Cost-Conscious, Self-Managed Care

[Dash man]

This sounds crazy. I just had my annual physical and most of the time was spent talking about ongoing health concerns and medications that I am taking to control those conditions.

Ditto. I have numerous ongoing conditions and my doctor always discusses how things are with them along with questions and discussions on any new concerns. Never paid a cent out of pocket for these annual physicals. I've also never felt rushed with her.


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[swakyaby]

Your example is humorous, but with all of your data in their computer, this information should be a click or a finger flick away. With annual per person medical costs in the USA about $9000 per, I think it is past time for docs to know what things cost. Maybe not a tongue depressor but surely an MRI.

I once had a patient's spouse inquire about the cost of my services just minutes before I was about to place an epidural catheter for alleviation of labor pains. I hesitated, not because I didn't want them to know what it would cost, rather it was because the answer was complex. Each insurance company has a different negotiated rate of pay for my medical group's services, and the charge for a labor epidural is not a static amount. The management of the epidural could be for 2 hours or for 14 hours. The patient could then go on to a Cesarean section using the same epidural. The rate of pay increases because it is now anesthesia for an operation and requires more intensive management. The negotiated rate of pay for each insurance changes from year to year, and the billing becomes so complex it requires a billing service to keep track of it all.

I told the husband that I could provide him a phone number for my medical group, that he should ask for the billing dept, that he will need to provide information of her insurance. The wife, in the middle of a painful contraction, shot her husband a look of exasperation, and said, "Never mind! I want the d--n epidural!"

 

[travelover]

I once had a patient's spouse inquire about the cost of my services just minutes before I was about to place an epidural catheter for alleviation of labor pains. I hesitated, not because I didn't want them to know what it would cost, rather it was because the answer was complex. Each insurance company has a different negotiated rate of pay for my medical group's services, and the charge for a labor epidural is not a static amount. The management of the epidural could be for 2 hours or for 14 hours. The patient could then go on to a Cesarean section using the same epidural. The rate of pay increases because it is now anesthesia for an operation and requires more intensive management. The negotiated rate of pay for each insurance changes from year to year, and the billing becomes so complex it requires a billing service to keep track of it all.

I told the husband that I could provide him a phone number for my medical group, that he should ask for the billing dept, that he will need to provide information of her insurance. The wife, in the middle of a painful contraction, shot her husband a look of exasperation, and said, "Never mind! I want the d--n epidural!"

Your example is interesting, but I still don't buy the argument that it is so complicated that we should cut off the conversation. And yes, you know that you have us by the short hairs, i.e. "The wife, in the middle of a painful contraction, shot her husband a look of exasperation, and said, "Never mind! I want the d--n epidural!", but we must do something to control costs. If physicians won't lead, then they will be forced to follow.

 

[swakyaby]

Your example is interesting, but I still don't buy the argument that it is so complicated that we should cut off the conversation. And yes, you know that you have us by the short hairs, i.e. "The wife, in the middle of a painful contraction, shot her husband a look of exasperation, and said, "Never mind! I want the d--n epidural!", but we must do something to control costs. If physicians won't lead, then they will be forced to follow.

This was not about anyone trying to "cut off the conversation." I was perfectly willing to hold off on the procedure while the couple researched the price. But minutes before a procedure to negotiate on cost when they knew she might want anesthesia services months ago was not good timing. To be angry that there wasn't an immediate price quote requires some understanding that it's not that simple for some procedures.

 

[redduck]

...but we must do something to control costs. /QUOTE]

Agreed something should be done to control costs. A small step might be requiring in-network hospitals to only use and/or refer to docs whom are also in the patient's network. If the hospital can't find an in-network doc, the patient needs to be told beforehand (I don't know how much before). Out-of-network treatment is a financial catastrophe.

 

[Sunset]

...but we must do something to control costs. /QUOTE]

Agreed something should be done to control costs. A small step might be requiring in-network hospitals to only use and/or refer to docs whom are also in the patient's network. If the hospital can't find an in-network doc, the patient needs to be told beforehand (I don't know how much before). Out-of-network treatment is a financial catastrophe.

+1
And so annoying because as the patient I select in-network doctor, hospital, and then get surprised afterwards to find out some supporting doctor I had no choice about is not in network

 

[ziggy29]

Agreed something should be done to control costs. A small step might be requiring in-network hospitals to only use and/or refer to docs whom are also in the patient's network. If the hospital can't find an in-network doc, the patient needs to be told beforehand (I don't know how much before). Out-of-network treatment is a financial catastrophe.

