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finding procedure costs ahead of time
Old 02-24-2014, 03:28 PM   #1
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finding procedure costs ahead of time

I have a moderately high deductible health insurance plan. My provider, Coventry encourages me to check on the cost of procedures ahead of time. Great, I'd love to since I have to pay until I hit the deductible.

After my mammogram, I'm encouraged to get an automated ultrasound - not because they saw anything but because of the density of my breasts.

OK, I've got 3 questions. Is the ultrasound needed? Are there risks? And what will it cost me? The need is equivocal - some studies suggest, "yes" - the machine that will be used is fairly new - no double blind studies on its use. No major risks to an ultrasound. Potential small risks of false positives.

Now for the kicker, "What will it cost me?" The provider sends me to their billing office. They say to check with the insurance company, who says to check with the provider. In the process of being kicked around to various supervisors, an online web site with cost estimator program, etc., I now have potential costs ranging from $44 to $1,200! But everyone says that they can't assure that is correct as the provider code might be wrong, the procedure code might be wrong... Assuming that the code that the provider's business office gave me is what will actually be billed, it looks like $75 is the most likely cost but I'm still unsure that is right.

What experiences do people have getting cost estimates ahead of time and what might be the pitfalls in this scenario. with the equivocal usefulness, I might skip it at $1,000 but would probably go with Doctor recommendation at $75.
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Old 02-24-2014, 03:45 PM   #2
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I looked into costs for specific blood work items (lipid, CBC, glucose, etc nothing out of the ordinary) and I had to call my doctors office and have someone look up what codes they would bill and I also needed my doctor's practices Federal tax ID number which they gave me.

From there I called my insurance company and asked for the allowed amount for those codes for my doctor's office lab. Then I asked for the same information for an outside lab (I already had their Fed ID number).

What I found was that my doctors lab had a reasonable retail price but their allowed amounts were only slightly smaller than retail. For the outside lab their retail rate was very high but their allowed amount was a bargain compared with my doctors office lab.

So DH and I both use the outside lab now. We get printed orders and take them to the lab. It's worked out well.

If you have the time and patience to make a few calls and gather the info you could learn a lot and possibly save some money. Or at least have more info for an informed decision.
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Old 02-24-2014, 03:55 PM   #3
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I had to call my doctors office and have someone look up what codes they would bill and I also needed my doctor's practices Federal tax ID number which they gave me.

If you have the time and patience to make a few calls and gather the info you could learn a lot and possibly save some money. Or at least have more info for an informed decision.
Thanks - This will help me know what to ask! I suspect I'll have better luck getting the info with these numbers.
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Old 02-24-2014, 04:28 PM   #4
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I have never had much health care costs out of pocket. 4 months ago I broke my collarbone and had choice of surgery or not. I assumed surgery would be mostly covered and wanted the more rapid recovery; might have done otherwise after a copay of $600 and about $1,800 as my part of surgery center, anesthesiology. I have thought about challenging some of it but just don't like dealing with the runarounds you describe. Not very cost conscious of me, I admit, but I hate dealing with insurance companies, car dealers, etc. Probably should turn DW loose on them; last car we bought she pokered them down $2k more than I was willing to settle for.

As an aside, I've been released but do NOT like the feel of the plate on my collarbone; I'm hoping it goes away. They said give it another two months. Of course, removing it would cost nearly what putting it in did. Suppose I could decline anesthesia?
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Old 02-24-2014, 04:43 PM   #5
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I tried to get my out of network surgery center to tell me what they would charge and what my insurance company(United Health Care) would pay for a routine screening colonoscopy about 6 years ago. After way too many calls to insurance and surgery center, I went to a 20 mile away surgery center that was in network. I told my GP that they lost the business due to not telling me what I might have to pay over reasonable and customary(Clinic owns surgery center). He told me they would never be in network with UHC .
Last year they went in network with UHC. They must have been losing too much business. I found it almost impossible to find out costs ahead of time.This should be changed. I used the same surgery center out of town for my follow-up 5 year rescreen because they did good on the first one even when the one 2 miles away was now in network.
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Old 02-24-2014, 06:26 PM   #6
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I have had great experiences with finding out the cost. When I had my cataract surgery my Surgeon was in network but the surgery center was not . They told me the cost . When I had my outpatient vein surgery they gave me a print out of the costs before I okayed the surgery . I worked in a Surgery Center before retirement and I did not know the costs of the procedures but I did know where patients could get that information.
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Old 02-25-2014, 08:21 AM   #7
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I wish the ACA could have required medical facilities to post the costs and codes of their procedures and insurance companies to post the coverage (in and out of network) for those codes. I suspect the industry would fight it tooth and nail but such transparency is needed for the much vaunted free market to be of any value.
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Old 02-25-2014, 10:38 AM   #8
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Wish I had a great story. The balance center I went to, sent a list of procedure names. Called BCBS they needed the codes. Balance center, verified with BCBS I was covered.

