More Health Care Billing Nonsense

[ivinsfan]

Having virtually everyone pay a different price for the same services doesn't help either. Just curious, if you were talking to a college professor about his class would expect them to know how much the tuition and books would cost you. You might be instate or out-of-state tuition, you might buy a new book or a used book. And I wouldn't be surprised if the professor didn't even know the per credit cost of your tuition.

We say we want to know what it will costs but we also say it's too expensive. Do we really want them to pay for computer software and people to answer your emails and send you estimates which will vary wildly depending on your particular course of treatment or surgery? Because of course we pay for that in the end too.


I don't have a fix either...don't think there is one with our present system.

 

[audreyh1]

When DH needed a diagnostic colonoscopy, we visited a couple of hospitals to get quotes. One gave us an unofficial ballpark. Another required that we register to get a quote, but then we met with a hospital financial person who talked to our insurance company and then gave us a quote plus discussed payment terms/schedules. We had a separate quote from the doctor.

Interestingly the first hospital strongly implied the price was lower if you didn’t use insurance.

A colonoscopy is a fairly routine outpatient procedure, so I would expect it to be easier to quote than most things.

 

[MRG]

I wonder... if one knows the providers and the codes for procedures, I would think that the insurer should able to tell you what your responsibility would be based on their contracts with the provider and your coverage.

I did that once. It was at a balance therapist who had an ENT he worked with. They gave me all the codes to check with my insurance. Seems like I had to give their office proof I had before they would schedule my half day testing.

I think in this case he didn't want to jack with people who couldn't pay for what might be a larger bill.

 

[Rianne]

When does OOP maximum stop? Say HI plan has max $15,000 OOP. But the health issue and treatment is out of network and plan pays 50% co insurance for OON. Are we responsible for OON costs beyond the said $15K?
imoldernu: cost $120K. We don't have medicare, if this scenario were us in Out of Network situation, what then?

I"m meeting with insurance broker tomorrow. I'll get back with her answer.

Broker said the key is not to take HMO plans. PPO protects out of network to an extent. You have to look at the details in the plan. If there's 50% covered out of network, they take the deductible first then go to co pays. I switched to BCBS, they have the highest discounts, so you end up paying less with high deductible plan. Kept the HSA. I would not do this without a broker. She said call her anytime. Signed up this AM. Easy peasy.

 

[Midpack]

The main point of my post was to encourage people to try to find out the costs ahead of time rather than throw their hands up and assume it can't be done. Glad to hear you'll try it next time.

Maybe picking nits, but I routinely ask very politely for costs ahead of time and rarely get an answer even for fairly routine procedures - I gave the example above where the doctor was plainly insulted I asked. But I've never asked anyone but the doctor, in hindsight that was probably not the best course of action. But again, when I didn't have an answer for a customer in my career, I made sure I knew who could answer and put them together with the customer. No doctor has done that for us yet.

They could provide answers (base or typical price, with disclaimers), they consciously make it a practice not to...

 

[SecondCor521]

Maybe picking nits, but I routinely ask very politely for costs ahead of time and rarely get an answer even for fairly routine procedures - I gave the example above where the doctor was plainly insulted I asked. But I've never asked anyone but the doctor, in hindsight that was probably not the best course of action. But again, when I didn't have an answer for a customer in my career, I made sure I knew who could answer and put them together with the customer. No doctor has done that for us yet.

They could provide answers (base or typical price, with disclaimers), they consciously make it a practice not to...

No worries about picking nits. I don't think you are doing that.

I think you will have more success getting prices if you ask the business office instead of the doctor.

Personally I would try to avoid receiving care from a doctor who acted insulted and was unhelpful or from a doctor whose business office would not either try to do their best to give me a price estimate or give me a good reason whey they couldn't.

 

[audreyh1]

Maybe picking nits, but I routinely ask very politely for costs ahead of time and rarely get an answer even for fairly routine procedures - I gave the example above where the doctor was plainly insulted I asked. But I've never asked anyone but the doctor, in hindsight that was probably not the best course of action. But again, when I didn't have an answer for a customer in my career, I made sure I knew who could answer and put them together with the customer. No doctor has done that for us yet.

They could provide answers (base or typical price, with disclaimers), they consciously make it a practice not to...

In my experience it’s the doctor’s office staff who have some idea of pricing, can call my insurance, etc.

 

[MichaelB]

The only time I was able to get a straightforward price for a procedure was when I had my cataracts done. Even routine stuff with specialist, like ophthalmologist visits, get a response along the lines of "it depends", or LabCorp, which gets the 20X list price quote.

