Cost-Conscious, Self-Managed Care

[travelover]

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

My question is why is there a 9X or 10X difference between in network and out of network reimbursements? I can't think of another business where there is this kind of variability.


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[bikeknit]

It's still virtually impossible to get prices just by asking around here. One doc's office could tell me the self-pay rate for my diagnostic colonoscopy- but not the rate negotiated with my insurance plan and not what the hospital would tack on for use of their facility.

I once spent hours trying to find out what a bone density test would cost me (the insurance negotiated rate, not the sticker price for someone without insurance) and was told everything from "you need to get that info from the insurance company", "you need to get that from the facility", our contract with the insurance company won't let us give you that info"...

Amazingly, they know what it costs after the procedure.

If anyone has had success getting this info from doctors or facilities before the procedure, I'd love to hear how you did it.

 

[redduck]

To answer your question, bikenit...

The hospital intake woman told me (without my asking) what the cost of my bone density test would be. The whole intake process took about five minutes as they already had my information on file.

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.

 

[bikeknit]

To answer your question, bikenit...

The hospital intake woman told me (without my asking) what the cost of my bone density test would be. The whole intake process took about five minutes as they already had my information on file.

I wish that would work for me. I live in Kansas and this was at Kansas University Medical Center. I got transferred to all sorts of offices both at KU Med and at my insurance company of the time, Coventry - and no one ever gave me any hope that they would tell me.

I changed to Blue Cross/ Blue Shield this year and they told me that I should be able to get that information from them. I'll see.

 

[redduck]

I changed to Blue Cross/ Blue Shield this year and they told me that I should be able to get that information from them. I'll see.

I am now on Medicare and have Blue Cross as the supplementary. The only thing so far that I've had to watch out for with medical bills is to make sure that the supplementary has been billed (and paid). I can't imagine BC/BS being willing to help you out with usable information re: upcoming medical costs.

I wish you good luck with them.

 

[athena53]

I once spent hours trying to find out what a bone density test would cost me (the insurance negotiated rate, not the sticker price for someone without insurance) and was told everything from "you need to get that info from the insurance company", "you need to get that from the facility", our contract with the insurance company won't let us give you that info"...



Amazingly, they know what it costs after the procedure.



If anyone has had success getting this info from doctors or facilities before the procedure, I'd love to hear how you did it.

I'm on the MO side (also KC suburb). It varies. Before we moved last year we were in KS and I had Coventry. When I called the office of the doc who did my last 2 colonoscopies, I got the runaround and was ping-ponged between Coventry and the doc's office (which, as I noted earlier, could give me only the self-pay rate and only for the doc).

I now have BCBS and tried doc #2, recommended by my PCP. They gave me the doc's rate agreed with BCBS and the phone # of the facility, which readily supplied their charge. Then I realized there could be lab fees. I called the doc's office again. The lab fee depends on what they find. Well, I suppose that makes sense. She did tell me the lab was in network. I suppose I ought to verify that. Hey, it's progress.

 

[MRG]

I'm on the MO side (also KC suburb). It varies. Before we moved last year we were in KS and I had Coventry. When I called the office of the doc who did my last 2 colonoscopies, I got the runaround and was ping-ponged between Coventry and the doc's office (which, as I noted earlier, could give me only the self-pay rate and only for the doc).

I now have BCBS and tried doc #2, recommended by my PCP. They gave me the doc's rate agreed with BCBS and the phone # of the facility, which readily supplied their charge. Then I realized there could be lab fees. I called the doc's office again. The lab fee depends on what they find. Well, I suppose that makes sense. She did tell me the lab was in network. I suppose I ought to verify that. Hey, it's progress.

I'm in Jackson County. When I shopped three years ago it was just BCBS and Coventry in this county. I went with BCBS and have been very happy. Third year zero surprises and I've had too many illnesses, hospitals, and surgeries.

First year of ACA I'd contacted a broker I know and her advice was if you plan on using the insurance(between those 2 in this area) BCBS was superior.

 

[athena53]

I'm also in Jackson! I dropped Coventry when, after I moved across the state line, Coventry cancelled my KS policy (which I knew would happen) and offered me a MO alternative I "might like". I looked up the details. ZERO out-of-network coverage. What a disgraceful bait-and-switch.

 

[redduck]

Kaiser Permanente doesn't cover skin tag removal at all. Mine were noted in the record, but I was told removing it would be cosmetic rather than medical. They're happy to give you a list of clinics/dermatologists that will take care of it for you - on your own dime.

I'm ok with that.

I think the location of skin tags or 'barnacles' is a factor. I had barnacles on my face and got a referral.

I imagine location may be a factor, but another factor is if it's a medical necessity. So, if your skin tags sometimes cause you pain or discomfort (let's say when you put on a shirt) or they bleed (even a little teeny tiny bit) you should be able to get them removed as it is considered a medical condition.

 

[rodi]

My husband is still fighting bills for his mother's big adventure last year. She has dementia but two of her sons were driving her to her grand daughters wedding. She had a panic attack and tried to hurl herself from a car... In the middle of no where, in a state that no family lived in. She was taken to the small podunk county hospital by ambulance, then transferred to a larger metro area hospital. (She'd fractured a spine section.)