Agreed, but at this point, what you are describing is very much starting to resemble an HMO.

Even many medical providers probably can't always tell when someone is in or out of network for a given procedure, or if your insurance covers it.

I do believe the state of New York does something like this now. When a patient goes to an in network ER hospital, for example, I believe the cost of all the out of network care has to be negotiated between the provider and the insurer, and they can't balance bill the patient. To me this is one of the biggest flaws in the system overall; even when a patient does their homework and chooses in-network facilities, they don't always know if the ER doc, or the radiologist or the anesthesiologist is in network. And sometimes the patient has no choice -- in an emergency you go to an in-network facility and if it's a true emergency you aren't going to wait for hours until an in-network practitioner is available.

 

[travelover]

...but we must do something to control costs.

Agreed something should be done to control costs. A small step might be requiring in-network hospitals to only use and/or refer to docs whom are also in the patient's network. If the hospital can't find an in-network doc, the patient needs to be told beforehand (I don't know how much before). Out-of-network treatment is a financial catastrophe.

Exactly. If an out of network resource is used, their charge should be capped at a reasonable level like a multiple of Medicare or an in network allowance.

And docs should have some idea of what things cost. If drug A is almost as effective as drug B, but costs 1/10 as much, this should be known. Otherwise the patient may just not fill a prescription for B, and not control their condition at all.

 

[Sunset]

A cancer diagnosis can also cause severe financial burden:
Financial burden of cancer can harm quality of life | Reuters
Emphasis added

So true.

My sibling takes a bunch of drugs for cancer, one used to be $70,000/yr but has since been replaced by a cheaper version at only $57,000/yr.

One time a nurse ruined the medicine to be injected, and it was quite a situation to get a replacement dose at $5,000.

 

[ziggy29]

And docs should have some idea of what things cost. If drug A is almost as effective as drug B, but costs 1/10 as much, this should be known. Otherwise the patient may just not fill a prescription for B, and not control their condition at all.

Except that these TV commercials have patients convinced that they NEED Drug B.

 

[travelover]

Except that these TV commercials have patients convinced that they NEED Drug B.

That is yet another issue, but my point is that prescribing drugs and procedures with no idea of their cost is a recipe for $9000 per year per American medical expenses.

 

[redduck]

... even when a patient does their homework and chooses in-network facilities, they don't always know if the ER doc, or the radiologist or the anesthesiologist is in network. And sometimes the patient has no choice -- in an emergency you go to an in-network facility and if it's a true emergency you aren't going to wait for hours until an in-network practitioner is available.

I was going to mention ER's and should have, got lazy and didn't. But, I guess if it's an ER, all bets are off and the patient gets what he gets.
(I'm also too lazy to do the he/she thing).

While it seems impossible for the hospital to know what a patient's insurance covers (and how much it covers) the hospital should be able to match a patient with an in-network MD--or die trying. If there is no match they should be required to give the patient that information.

I wonder if the out-of-network situation occurs mainly in small hospitals or hospitals in less-populated areas--or, if the patient has some "off-brand" type of insurance.

 

[simple girl]

So true.

My sibling takes a bunch of drugs for cancer, one used to be $70,000/yr but has since been replaced by a cheaper version at only $57,000/yr.

One time a nurse ruined the medicine to be injected, and it was quite a situation to get a replacement dose at $5,000.

Yep. I have never been so thankful for good insurance. Although paying our high deductible in full the past 5 years (going on 6, counting this year) hasn't been fun, the amount pales in comparison to what my insurance company has paid out. My reconstruction surgeries have NOT been cheap (each surgery costs them at a minimum $100K)...coming up on #6 to try and fix radiation damage. My poor insurance company, I feel bad for it...I truly do.

 

[athena53]

While it seems impossible for the hospital to know what a patient's insurance covers (and how much it covers) the hospital should be able to match a patient with an in-network MD--or die trying. If there is no match they should be required to give the patient that information.

I wonder if the out-of-network situation occurs mainly in small hospitals or hospitals in less-populated areas--or, if the patient has some "off-brand" type of insurance.