One of the issues we (collectively) are dealing with now is many health care providers apply billing codes that generate the most revenue for the visit, not necessarily the actual service that was provided. The billing code system is so complex it is not realistic to expect patients to navigate and challenge.

 

[pb4uski]

.... One of the issues we (collectively) are dealing with now is many health care providers apply billing codes that generate the most revenue for the visit, not necessarily the actual service that was provided. The billing code system is so complex it is not realistic to expect patients to navigate and challenge.

That was a perennial problem with our former doc. We would go in for a routine wellness physical and have bloodwork done at the adjacent hospital (both the doc practice and hospital are owned by the same mega health complex) and the doc's office would miscode the blood work so the hospital would bill us for it. So I had an annual chore to call the business office at the doc and have them resubmit with the correct coding.

That is why they WERE our doc and are no longer our doc.

I swear that they did it intentionally to generate a bill that most people would get, think that they owed for, and pay rather than question it like we would.

 

[Scrapr]

Maybe picking nits, but I routinely ask very politely for costs ahead of time and rarely get an answer even for fairly routine procedures - I gave the example above where the doctor was plainly insulted I asked. But I've never asked anyone but the doctor, in hindsight that was probably not the best course of action. But again, when I didn't have an answer for a customer in my career, I made sure I knew who could answer and put them together with the customer. No doctor has done that for us yet.

They could provide answers (base or typical price, with disclaimers), they consciously make it a practice not to...

I suspect your Doc was all insulted because he's practicing medicine and you know ....curing cancer. AKA the God complex. The trivial things like bills to be paid by the patient are for the "little people" in the billing section

I bet he is a treat to work with. I'm betting it was not a woman doc

 

[sengsational]

One of the issues we (collectively) are dealing with now is many health care providers apply billing codes that generate the most revenue for the visit, not necessarily the actual service that was provided. The billing code system is so complex it is not realistic to expect patients to navigate and challenge.

Billing for something that wasn't performed is fraud, and should be reported to your state's attorney general. Of course they'd say it was just a mistake, but if enough people report them, they'd have a hard time claiming so many mistakes that went in their favor.

 

[SecondCor521]

One of the issues we (collectively) are dealing with now is many health care providers apply billing codes that generate the most revenue for the visit, not necessarily the actual service that was provided. The billing code system is so complex it is not realistic to expect patients to navigate and challenge.

MichaelB, can you point me to the data that demonstrates your first statement?

I agree that the billing code system is very complex. I don't think it was made complex in order to facilitate billing fraud; I am not sure if you are implying that or not. Personally I think it was made complex because medicine and the human body is complex and because the health care and health insurance industry want to collect more data in order to provide care more cost effectively.

 

[ivinsfan]

I'm not MichaelB but I took his statement to mean there are so many codes to describe basically the same service that the default is to look for and select the most expensive one that might apply rather then the least expensive one that might apply.

For example my DH was on blood thinners for awhile and used the INR clinic, which is staffed with RN's but the bill always got through as a short office visit with a doctor he's never seen in his life..we got a Medicare questionnaire asking us to rate the doctor...LOL

 

[MichaelB]

MichaelB, can you point me to the data that demonstrates your first statement?

I agree that the billing code system is very complex. I don't think it was made complex in order to facilitate billing fraud; I am not sure if you are implying that or not. Personally I think it was made complex because medicine and the human body is complex and because the health care and health insurance industry want to collect more data in order to provide care more cost effectively.

I didn’t say the billing system was made complex to enable fraud. As you point it, it is complex by nature. Still, there is little doubt that some providers exploit the billing complexity to further increase their revenues by up-billing, which is very difficult to prove in any specific case but easier to identify by group behavior. ProPublica has published a lot about this, here is one example.
https://www.propublica.org/article/...-the-most-complicated-expensive-office-visits

As it stands now, doctors and their staffs decide how to bill for a patient visit based on a host of factors, including how thoroughly they review a patient’s medical history, the intensity of the physical exam and how complicated the medical decision-making was. The coding system developed by the American Medical Association gives doctors five options.

In addition, hospital are now engaging in wildly abusive and mostly uncontrolled overbilling. By overbilling, I mean charging more than the reasonable and customary price. That is the thread topic, and there cannot be any doubt.

Sarah Kliff has been working on a fascinating project to document actual hospital bills and analyze the results. This is quite difficult because of privacy laws. Here’s a write-up. https://www.cjr.org/q_and_a/sarah-kliff-vox.php

IT STARTED WITH A BAND-AID. A $629 Band-Aid.

