost-effective” to keep them under the bottom line for the facility and as such those services are contracted out. You have no say on being able to shop for those items at all, just a bill that shows up stating that you also need to pay these people and never mind- they’ve already and sent along those charges to the insurance company as well….. sigh.
WereBear
I work for a non-profit for not much, but fortunately I have health insurance. Yet, even with the co-pay, I’m over $100 in the hole for medications with my recent bout of ill health. Which is incredibly painful but doesn’t even have the dignity of being life-threatening. (To me. Mess with me now, and you hope you have health insurance.)
Doesn’t seem like much, but when you live paycheck to paycheck and one of the partners is on disability, which isn’t much, and is set to be hacked by our Pithed Frog Friends in Congress, it’s a dent.
Morat20
Two horror stories from this year alone: A surgeon who was in network, whose surgical center (attached to the office) was not. A 24,000 dollar bill that the insurance “negotiated” to a 13,000 dollar out-of-network bill that cost me…3 grand. (The procedure in-network would be roughly 2500).
And a doctor who prescribed me a 1500 dollar a month drug, didn’t know it cost 1500 a month, and when the drug consisted of…Aleve and Nexium. (Not kidding. OTC doses of both, combined into a single pill).
Nobody knows what anything costs, and we’re supposed to shop around? I *need* my insurance company entirely to make sure I’m not getting screwed, and that’s only if I don’t accidentally wander through the wrong door and end up out of network.
japa21
@Chris: Actually, since most ambulances are required to go to specific hospitals in specific areas, you would probably be covered. Most insurance companies, some due to state law, do cover emergency situations such as this at an in-network level. If you were, however, admitted but were able to be transferred to an in-net hospital, the stay itself would probably not be covered.
RSA
@Richard Mayhew:
That’s great. I’ve never been on a rock wall, but with the harnesses and such it looks pretty safe against a bad fall. And teaching kids confidence is the best.
Richard Mayhew
@Central Planning: Yep, she got the X-rays, will cost me about $25 in September, and she is good to go and do all the fun kids stuff she can do.
Vickie Feminist
If there is a theme to my marriage, it is health insurance. We got married 15 years ago so I could get on his plan.
Now we’ve watched our savings go to COBRA coverage for both of us. He got laid off and I worked as a social worker for a military contractor providing Harpo Marx quality coverage.
Now he’s on a ACA plan with Kaiser with a $4K deductible. Talk about walking on egg shells.
Thanks for all the great information on this complicated topic. I good for the violent computer game.
The Raven on the Hill
Now, I was just billed twice, one for my annual checkup and once for the monitoring of chronic conditions which at my annual checkup. Apparently my clinic and insurance view the “annual checkup” as an excuse to double-bill. What’s the point of an annual checkup if not to monitor chronic conditions?
I’m going to complain to our medical center, but I am not hopeful that the double billing will be rescinded. My doctor told me that the routine monitoring tests, which I turned down because of costs, would she was sure would be covered as preventative care. Ha. Ha. Ha.
Bart
Ferfacksakes Richard, when are you going to stop confusing “then” and “than”? It’s “different THAN”.