Understanding medical bills and charges

[audreyh1]

I think having a basic standard of coverage spread over everybody is important. We were all born. Just like we all went to school even though not all of us had children, yet we pay property taxes that support education for everyone’s children. Costs are spread across everyone as a way of lowering the costs for each individual.

Sure, people want to only pay for insuring the things they think they might need. For a lot of folks that means not carrying any insurance at all because they don’t need it right away and they prefer not to buy it until after something bad happens. That is not how insurance works and shouldn’t be allowed.

Offering services across state lines - very complicated as providers are local. I’m not sure health care services can scale that way at all even though it sounds good as a sound bite. Couple that with insurance being regulated per state.

[NC 57]

The system has several oligopolies that have formed thanks to the ability of industry players to successfully lobby government for special protections from market forces:
1). Insurance companies.
2). Multinational pharmaceutical companies
3). Hospital/provider organizations
4). Bloated bureaucracies in state and federal government charged with oversight of the industry and writing regulations.

All four have protections against competition and transparency written into law and regulations. They function as cartels and the first three spend heavily funding political campaigns and academic studies in addition to lobbing #4. The billions spent on advertising by the insurance and pharmaceutical companies has the side benefit of minimizing unfavorable press by the big media news organizations.

Even AARP, the organization claiming to be the #1 advocacy group for seniors, has a vested interest in this heavily controlled market given it is a significant seller of insurance services. AARP supports government mandates and the complexity of the current system.

With so much money in the hands of organizations having a vested interest in preventing increased competition and price discovery, I see very little prospect for meaningful market reforms in the near future. Not only is healthcare an obscene and unnecessary cost for consumer and government to bear, the complexity of the system results in barriers to access, needless suffering, and in the worst case loss of life. Polls, as well as letter and phone calls from constituents, tell Congress the system is unacceptable, yet as we have seen over the past few years Congress is unwilling to install the simplest marketplace reforms (national market competition and price transparency). It is a deplorable situation.

[Car-Guy]

And good luck keeping up with when a doctor (service provider) is "in-network" with lower negotiated rates or "out of network" with full cost.

True story.

We went to a doctor who was listed as "in-network" on our insurance companies web site. When the bill was received at the insurance company, they paid the negotiated rates as a "in-network" provider. The doctor received the payment but said "no", they had dropped out of that insurance providers network a few months earlier. So the insurance company recalculated the payment as "out of network" and paid the higher rates. Of course then the doctor charges us a higher rate too for our co pay. We are disputing the higher rates and particularly the misleading (wrong) information on the insurance companies web site. (Which has now been changed to show that doctor as "out of network")

So if a insurance company says a doctor is in-network (according to their web site) and processes the bill as in-network, but later changes their opinion, who is responsible for the mistake? (hint, it isn't the insurance company or the doctor ). Anyway, we are protesting the billing difference with our insurance company and if that fails, I plan to take this to the state insurance board as an unfair business practice.

Merry Christmas.

[zedd]

Quote:

Originally Posted by NC 57 For the free market to deliver efficient pricing there must be multiple competitors, pricing must be transparent to the consumer, and pricing must be available to the consumer before the sale or service occurs. Ideally an informed consumer can then negotiate freely with the seller to arrive at an optimal price. Our health care system incorporates none of these features. The regulation of insurance companies by the individual states prevents a national market with many providers from forming. Pricing is hidden from the consumer by the health care providers and the insurance companies. Even savvy consumers willing to spend hours researching are unable to determine final cost until after the service is delivered. Real healthcare reform would allow insurance providers to sell across state lines. It would require healthcare providers to post prices publicly (a price list in the office plus on the provider’s website) so consumers can research costs prior to contracting with a provider. The consumer would be able to go on a website to see the list of services, the list price for each, the discounted price for cash payment, and the discounted price extended to each insurance company by name. An efficient market would also allow individuals to contract with insurance companies for the basket of services the consumer wants, not a list of services required by the government. A 60 year old man would not be required to buy maternity or pediatric dental insurance he will never use as the current law mandates. Look at what has happened with pricing of consumer products since internet shopping developed over the past 20 years. With the transparency of pricing and product specifications globally competition has intensified and prices have declined or rise very slowly. Compare to cost inflation in the highly regulated healthcare marketplace where price discovery is difficult. Strange that none of the healthcare plans seriously considered by Congress in recent years have permitted a national market for services and insurance, much less complete price transparency.