 

[SecondCor521]

I didn’t say the billing system was made complex to enable fraud. As you point it, it is complex by nature. Still, there is little doubt that some providers exploit the billing complexity to further increase their revenues by up-billing, which is very difficult to prove in any specific case but easier to identify by group behavior. ProPublica has published a lot about this, here is one example.
https://www.propublica.org/article/...-the-most-complicated-expensive-office-visits


In addition, hospital are now engaging in wildly abusive and mostly uncontrolled overbilling. By overbilling, I mean charging more than the reasonable and customary price. That is the thread topic, and there cannot be any doubt.

Sarah Kliff has been working on a fascinating project to document actual hospital bills and analyze the results. This is quite difficult because of privacy laws. Here’s a write-up. https://www.cjr.org/q_and_a/sarah-kliff-vox.php

MichaelB, thanks for the reply.

The first article you linked showed a total of 1,825 health care professionals who statistically appear to be engaged in fraud and probably are.

The first Google result I found for "How many health care professionals are in the United States" gave a link to the CDC and the number of 18 million: https://www.cdc.gov/niosh/topics/healthcare/default.html

1,825 / 18 million = 0.0001014 or 0.01014 percent.

Health care professionals obviously includes nurses and others who may not be responsible for coding and billing.

I agree that there is fraud in medicine, just like any other field. Your previous post could have been read to mean that the problem was widespread or systemic. I'm not sure if that's what you meant, but I don't think I would agree.

I'll look at the hospital article as well.

 

[MichaelB]

SecondCor521, it was never my intent in either post to suggest fraud is rampant or the primary cause of high medical billing. It is also not trivial, despite your math. Medical coding is a black hole, and the evidence of abusive hospital bills is too overwhelming to give the benefit of the doubt to the service providers. The links in my previous post were not intended to quantify the entire scope, just give examples.

The thread is about outrageous prices. Among the reasons we don’t have more examples are privacy laws and secrecy pact and practices. There is still enough documentation to see this as a highly complex pervasive issue that is, if anything, growing in scope.

 

[indiajust]

I try to get a quote in advance and shop the business around for elective stuff.

 

[JoeWras]

S Medical coding is a black hole, and the evidence of abusive hospital bills is too overwhelming to give the benefit of the doubt to the service providers. The links in my previous post were not intended to quantify the entire scope, just give examples.

Some of these codes now have modifiers. This is one place where confusion and possible mischief is occurring. Or, the person doing the coding simply always gives the "level 4" modifier because that's what they've always done, not knowing why.

This article gives a good example: https://www.vox.com/policy-and-politics/2018/2/7/16851134/rabies-treament-expensive-emergency-room

What jumped out at Peterson was that her emergency room would charge different prices for her follow-up visits. To her, the visits all seemed the same: a quick stop by the emergency room to receive a shot of the rabies vaccine.
But sometimes her visits were billed with a “level 1” facility fee, the cheapest fee for the simplest visits. But another visit was coded as “level 2,” which came with a higher price. And still another was “level 4,” typically reserved for some of the most complex visits.
“Every time, the fee was different,” Peterson says.

 

[MRG]

Just had a small example of the insanity. A couple weeks ago I was given a holter monitor to wear for a week by my in network cardiologist.

When I packed it up to return it, I noticed a pamphlet about billing issues and the network they're in. Well go figure, they have cardiologists and they're in some networks not others.

Today my health insurance denied their claims. Wow, $5,500 that is all out of network! The pamphlet said, call us about billing issues. The gal told my they'd would make an appeal. I asked about appealing out of network, as I certainly wasn't paying that price. "Oh don't worry sir, the maximum we charge you is $255." WTx?

 

[TwoByFour]

In addition, hospital are now engaging in wildly abusive and mostly uncontrolled overbilling. By overbilling, I mean charging more than the reasonable and customary price. That is the thread topic, and there cannot be any doubt.

Sarah Kliff has been working on a fascinating project to document actual hospital bills and analyze the results. This is quite difficult because of privacy laws. Here’s a write-up. https://www.cjr.org/q_and_a/sarah-kliff-vox.php

The article above starts with a "$629 bandaid" as an example of abuse. But really, who goes to the ER for a cut finger? Perhaps the treatment was a bandaid, but the patient went in there thinking it was an emergency, and this is what one should expect to pay for service that specializes in emergencies of any stripe - from gory accidents to heart attacks. It was not the bandaid that cost so much, it was the setting the patient chose to go to. If you don't want to pay $629 then go to an urgent care clinic. Our medical care has lots of problems with costs, but this one is on the patient.