I wish. I'm too lazy to figure out how to post a link with my phone, but look up the case of Cristiano vs. The Valley Hospital in NJ last year. The couple selected an OB in network. The hospital was in the network. They got nailed for $1,800 in out-of-network charges from the only anesthesiology group that practices at Valley.

I know this hospital- I used to live near there and Catherine Zita-Jones and Michael Douglas selected Valley for the birth of their last child. It's no second-rate outfit. The couple in the lawsuit had Cigna, not Joe's Insurance of the Turks ad Caicos. It happens everywhere. And the couple lost their case.

 

[pb4uski]

And my understanding is that states are legislating against these outrageous situations.

IMO if a consumer has an in-network doc or specialist and an in-network hospital then any out-of-network specialists who perform work should be deemed to have agreed to accept the insurer's in-network rate for the service and no balance billing is allowed (unless specifically agreed to in writing by the patient 48 hours prior to the services being performed so the patient can't be shaken down in pre-op).

 

[redduck]

...IMO if a consumer has an in-network doc or specialist and an in-network hospital then any out-of-network specialists who perform work should be deemed to have agreed to accept the insurer's in-network rate for the service and no balance billing is allowed (unless specifically agreed to in writing by the patient 48 hours prior to the services being performed so the patient can't be shaken down in pre-op).

Sounds good. Let's clarify ER situations and then we can vote on it.

 

[simple girl]

And my understanding is that states are legislating against these outrageous situations.

IMO if a consumer has an in-network doc or specialist and an in-network hospital then any out-of-network specialists who perform work should be deemed to have agreed to accept the insurer's in-network rate for the service and no balance billing is allowed (unless specifically agreed to in writing by the patient 48 hours prior to the services being performed so the patient can't be shaken down in pre-op).

This is the way my insurance works. I called them to make sure specifically before undergoing surgery at my in-network hospital, as I had heard of the "anesthesia out-of-network" issue.

 

[bmcgonig]

This is the way my insurance works. I called them to make sure specifically before undergoing surgery at my in-network hospital, as I had heard of the "anesthesia out-of-network" issue.

Who do you talk to? As far as I could tell at my last surgeries no one knew who the anesthesiologist would be on any particular day or hour.


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[Options]

I had two blood tests with Grouphealth in Washington, and was stunned to discover that my share of the bill was $600.

Some of the tests were central to treatment I was receiving, but others seem to have been just thrown in. I was not warned of the cost of any of these procedures, and the GH customer service rep told me that the doctors likely don't know what the costs are upon ordering the tests.

Going forward, I now intend to learn what blood tests are slated to be conducted with each blood draw visit, and what each of them costs.

This experience prompts me to ask whether anyone else has opted to participate more in their health care decisions to avoid costs of this magnitude for services that may not necessary.

See this:

It's Time to Get a Second Opinion Before Paying That Medical Bill - NBC News

The next time you get a medical bill, don't pay it — at least not right away. It pays to check for errors first.

Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent.

"Don't pay it until you understand it," said Sara Taylor, health solutions and strategies manager for benefits administrator Aon Hewitt.

 

[simple girl]

Who do you talk to? As far as I could tell at my last surgeries no one knew who the anesthesiologist would be on any particular day or hour.


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I couldn't find out who the anesthesiologist would be. What I did was call my insurance company and ask them what to do to avoid these kinds of charges. They told me my policy had some type of clause or arrangement with their in- network hospitals that required the hospitals to have all providers agree to accept the network rate for all patients under the plan. There was a name for this arrangement, but I forget what it was called.

 

[redduck]

I went to Cedars-Sinai Hospital Imaging Center today to have a bone-density test done. They already had all the info they needed in their system--but they did confirm some of it with me (including insurance info). They told me the bone-density test would cost approximately $158 and they would first bill Medicare and then bill my secondary provider. They also have checked and, yes, I am eligible for this procedure.

Now, I should probably leave it right here, but there's more good stuff:
I remember this bone-density tech from 6 years ago (and she remembers me).

She tells me to lie on the table and I start taking stuff out of my pockets. She says there's not need to do that, and that she will pull down my pants once I'm on the table. I get on the table real quick-like. She, with one hand, unbuckles my belt, unbuttons the pants button, zips down my fly and then pulls my pants down just a bit. (All this time I'm wondering what my co-pay is gonna' be for all this as I continue to cram one dollar bills in her lab coat). After the bone-density test (how appropriate) is over, she re-dresses me, but for some reason, she doesn't buckle my belt and I have to do it myself. I'm not sure if I should complain to her supervisor or not about not buckling the belt. Any suggestions?

