Poll: Would you share the price you paid for medical procedures?

[sengsational]

In another thread we touched on the fact that the prices of medical procedures are typically unknown until after the fact. http://www.early-retirement.org/for...s-is-about-to-double-79464-3.html#post1656675 Wouldn't it be nice to have a place to go to check the pricing before the fact? Even if the prices looked-up weren't guaranteed to be perfect, it would be better than nothing.

If there existed a non-profit site where you could submit your EOB's, and that site would save only procedure codes, provider identity, and negotiated price, and not save any personal information and not save the original EOB document (pdf or scan), would you be willing to help build this price database by submitting your EOB's?

There are sites that seem to be succeeding that have this crowd-sourced idea. Glassdoor is a site for employees of megacorps to compare notes on things, including sensitive information like salary. 800Notes has people on there disclosing phone numbers that are used by telemarketers and scammers. None of the participants gets anything back except the knowledge that they are helping their fellow man. But would this model work for something as touchy as healthcare records?

I would think the site would need to do a real-time scan of the uploaded documents, convert it to text, show it to the uploader with a statement like "What you see in this window is all we scanned, if you click agree, we'll post it to the database and delete your EOB. If you click disagree, we'll delete you EOB and data scanned from it."

But would that be enough? Most of us have little trust in web sites to keep our data from getting stolen. The data on this web site would have only public data; nothing to steal. I just wondered how people here would react to a web site that provided this service. Would you want to be a part of building a database to help your fellow health services consumer?

 

[utrecht]

I dont understand why people aren't outraged that its almost impossible to know what we are being charged for medical procedures before hand. If we overhauled the insurance system anyway, why didnt Obamacare fix that? Tell me what else we buy without knowing what it costs?

 

[wanaberetiree]

Insurance companies will kill an owner of such a website before it goes live

 

[harley]

I chose maybe, since I would want to wait for the unintended consequences to surface. I would actually prefer a Tripadvisor-like site, where you could type in your procedure and see available prices and surgical mechanics (ie. doctors), as well as ratings by other customers.

 

[sengsational]

Insurance companies will kill an owner of such a website before it goes live

Well, it would go live without data (no threat). If it became successful, well, then the owner's life would be in danger!

I chose maybe, since I would want to wait for the unintended consequences to surface. I would actually prefer a Tripadvisor-like site, where you could type in your procedure and see available prices and surgical mechanics (ie. doctors), as well as ratings by other customers.

The data to feed such a site is what we're trying to gather. If there's no legislation forcing them to disclose, the only way to get the information, that I can see, is to crowd source it.

 

[sengsational]

I dont understand why people aren't outraged that its almost impossible to know what we are being charged for medical procedures before hand. If we overhauled the insurance system anyway, why didnt Obamacare fix that? Tell me what else we buy without knowing what it costs?

In a galaxy far far away, this is the way they buy food:

There are 3 grocery stores in town. You must become a member of one store and pay a lot of money to become a member. If you don't become a member, the government fines you. Not only that, if you ever need to enter a store, you're charged three to five times members would pay. But you're compelled to become a member. You are provided with very limited information to help you decide which store to join: only the annual cost of membership and a list of what brands of food the store carries. Nothing about the price or quality of the food in the store is provided. You are not allowed inside the store before becoming a member. Even when you are a member, the food on the shelves have no prices and there is no way to check the quality of the food. It is well known that some of this food is horrible and some people die more often with some brands, but that information is not available to you. Some stores will carry only local brands (supposedly priced normally), but if you find yourself needing something besides the local brand, they will special order it for you and charge you at least double, maybe five times what the local brand would sell for. If they run out of the local brand and special order for you, they still charge you the outrageous price for the same thing you would have got if they hadn't run out of stock.

Most people come into the store once or twice a year, look at the brands available, randomly pick something from the shelves (without knowing the price or if it tastes horrible), walk out, and only later find out much they owe for it. In this world, a mystical thing happens on the way home from the store: sometimes the food shrinks. It depends upon your DNA as you move through the space-time continuum. Anyway, through a roll of the dice, you might find yourself one of the people who's food shrinks on the way home and so you must visit the store very often. The first time you visit, it's the same as the guy above, but by the time you get home, you realize you need to go back. The next time, the same thing. But after the third visit to the store, everything in the store becomes free! Now you visit the store all the time and take whatever you want. After all, it costs you nothing. The brand owners are all about giving you all the product you want for free, but sometimes when you get home, the store owner will have randomly decided that one thing the brand owner gave you is NOT free after all! Then you argue with the store owner, and get the state store regulation office involved. You realize that the store regulator doesn't want to upset the store owner, so you're left holding the bag. Some people then go bankrupt. The end.