 

[MichaelB]

The article above starts with a "$629 bandaid" as an example of abuse. But really, who goes to the ER for a cut finger? Perhaps the treatment was a bandaid, but the patient went in there thinking it was an emergency, and this is what one should expect to pay for service that specializes in emergencies of any stripe - from gory accidents to heart attacks. It was not the bandaid that cost so much, it was the setting the patient chose to go to. If you don't want to pay $629 then go to an urgent care clinic. Our medical care has lots of problems with costs, but this one is on the patient.

From the article

This whole project actually started with a bill that a reader sent to me. This guy in Connecticut had taken his daughter to the emergency room. It was a 1-year-old girl and he’d been clipping her fingernails and had cut her finger, and it was gushing blood. He was really worried, and it was a weekend, so the urgent care was closed. So he took her to the emergency room. And they said it was nothing to worry about, they put a Band-Aid on her finger and sent them home. And then he received a bill for $629.

Read the entire article, it's very interesting. Emergency rooms see lots of people that would be better treated elsewhere.

 

[Walt34]

The article above starts with a "$629 bandaid" as an example of abuse. But really, who goes to the ER for a cut finger?

Apparently a lot of people do. Last night I waited three hours to be seen in the ER because of all the people who use the ER as primary care. Those are the ones without insurance, on Medicaid, some on Medicare. The whole hospital didn't have a single bed available and ambulances were being told to divert because of this nonsense.

The staff was telling me that people go to the ER for sore throats, earaches, headaches, nosebleeds, minor stuff that most people deal with themselves, go to their primary care physicians, or perhaps an urgent care place.

But these people go to the ER because they'll never pay the bill.

 

[sengsational]

This site "https://erbills.vox.com/" is kind of like what I was talking about when I started this thread/poll:


http://www.early-retirement.org/for...ce-you-paid-for-medical-procedures-79499.html


My idea was to automate the process of pulling information off of EOB's that are sent to individuals so that a database of negotiated prices could see the light of day.


I don't think anybody here would object to more light shed on prices that people actually paid, along with the CPT codes and facility. The idea lost steam with me when my insurance company started publishing EOB's without CPT codes. It didn't last long, but there was a few months where the codes were missing. I wonder if the attorney general got them back on track (I did report them). A supplier tried that crap with me and I called them and said unless you give me the codes, I'm not paying. The relented and sent me a bill with the codes. I can't believe the business practices they try to get away with; about as close to criminal as they can get.

 

[audreyh1]

Just had a small example of the insanity. A couple weeks ago I was given a holter monitor to wear for a week by my in network cardiologist.

When I packed it up to return it, I noticed a pamphlet about billing issues and the network they're in. Well go figure, they have cardiologists and they're in some networks not others.

Today my health insurance denied their claims. Wow, $5,500 that is all out of network! The pamphlet said, call us about billing issues. The gal told my they'd would make an appeal. I asked about appealing out of network, as I certainly wasn't paying that price. "Oh don't worry sir, the maximum we charge you is $255." WTx?

Wow!

But you know I had a very similar thing happen last year. A special test that I knew was far more reliable than the standard very unreliable one. I paid some amount up front, and submitted my insurance information.

Then a few weeks later I see a claim for a far higher amount is denied by my insurance and treated as out of network. OK was expecting that. So I get this much larger bill - about 6x what I originally paid, and no mention of my prepayment. This amount is quite a bit higher than I would have paid up front as self-pay/no insurance.

So I decide to call and ask for more details especially why wasn’t I credited for this prepayment on my bill or an explanation of how that factored in. Talking to billing, they look it up, and announce that my account has zero balance. I’m don’t owe anything. OK good for me, but Huh? They weren’t going to send me another statement. Do they just hope someone pays these bogus bills?

BTW - some of these games here are writeoffs the providers take.

 

[JoeWras]

From the article
Read the entire article, it's very interesting. Emergency rooms see lots of people that would be better treated elsewhere.

For sure. When I was a kid, a trip to the doc office for most stuff like bad cuts and broken bones was routine. He was our emergency room. That of course assumes working hours. We kids usually got in trouble during the day in the summer. We planned well.

I read the article and saw the linked article about rabies shots. THAT was interesting. Apparently, if you think you were bit or scratched by a rabid animal, usually a bat, going to your doctor won't help. They only stock the required medicines in emergency rooms since this is an aggregated site that handles the medicines with occasional usage.

What was eye opening was the patient in the article was perplexed that the subsequent visits to the ER for the shots got graded randomly from level 1 to 4. There was no choice but to go to the ER, and they didn't know what kind of grade they would get, even if it was for a simple shot. One would think a follow up shot would be level 1. Not the case, it varied even though all the visits were short, sweet and scheduled.