+1

Look at what HealthSherpa.com did in the early days when the ACA website was struggling. We need a national health care consumer-sponsored website that has the ease of use of HealthSherpa.com with the reach of GasBuddy.com. Shoot I'd even be willing to pay a subscription fee to such a service.

[NC 57]

Quote:

Originally Posted by audreyh1 I think having a basic standard of coverage spread over everybody is important. We were all born. Just like we all went to school even though not all of us had children, yet we pay property taxes that support education for everyone’s children. Costs are spread across everyone as a way of lowering the costs for each individual. Sure, people want to only pay for insuring the things they think they might need, for a lot of folks that means not carrying any insurance at all because they don’t need it right away and they prefer not to buy it until after something bad happens. That is not how insurance works and shouldn’t be allowed. Offering services across state lines - very complicated as providers are local. I’m not sure health care services can scale that way at all even though it sounds good as a sound bite. Couple that with insurance being regulated per state.

audreyh1,

Whether coverage of some type is mandated or not, price transparency will work to lower costs. As long as prices are hidden or disguised prior to the service being delivered, buyers of services (medical care or insurance) cannot make informed choices. There is no downside to consumers being able to see and compare prices.

In my state there is only one insurance provider in the private marketplace. Blue Cross essentially tells the state regulators how much it will increase prices each year and threatens to pull out of the state if it doesn't get the increase it wants. My cost for private insurance has increased over 20% per year for the past four years. In 2018 my wife and I will spend $2100 per month for healthcare insurance premiums (plus $7500 each in deductibles), up from $630 per month five years ago for a "catastrophic" policy with $5000 each deductibles. These increases were the direct result of increased regulation of the marketplace by government and the resulting reduction of competition.

I fail to understand why creating a national marketplace for health insurance will result in more competition. Worst case, it will not improve the situation. Best case more competition results in lower prices and a broader array of product choices.

As to insurance being regulated by state, what is the advantage to the consumer of services of each state restricting access to its market? None that I can see. Since the current system is creating monopolies perhaps state by state regulation should be eliminated for a national market for insurance. There is certainly significant costs of having bureaucrats at both the state and federal levels adding thousands of pages of regulations per year which no single human being can begin to comprehend and which do not seem to be improving costs or delivery of services. Take out state bureaucrats and let the states spend the millions of dollars in savings on public health programs that directly benefit people.

With respect to the assertion offering services across state lines is complicated as providers are local, even in the heavily regulated healthcare industry that is changing. The Novant system in North Carolina is currently buying up hospitals and creating affiliations with doctors in Virginia, and South Carolina. The Mayo Clinic has locations in three states (Minnesota, Arizona, and Florida) and the Cleveland Clinic operates in multiple states. Some of the national drug retail chains, as well as Wal-Mart, are testing doctor offices in stores. Costco provides eye care services in many of its locations. Eliminate the state bureaucracies regulating healthcare and you might be surprised at how quickly national chains and/or alliances of local providers form using modern technology to drive cost efficiency and improved services in a national market.

Competition and price transparency works in every market where it is permitted. The only reason to restrict competition and disguise pricing is to protect the profit margins of entrenched players in a market.

[MJ]

Quote:

Originally Posted by audreyh1 I think having a basic standard of coverage spread over everybody is important. We were all born. Just like we all went to school even though not all of us had children, yet we pay property taxes that support education for everyone’s children. Costs are spread across everyone as a way of lowering the costs for each individual. Sure, people want to only pay for insuring the things they think they might need, for a lot of folks that means not carrying any insurance at all because they don’t need it right away and they prefer not to buy it until after something bad happens. That is not how insurance works and shouldn’t be allowed. Offering services across state lines - very complicated as providers are local. I’m not sure health care services can scale that way at all even though it sounds good as a sound bite. Couple that with insurance being regulated per state.