 

[Gumby]

I'm wondering how accurate such a site could ever be. Even after seeing the EOB for procedures, I couldn't tell you how much something costs on the open market, only the rate negotiated by my particular insurance company. It is my understanding that the "list price" could be multiples of that.

 

[MRG]

I'm wondering how accurate such a site could ever be. Even after seeing the EOB for procedures, I couldn't tell you how much something costs on the open market, only the rate negotiated by my particular insurance company. It is my understanding that the "list price" could be multiples of that.

Thank you,

I've been wondering the same. All you would have is billing codes and costs? I may be ignorant but I thought billing codes could be very granular.
That's the root of my concern, I'm not sure how to match the data correctly. Then replicate that to some degree for different markets in the country.

Nonetheless I'm interested in the concept. There's no way the payor or providers are going to disclose the information and I don't think our representatives will help us see it.

 

[EastWest Gal]

A physician in a large group is in the same boat, and it's freaky. We had an Amish father who wanted to pay cash for their newborn's circumcision, since the mother had a complication and the baby delivered at the hospital instead of at home. The family had already made arrangements for circumcision with a local physician as an outpatient, but were much more comfortable to have it done under the watchful eye of all the nurses taking care of the mom and baby. I asked our Medical Director, he had no idea. I asked our onsite billing specialist and she had no idea either. She contacted the regional headquarters and she and I were on with them on the speakerphone for an hour, as they explained the charge was different for every insurance company. They did not have a cash basis fee. I asked them to give me the most common charge, the lowest charge, anything, and they actually had to kick it up to the national office to get some kind of answer. The amount we pinned them down for was high, but we always discounted 35% for cash pay patients, so it wasn't too bad.

Back when I was in a moderately sized private group practice, we knew what the charge was.

It's really crazy.

 

[Running_Man]

How do you know what the actual charge is? If an insurance group takes a 1000 patients for $750 a piece it will negotiate with a doctor group to cover medical services in exchange for upfront lump sum and certain prices for certain procedures. If another insurance group comes in and charges $500 for insurance and larger deductibles, it may be that the negotiated rates for the same services may be higher as the lump sum paid up front is lower.

Most of this pricing I thought was trade secrets of the insurance industry and how they make their profits.

 

[photoguy]

I posted about this in another thread but there's a startup called SmartShopper that has data on how much a procedure will cost and will pay you to use a cheaper provider: Episode 655: Pay Patients, Save Money : Planet Money : NPR

I have no idea how they get that information or how accurate it is. I suspect they receive it from insurance companies who also rebate some portion of the cost savings back to SmartShopper and patient.

But I think a crowd-sourced and openly available database would be fantastic. Aggregate data would be great to see trends but for an individual I think I would want to know the cross-product of insurance plan vs procedure.

 

[sengsational]

I'm wondering how accurate such a site could ever be. Even after seeing the EOB for procedures, I couldn't tell you how much something costs on the open market, only the rate negotiated by my particular insurance company. It is my understanding that the "list price" could be multiples of that.

When I look at the EOB's, there's an "allowed" price. That's what is normally kept secret until after you've had the work done. That's the price that's in the contract between the insurance company and the doctor/practice.

All you would have is billing codes and costs? I may be ignorant but I thought billing codes could be very granular.
That's the root of my concern, I'm not sure how to match the data correctly. Then replicate that to some degree for different markets in the country.

Not exactly how I see it working. The EOB would include the provider and the provider location too. So MegaPractice Corp in Gotham City would show several prices for each service code, one price per insurance company. The web site would have to map the provider (which is usually a doctor's name) into the practice, because that's where the contracted price is defined (between the insurance company and the practice).

How do you know what the actual charge is? If an insurance group takes a 1000 patients for $750 a piece it will negotiate with a doctor group to cover medical services in exchange for upfront lump sum and certain prices for certain procedures. If another insurance group comes in and charges $500 for insurance and larger deductibles, it may be that the negotiated rates for the same services may be higher as the lump sum paid up front is lower.

Most of this pricing I thought was trade secrets of the insurance industry and how they make their profits.

I would hope they could still manage to make a profit if their competitors know what they charge. After all, that seems to work pretty good in everything else we need to shop for.

The actual charge is what's on all of our EOB's. I doubt that there is an after the fact negotiation going on. There exists a contract that has prices for everything. One contract between each practice or group and the insurance company. Big practices probably actually do negotiate pricing, but small practices probably all get the same "take it or leave it" contract. I'm just guessing based on business principles, I really don't know for sure, but whatever the data collected tells us is whatever the data collected tells us! For instance, there's probably no rule that says they can't re-negotiate the contract every month. So the prices could change every month.