So I pay my $40.00 specialist copay to see the DR. I think I'm good to go. Then I received an EOB for the audiologist I saw in addition to the DR. $700 against my deductible. Really wish someone had told me upfront that there were two separate changes. I guess in the future I'll ask more questions. Good news is with that deductible and the ones for PT, I'll be done with deductibles for the year.

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Old 02-25-2014, 12:36 PM   #9
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This is a murky subject.
Estimating the cost really requires a lot of stick-to-it-tiveness.
With insurance, it doesn't usually get much attention, as the bill comes after the fact, and the "consist" is a mix of unintelligible descriptions and obscure codes that few will take the time tosort out...
...especially when insurance pays.
But...
Finding out in advance is tricky.
Hospital vs. Clinic vs. Private facility can make a huge difference. Often multi thousands of dollars.
Doctor/Surgeon fee normally fairly easy, but add to that the specialists who attend the operation... aides, assistants, machine operators, lab costs, anaesthesiologists, nurses, ancillary drugs, and then the dreaded recovery room cost if necessary... hundreds of dollars per hour.
My simple carpal tunnel operation ended up costing almost $12,000. Total time in Clinic Lab 37 minutes.

Here's a recap of cost for stress test for DW...
301 Laboratory Chemistry $497.50
306 Lab Bacteriology/Microbio $654.50
341 Nuclear Medicine Diagnos $2,381.00
343 Diagnostic Radiopharmaceut $828.00
483 Cardiology Stress Test $1081.00
636 Drug Spec ID Detail Coding $319.75
983 Profee Clinic $391.00

Current total $6152.75

Here's an interesting read that begins... Surgery @ $147.00 a minute.
http://www.kevinmd.com/blog/2012/07/...47-minute.html
.................................................. ........................................
Short story:
Many years ago, DW had urgent carotid surgery. After the surgery, the normal time for recovery from anaesthesia is about /4 to 1/2 hour and takes place in the "recovery room"... The cost of that room at the time was about $500. At the same time she was there, a young gunshot victim was in the ward where she would go for the balance of her recovery. He became very violent, and destroyed much of the equipment in that room, forcing my wife to spend the next 36 hours in the recovery room... since the other room was being cleaned and repaired. Per the normal billing process, she was charged $18,000 for recovery room charges.... The beginning of an even longer story.
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Old 02-25-2014, 01:14 PM   #10
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Short story:
Many years ago, DW had urgent carotid surgery. After the surgery, the normal time for recovery from anaesthesia is about /4 to 1/2 hour and takes place in the "recovery room"... The cost of that room at the time was about $500. At the same time she was there, a young gunshot victim was in the ward where she would go for the balance of her recovery. He became very violent, and destroyed much of the equipment in that room, forcing my wife to spend the next 36 hours in the recovery room... since the other room was being cleaned and repaired. Per the normal billing process, she was charged $18,000 for recovery room charges.... The beginning of an even longer story.
Wow! That seems unfair, in addition to being a little too exciting!
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Old 02-26-2014, 06:47 PM   #11
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In the process of being kicked around to various supervisors, an online web site with cost estimator program, etc., I now have potential costs ranging from $44 to $1,200! But everyone says that they can't assure that is correct as the provider code might be wrong, the procedure code might be wrong... Assuming that the code that the provider's business office gave me is what will actually be billed, it looks like $75 is the most likely cost but I'm still unsure that is right.
$75 seems a bit low. The document linked to below gives the two most common CPT procedure codes for automated ultrasound and the 2013 Medicare payment of $82.68 and $100.37 for each code. Please keep in mind the following. (1). These rates have not been adjusted for high cost locations. (2). Medicare payment represents 80% of the Medicare allowable so a payment of $100.37 would mean a Medicare allowable amount of $125.46. (3). Medicare allowable amounts are among the lowest in the industry. Private insurance companies almost certainly have a higher allowable amount. In other words, if the private insurer has an allowable amount of $175.00 and you have not yet met your deductible, you would be responsible for this amount. (4) As the document states, the doctor's billing office will also need to submit an ICD-9 diagnosis code that is compatible with the CPT procedure code.

Link to document: http://www3.gehealthcare.com/en/Prod...sound-ABUS.pdf
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Old 02-26-2014, 09:50 PM   #12
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Even if you have a HDHP isn't the price charged to you by the provider the price negotiated by your insurance company - in other words the 'allowed amount' on your EOB? This is of course assuming that the provider you are using is in network. If it is the negotiated price, then will it vary from provider to provider or is the price basically 'set' by the insurance company and dictated to the provider like Medicare?

If it can vary, I would think that the insurance company would be in a much better position to tell a policyholder where they will find the best available price as that would be in their system. Why make every person go through the complicated and time consuming shopping experience?