 

[travelover]

I........After the bone-density test (how appropriate) is over, she re-dresses me, but for some reason, she doesn't buckle my belt and I have to do it myself. I'm not sure if I should complain to her supervisor or not about not buckling the belt. Any suggestions?

<insert happy ending joke here>

 

[Tadpole]

My husband and I never had problems when we were in MD and on regular workplace insurance. We moved to WA and were on the same insurance at first but rapidly reached Medicare age and went on a coordinated plan between Medicare and my workplace insurance with Medicare as primary. This means that Medicare Assignment determines the price for both. Now, if we need a specialist or lab test, as soon as we show up we are asked to sign a paper that says we will pay any amount our insurance does not cover. It seems like it is every doctor that we encounter. Most of them have been part of Peacehealth, a conglomerate that seems to own most to all the hospitals and specialists clinics and some labs in the area. I asked one facility why, if they accepted Medicare Assignment, they were making people sign these papers prior to treatment. The woman at the desk said "well, we have to get paid, don't we".

We recently got two bills from Peacehealth. The first was for two services on the invoice which Medicare had denied. When I talked to Medicare and my insurance they said that the doctor had triple billed for the same service and told me not to pay. I called Peacehealth and told them that Medicare and my insurance said that I didn't owe them anything and that Peacehealth needed to deal directly with Medicare and not with the patient. This took time but was easily resolved because I had a copy of the itemized payments and could back out the discrepancy. The next time they sent me a bill, they only sent a code and a number so I couldn’t do an investigation. I determined that they had billed me as soon as Medicare made payment and didn't wait for the payment from my secondary. I checked and the secondary had already paid them the day before they mailed the bill to me. I called Peacehealth and the person on the phone said they couldn't confirm what I was saying (a week later) and if I was sure then I could just not pay the bill.

What if I were 85 and getting a little slow?

There is less and less medical choice in this area as more and more medical choices are bought up by the Peacehealth conglomerate. But it is contagious. The last non-Peacehealth doctor I went to said he accepted Assignment but still had a line on the new patient form that said we would pay anything our insurance didn't pay.

The day of my cataract surgery, we were given a ten page thing to sign. I might be the first person to read it, including the staff of the facility. A comment was made in the document that the facility relied on "contractors". I went to the desk and asked if all the contractors accepted Medicare Assignment. Guess what? - no one knew. A while later one of the receptionist came back and said they had talked to the contractors on my case and they did accept assignment. I left wondering if they accepted assignment if you asked and what they charged if you didn't.

And that is the scary part of all of this. To get medical treatment you promise to pay any amount they pull out of their hat. Little Johnny is starting school at the Richy Rich Academy, Tadpole need to make a donation. There is no price negotiation; just a promise to pay whatever they want or what? – no medical services?-.

 

[athena53]

What if I were 85 and getting a little slow?
<snip>

And that is the scary part of all of this. To get medical treatment you promise to pay any amount they pull out of their hat. Little Johnny is starting school at the Richy Rich Academy, Tadpole need to make a donation. There is no price negotiation; just a promise to pay whatever they want or what? – no medical services?-.

I agree on the age 85 issue. I'm 63, computer-friendly and numerically literate. I've still found DH's Medicare/Medicare Supplement issues time-consuming to sort out. Most recently, I FINALLY got 40 pages of Medicare claim documentation to his Medicare Supplement provider and got $550 worth of reimbursements last week, even though the hospital's boilerplate on the bills 4 months ago said that all the insurance had been processed. (The Supplement carrier has always been prompt at processing claims so I figured the hospital hadn't submitted them even though two separate employees said they had. I was right.) I'm just glad I have enough brain cells and enough time to get what's ours.

And I'm still plodding through the process of finding out what my diagnostic colonoscopy will cost. I've pried numbers out of the doc and the facility but still need to see if there are separate lab and anaesthesiology costs. Sigh. I hate it, but they need to learn that people who have high deductibles don't write blank checks.

 

[simple girl]

Not sure if this article has been posted yet or not. Great to see legislation like this being passed:

The Hospital Is In Network, But Not The Doctor: N.Y. Tries New Balance Billing Law | Kaiser Health News