I have not been able to get a doctors office to quote a price for a procedure code. They have it right in their contract, but there must be a "gag order" in the contract so they are not allowed to disclose the price unless the service is billed. Seems like some very simple legislation could resolve this (outlaw the gag order in this type of contract), but the special interests are too strong to get this passed.

 

[sengsational]

But I think a crowd-sourced and openly available database would be fantastic. Aggregate data would be great to see trends but for an individual I think I would want to know the cross-product of insurance plan vs procedure.

That "cross-product" exactly what I see this database providing.

I see going to the web site, typing in my zip code and procedure name or code and getting a list of price ranges by insurance company.

Procedure 99396, Preventive, Established Patient, Zip code 12345:

                                                Allowed Amount    
Company                         Plan            Low     High
Blue Cross Blue Shield of NC    Blue Value      $178.45    $193.97
Blue Cross Blue Shield of NC    Blue Local CHS  $173.10    $188.15
Blue Cross Blue Shield of NC    Blue Advantage  $178.45    $193.97
United Healthcare               Compass         $180.02    $195.68

The user would have the ability to drill down into an entry and see the individual practices. Clicking into the first one:

Procedure 99396, Preventive, Established Patient, Zip code 12345, Blue Value:        
        
                                Allowed
MegaPractice A                  $191.06
MegaPractice B                  $193.97
Mom and Pop Doc A               $178.45
Mom and Pop Doc B               $178.45
Mom and Pop Doc C               $178.45

 

[MRG]

When I look at the EOB's, there's an "allowed" price. That's what is normally kept secret until after you've had the work done. That's the price that's in the contract between the insurance company and the doctor/practice.

Not exactly how I see it working. The EOB would include the provider and the provider location too. So MegaPractice Corp in Gotham City would show several prices for each service code, one price per insurance company. The web site would have to map the provider (which is usually a doctor's name) into the practice, because that's where the contracted price is defined (between the insurance company and the practice).

I would hope they could still manage to make a profit if their competitors know what they charge. After all, that seems to work pretty good in everything else we need to shop for.

The actual charge is what's on all of our EOB's. I doubt that there is an after the fact negotiation going on. There exists a contract that has prices for everything. One contract between each practice or group and the insurance company. Big practices probably actually do negotiate pricing, but small practices probably all get the same "take it or leave it" contract. I'm just guessing based on business principles, I really don't know for sure, but whatever the data collected tells us is whatever the data collected tells us! For instance, there's probably no rule that says they can't re-negotiate the contract every month. So the prices could change every month.

I have not been able to get a doctors office to quote a price for a procedure code. They have it right in their contract, but there must be a "gag order" in the contract so they are not allowed to disclose the price unless the service is billed. Seems like some very simple legislation could resolve this (outlaw the gag order in this type of contract), but the special interests are too strong to get this passed.

Got it thank you. How can I help?

 

[Gumby]

I would recommend this article to understand why the rate paid by your insurance company has absolutely no relation to the cash price that you would pay on your own, the rate paid by any other insurance company, the actual cost to the hospital of providing the service, or any other rational metric. My memory is far from perfect, but I think it has been discussed on this board before.


Bitter Pill: Why Medical Bills Are Killing Us - TIME


Edit to add: Another problem is that insurance companies don't have a strong incentive to negotiate prices lower, because in the end they simply pass along the rate increases to those paying the premiums.

 

[sengsational]

I posted about this in another thread but there's a startup called SmartShopper that has data on how much a procedure will cost and will pay you to use a cheaper provider: Episode 655: Pay Patients, Save Money : Planet Money : NPR

The site they talk about is https://www.vitalssmartshopper.com and sounds like a really good thing. I'm going to investigate.

 

[Gotadimple]

The site they talk about is https://www.vitalssmartshopper.com and sounds like a really good thing. I'm going to investigate.

Hmmm . . . might work well for those no health insurance at all. Showing you which provider will do a procedure at a more reasonable price is meaningless if the provider is not in your health plan's provider network.

Unless of course one has a separate set of funds to pay for the procedure outside of insurance reimbursement.

 

[sengsational]

Vital SmartShopper might also be good for someone with high deductible insurance that stands little chance of hitting that deductible.

 

[sengsational]

How About THIS for incentive to contribute

I just realized that there is a use-case (function) that having this database built would enable: Price My EOB

The user would upload an EOB and they would get back the "allowable" total for everything on the EOB.