The podunk hospital is still sending bills and finally, 2 months ago, agreed to submit to the secondary insurance - after being asked after every bill sent... It's looking like that one is finally settled out - 10 months later. The larger hospital had it more together - it only took 6 months to get them to bill the secondary insurance.

My husband spends at least 5 hours/month fighting the bills for his mother - because the providers seem incapable of accurate billing, billing the secondary provider, etc... He's gotten fairly adept at knowing who to call and what to look for on the bills. His mother could not handle it at all - even without dementia....

 

[Walt34]

I changed to Blue Cross/ Blue Shield this year and they told me that I should be able to get that information from them. I'll see.

Only once did I have an issue with BCBS billing incorrectly and that was straightened out with one phone call. Perhaps that is the rarity and not normality. Clearly, others have had less-than-positive experiences. That said I am given to understand that BCBS is not one entity, but a series of different insurance companies operating in somewhat loose formation. This could account for the wide disparity of outcomes for different people and areas.

 

[rodi]

Only once did I have an issue with BCBS billing incorrectly and that was straightened out with one phone call. Perhaps that is the rarity and not normality. Clearly, others have had less-than-positive experiences. That said I am given to understand that BCBS is not one entity, but a series of different insurance companies operating in somewhat loose formation. This could account for the wide disparity of outcomes for different people and areas.

I think you're right about the variation among BCBS. Here in CA the BCBS company is Anthem.... I've heard very mixed reviews...

 

[MRG]

Only once did I have an issue with BCBS billing incorrectly and that was straightened out with one phone call. Perhaps that is the rarity and not normality. Clearly, others have had less-than-positive experiences. That said I am given to understand that BCBS is not one entity, but a series of different insurance companies operating in somewhat loose formation. This could account for the wide disparity of outcomes for different people and areas.

That describes them as I know them. When I w*rked Megacorp sold software in that space. I'd met with several of the blue's technology folks to discuss system requirements, naturally a discussion of their technology stack and integration followed. As I recall most had different stacks with different 3rd party systems to supply functionality that (individual) blue bought rather than build.

It was funny to watch the true salesman. They wanted to believe as soon as they sold the first blue the rest would just follow along. Wasn't how it seemed to work.

 

[redduck]

It seems as if only a very few people posting in this thread actually got shafted by their doctors, labs and hospitals regarding ridiculously high fees. Lawman (the OP) never returned to the thread, so we don't have enough info. Trawler (post 35) got jerked around for sure and I think there has to be more to Flyboy 5's story (post29). But, mostly the outrageous charges turned out to be just interesting anecdotes (as long as you had insurance).

 

[travelover]

It seems as if only a very few people posting in this thread actually got shafted by their doctors, labs and hospitals regarding ridiculously high fees. Lawman (the OP) never returned to the thread, so we don't have enough info. Trawler (post 35) got jerked around for sure and I think there has to be more to Flyboy 5's story (post29). But, mostly the outrageous charges turned out to be just interesting anecdotes (as long as you had insurance).

For me, it is stressful having to worry about this possibility every time I have any medical care. Granted the outrageous stories are rare enough that people are not in the streets, but it is a very real, but unnecessary problem.

 

[athena53]

For me, it is stressful having to worry about this possibility every time I have any medical care. Granted the outrageous stories are rare enough that people are not in the streets, but it is a very real, but unnecessary problem.

I agree. I am SO thankful that my health issues are mostly dealing with the occasional preventative things. No other professional services that I know of are so mysterious about costs. We've had some expensive work done to our house since we bought it last year. In no case did we ever just agree in advance to pay whatever they billed us. Nor did I have to estimate the cost of our new porch enclosure by calling the factory to get the cost of the panels, getting an estimate from the architect, calling the guys who installed it to ask what they'd charge, etc. We even got competitive bids when replacing our furnace and A/C. Radical, huh?

And, while I'm in a position where blowing through my deductible would hurt (heck, DH and I could fly to Europe in Business Class with that money), there are more people out there who'd be destroyed financially if they had to fork over the whole deductible amount. So yes, it IS stressful.

 

[Options]

The single best way of engaging in cost-conscious, self-managed care is to minimize your probability of needing it as much as possible. This comes down to diet and exercise management:

The World May Have Too Much Food - Bloomberg

The past 40 years have seen an unprecedented increase in the number of obese adults worldwide, climbing to about 640 million from 105 million in 1975. If the current trend continues, about one-fifth of adults will be obese by 2025.

A person who has a body-mass index higher than 30, or weighs at least 203 pounds and is 5-foot-9-inches tall, is considered obese. The world population’s average weight has increased by about 3.3 pounds (1.5 kilograms) per decade since 1975, the researchers estimate. Excess weight raises the risk of diabetes, heart disease, and other chronic conditions.

Governments need to prepare for the jump in medical costs that accompany unhealthy weight and focus on prevention now to avoid higher costs in the future, said Bill Dietz, director of the Sumner M. Redstone Global Center for Prevention and Wellness at George Washington University. “They should be as nervous as a cat on a hot tin roof about the tsunami of diabetes that’s coming their way,” Dietz said. “The cost of this rise in the prevalence of obesity is going to be staggering.”