If it doesn't vary from one preferred provider to another then why are we shopping in the first place, other than to make sure we're using an in-network provider?

Is there something I'm not understanding here?
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Old 02-27-2014, 12:37 PM   #13
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Even if you have a HDHP isn't the price charged to you by the provider the price negotiated by your insurance company - in other words the 'allowed amount' on your EOB? This is of course assuming that the provider you are using is in network. If it is the negotiated price, then will it vary from provider to provider or is the price basically 'set' by the insurance company and dictated to the provider like Medicare?

If it can vary, I would think that the insurance company would be in a much better position to tell a policyholder where they will find the best available price as that would be in their system. Why make every person go through the complicated and time consuming shopping experience?
When a procedure is covered by insurance, the charge or "billed amount" is about as useless as the MSRP on a new car. The insurer creates a proprietary fee schedule (FS) containing the allowed amount, before rate negotiations, for each covered procedure. The insurer then has to enroll a network of providers. A large provider will generally be able to negotiate a rate more favorable to them, say 95% of the FS as their allowed amount. A small provider generally has less power and may accept 90% of the FS as their allowed amount. One provider may have several negotiated rates for different categories of service. For example, the provider may be locked in to accept 90% of FS for office visits, 95% for radiology, and 100% for in-office lab tests. These are the 'allowed amounts' on the EOB.

In the past, insurers received very few calls requesting the allowed amount prior to a procedure being performed. Therefore, the insurer had little incentive to spend a portion of their profits developing, testing, and implementing a solution their Customer Service Associates could use to determine which provider has the lowest negotiated rate for a particular procedure. Depending on the insurer and their technology, they are pretty much limited to seeing the negotiated rates for the one particular provider in question. As more people become price conscience about their medical care, I hope there will be more transparency at the provider and insurer.
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Old 02-27-2014, 05:22 PM   #14
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When a procedure is covered by insurance, the charge or "billed amount" is about as useless as the MSRP on a new car. The insurer creates a proprietary fee schedule (FS) containing the allowed amount, before rate negotiations, for each covered procedure. The insurer then has to enroll a network of providers. A large provider will generally be able to negotiate a rate more favorable to them, say 95% of the FS as their allowed amount. A small provider generally has less power and may accept 90% of the FS as their allowed amount. One provider may have several negotiated rates for different categories of service. For example, the provider may be locked in to accept 90% of FS for office visits, 95% for radiology, and 100% for in-office lab tests. These are the 'allowed amounts' on the EOB.

In the past, insurers received very few calls requesting the allowed amount prior to a procedure being performed. Therefore, the insurer had little incentive to spend a portion of their profits developing, testing, and implementing a solution their Customer Service Associates could use to determine which provider has the lowest negotiated rate for a particular procedure. Depending on the insurer and their technology, they are pretty much limited to seeing the negotiated rates for the one particular provider in question. As more people become price conscience about their medical care, I hope there will be more transparency at the provider and insurer.
Yes, you have confirmed my educated guess about how this all works and I agree that price transparency is paramount to solving the problem of spiraling health care costs.

In my opinion there needs to be pressure put on the insurance companies to provide policy holders with the names of providers who have the lowest rates. We also need quality ratings of individual providers from some reliable source(s). Only armed with that information, and in conjunction with High Deductible Health Plans, will market forces serve to put downward pressure on health costs.

Unfortunately, since most are covered by plans which provide no consumer motivation to even know let alone reduce costs, that first needs to change.
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Old 02-28-2014, 02:13 PM   #15
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Yes, you have confirmed my educated guess about how this all works and I agree that price transparency is paramount to solving the problem of spiraling health care costs.

In my opinion there needs to be pressure put on the insurance companies to provide policy holders with the names of providers who have the lowest rates. We also need quality ratings of individual providers from some reliable source(s). Only armed with that information, and in conjunction with High Deductible Health Plans, will market forces serve to put downward pressure on health costs.

Unfortunately, since most are covered by plans which provide no consumer motivation to even know let alone reduce costs, that first needs to change.
There is no entity that will benefit from price transparency except for the consumer. My idea was to establish a site that could collect actual data, experienced by real people, anonymize it, and make it available to the heathcare consumer. The way I pictured it working would be after you had your procedure, you'd upload your EOB PDF documents, letting an anoymizing process remove your personal info. You would see the sanitized version of the document, and if approved, it would go into the database. The problem is the motivation to upload your EOB docs. You could make sharing a condition of using the site, but those models don't seem to work very well. There would have to be an incentive. I wonder if an advocacy group backed the jdea, if that would work. There would need to be a very large user base for this to work. Maybe the backing organization could offer to assist members in billing problems. Maybe "gold" members get the billing advocate, where you don't get gold status until you have been a member for 6months and have uploaded some number of actual expenses.
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