Total Price for Services in the EOB you uploaded:                
                       BC V       BC L        BC A       UCC C                
MegaPractice A          $2,711    $2,448    $2,432    $2,352
MegaPractice B          $2,439    $2,484    $2,423    $2,452
Mom and Pop Doc A       $2,384    $2,531    $2,542    $2,532
Mom and Pop Doc B       $2,384    $2,531    $2,542    $2,532
Mom and Pop Doc C       $2,384    $2,531    $2,542    $2,532
Hospital X              $7,208    $7,153    $7,139    $7,200
Medicare                $1,139    $1,139    $1,139    $1,139

 

[sengsational]

Got it thank you. How can I help?

I think one thing would be to find out from vitalssmartshopper.com how additional states get added to their list of covered states.

Currently the SmartShopper program is only available to Employers and Insurance Carriers in the following states: NH, MA, CT, IN, KY. To learn more about qualifying for the SmartShopper program, please contact your Employer, Health Plan, or Broker for more information.

Their number is 1-800-824-9127, but not open today (Saturday).

The login screen on the SmartShopper site requires an "exact match" on your health insurance ID card number, date of birth, zip code. Just putting in a state that the site covers doesn't work, so it's doing something with the ID card number. I suspect that each state's insurance commissioner or each state's laws have compelled any company wanting to sell insurance in that state to disclose what policy the insured people in the state have assigned. I can't see how all health insurance carriers in a state would voluntarily give up that information unless compelled. Or maybe not all insurance companies participate.

 

[savory]

I really like this idea. Wish I thought of it.

 

[athena53]

I'd sure contribute. We need something like this.

 

[photoguy]

I just realized that there is a use-case (function) that having this database built would enable: Price My EOB

I think there will a be gazillion uses for this data and an incredible number of researchers / economists who would like to access it. Also, I wonder if the BLS would be interested in it for CPI? (side question does CPI-U actually track any healthcare costs besides premiums?)

The only problem I see is how do you get a critical mass of users uploading photos/scans/screenshots of their EOB?

 

[sengsational]

I think there will a be gazillion uses for this data and an incredible number of researchers / economists who would like to access it. Also, I wonder if the BLS would be interested in it for CPI? (side question does CPI-U actually track any healthcare costs besides premiums?)

The only problem I see is how do you get a critical mass of users uploading photos/scans/screenshots of their EOB?

You hit the nail on the head. I know for a fact that if you build it, they will NOT come unless something compels them.

The "what's in it for me" would have to be, I think, the ability to have their historic EOB's priced-out under different insurance companies / different insurance plans. The first batch of people wouldn't get information since there would be none. Maybe there could be a message that they could log back in at a later date and get the pricing.

Another possible benefit could be an analysis of if the collection of services (group of codes) that made-up a procedure. For instance, my colonoscopy had 15 codes, yours had 20. What are the other 5 and am I getting more or less than I need? This would be a report on the differences between the doctors and facilities more than the insurance company's secret pricing.

For the BLS to want it, there would have to be a whole bunch of people from all walks of life using it. Unfortunately, I only see a sliver of the population that would use it, even if it could deliver perfect results on day one.

 

[MBSC]

HMO providers receive a monthly capitation payment for routine services, not the EOB allowed amount.
https://www.acponline.org/residents_fellows/career_counseling/understandcapit.htm

For providers not in capitation agreements:
1) You would need access to the claim's DUT field for any procedure that could be billed in multiple units, such as ambulance mileage and minutes under anesthesia. Example: A physical therapy procedure code specifies "each 15 minutes" so an hour of PT is billed with 4 DUTs. The EOB allowed amount is 4x the fee schedule rate. Another EOB will have half that amount because they received 30 minutes of PT.

2) Some claims have modifiers appended to the procedure code which adjusts the fee schedule rate (150%, 62.5%, 50% etc) altering the EOB allowed amount.

3) On some claims the rendering provider is a PA, NP, CRNA, or PT which adjusts the fee schedule rate (85%, 65%, etc) altering the EOB allowed amount.

4) After the above adjustments are made, the provider's contracted rate is applied. Group A may be contracted at 97% and B at 110%. The EOB allowed amount is after this adjustment also.

5) Medicare Part B fee schedule rates are public. TRICARE and Medicare Advantage plans also use these rates. This is what private insurers should do.
https://www.cms.gov/Medicare/Medica...ent/PFSLookup/index.html?redirect=/pfslookup/

6) The Medicare Part A pricers used to determine allowable amounts are public. MA plans also use these. TRICARE uses these except they modify the Inpatient PPS (IPPS) pricer for maternity.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/