I wholeheartedly agree. As a society, you can't just pick or choose which tax you want to pay just because you don't need specific social services UNLESS you want to leave our society and live along side Ernest T Bass (The Andy Griffith Show)

[travelover]

Quote:

Originally Posted by NC 57 ..........In my state there is only one insurance provider in the private marketplace. Blue Cross essentially tells the state regulators how much it will increase prices each year and threatens to pull out of the state if it doesn't get the increase it wants...........

It is somewhat of a chicken and egg situation. Per the ACA, an insurance company has to pay out 80% of premiums, with 20% for overhead and profit. If medical costs do not rise, the insurance company can't raise rates. That said, since they get to raise rates and keep 20% if costs go up, their incentive to hold down rates is mitigated.

[Gotadimple]

Quote:

Originally Posted by zedd +1 Look at what HealthSherpa.com did in the early days when the ACA website was struggling. We need a national health care consumer-sponsored website that has the ease of use of HealthSherpa.com with the reach of GasBuddy.com. Shoot I'd even be willing to pay a subscription fee to such a service.

You are describing one of HealthSherpa's competitors: ehealthinsurance.com.

Both are not consumer-sponsored, they are licensed agents. They have licenses in all 50 states and agency contracts with all the health insurance carriers. Any licensed agent can sell an ACA policy, the get paid a commission by the carrier for making the sale.

[Just_Steve]

Quote:

Originally Posted by Car-Guy And good luck keeping up with when a doctor (service provider) is "in-network" with lower negotiated rates or "out of network" with full cost. True story. We went to a doctor who was listed as "in-network" on our insurance companies web site. When the bill was received at the insurance company, they paid the negotiated rates as a "in-network" provider. The doctor received the payment but said "no", they had dropped out of that insurance providers network a few months earlier. So the insurance company recalculated the payment as "out of network" and paid the higher rates. Of course then the doctor charges us a higher rate too for our co pay. We are disputing the higher rates and particularly the misleading (wrong) information on the insurance companies web site. (Which has now been changed to show that doctor as "out of network") So if a insurance company says a doctor is in-network (according to their web site) and processes the bill as in-network, but later changes their opinion, who is responsible for the mistake? (hint, it isn't the insurance company or the doctor ). Anyway, we are protesting the billing difference with our insurance company and if that fails, I plan to take this to the state insurance board as an unfair business practice. Merry Christmas.

Couldn't this whole situation have been avoided by simply asking if they accept your insurance when making the appointment?
I know on my insurance company provider lookup site there is a disclaimer stating that you should confirm participation with provider. I assume just so situations like you have can be avoided.

[sengsational]

I think they indicated they took the insurance, then, in a customer hostile move, decided later that they didn't take the insurance. That's the kind of treatment customers get when they are dealing in a market where they are prevented from shopping.

[Car-Guy]

Quote:

Originally Posted by Just_Steve Couldn't this whole situation have been avoided by simply asking if they accept your insurance when making the appointment? I know on my insurance company provider lookup site there is a disclaimer stating that you should confirm participation with provider. I assume just so situations like you have can be avoided.

We had been going to this doctor for a couple of years without a problem and this was just another routine visit. (And yes, I check the insurance web site periodically to be sure our doctors are still in-network) In the past, we have been notified by the insurance company when a service provider we have been using drops out of their network. As I said originally, good luck keeping up.

[Just_Steve]

Quote:

Originally Posted by Car-Guy We had been going to this doctor for a couple of years without a problem and this was just another routine visit. (And yes, I check the insurance web site periodically to be sure our doctors are still in-network) In the past, we have been notified by the insurance company when a service provider we have been using drops out of their network. As I said originally, good luck keeping up.

Pretty underhanded by the Dr's office to not tell a long time patient that they don't accept what has alway been accepted after the fact.