 

[ziggy29]

The single best way of engaging in cost-conscious, self-managed care is to minimize your probability of needing it as much as possible. This comes down to diet and exercise management

(link deleted)

I love that it says someone who is 5'9" and 203 is obese. We should all be obese as former NFL running back LaDainian Tomlinson, who was 5'10" and 216 officially, and unofficially over 220.

 

[travelover]

Consumers Union is actively working to stop these surprise out of network bills. Article here includes some steps to take if you have been hit with an out of network charge.

What to do if you get a surprise out-of-network bill

There's no guarantee that any of these steps will work, but you won't know unless you try. In order, you should:

• Call the out-of-network doctor and ask for the bill to be lowered.
• Contact your insurance company, tell it about the problem, and ask if it will use its influence with the doctor.
• Contact your state insurance department and tell it your problem. Some states have consumer ombudsmen specifically assigned to help. "Even if they can't provide an immediate solution, every insurance department needs to be aware consumers are facing this issue," Hutson said.
• Share your story with us. It may help to vent, and we use these stories to demonstrate to lawmakers and regulators how the problem is affecting real people.

One can also sign a petition sponsored by CU here.

 

[Options]

I love that it says someone who is 5'9" and 203 is obese. We should all be obese as former NFL running back LaDainian Tomlinson, who was 5'10" and 216 officially, and unofficially over 220.

I don't think they were referring to NFL running backs.

The main takeaway? Excess weight has become a far bigger global health problem than weighing too little. While low body weight is still a substantial health risk for parts of Africa and South Asia, being too heavy is a much more common hazard around the globe.

 

[ziggy29]

I don't think they were referring to NFL running backs.

True. But when someone only uses a height/weight chart to define obesity or someone's BMI, they should know the limitations of it.

 

[athena53]

The single best way of engaging in cost-conscious, self-managed care is to minimize your probability of needing it as much as possible. This comes down to diet and exercise management.

Boy, did I tick off a friend on FB awhile ago when she posted a stupid meme saying that the reason health insurance cost so much was the exorbitant salaries of insurance company CEOs. I responded that the costs of obesity are far higher-one Harvard study estimated $1.5 billion per year and that was 2009. She got really defensive.

Last night she posted from an ice cream place where she and her BF had gone for dessert after having pizza somewhere else.

I had to sit on my hands to keep from typing a reply.

It doesn't solve the cost transparency issue, though. Those of us who, through luck and discipline, are healthy, still have to deal with preventative testing and the occasional accident or disease that can strike anyone.

 

[M Paquette]

I love that it says someone who is 5'9" and 203 is obese. We should all be obese as former NFL running back LaDainian Tomlinson, who was 5'10" and 216 officially, and unofficially over 220.

If the hypothetical 5'9" 203 lb person conducts the same physical training as Tomlinson they likely are quite healthy. If, on the other hand, they conduct the same physical training as the typical 5'9" 203 lb person (lift and press that remote, feel the burn...) yeah, they're obese.

Weight/height estimation of health are a first order screening tool. More accurate measurement of body composition can be paid for by any person the initial screen calls overweight or obese, of course. But the typical 5'9" 203 lb person likely knows that would be a waste of money in their own case.


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[athena53]

Dream with me here for a minute, people.


In my early years in the actuarial field (late 1970s), we were constantly being frustrated because we KNEW what data went into the computer, but the Keepers of the Data insisted that there was no way to get it back out again except in their canned reports. This frustration led to actuaries being generally the first to get a "minicomputer" in their department and get some of the first laptops. We finally just sucked all the data in and took charge of it. (Or, as one colleague used to say, "Just gimme the da*n data".)


Nearly every doc has a computer at his/her fingertips during an office visit. They have to, with the new laws requiring automation of healthcare data. Imagine the doc typing on the computer and saying, "well, I can prescribe Isoveltrex and your copayment would be $50 a month with your insurance, or I could prescribe Oomphimexx and you can get it for $3 at Wal-Mart for 30 days, but I've found people tend to get more stomach upset. What are your thoughts?" Or, I'd like to do a test to rule out arthritis and it will cost $500 with your insurance."


The data exists. It's just in multiple computers and multiple systems. We'd have to get many people, including competitors, playing nice together.


But wouldn't it be worth it?

 

[meierlde]

Dream with me here for a minute, people.


In my early years in the actuarial field (late 1970s), we were constantly being frustrated because we KNEW what data went into the computer, but the Keepers of the Data insisted that there was no way to get it back out again except in their canned reports. This frustration led to actuaries being generally the first to get a "minicomputer" in their department and get some of the first laptops. We finally just sucked all the data in and took charge of it. (Or, as one colleague used to say, "Just gimme the da*n data".)


Nearly every doc has a computer at his/her fingertips during an office visit. They have to, with the new laws requiring automation of healthcare data. Imagine the doc typing on the computer and saying, "well, I can prescribe Isoveltrex and your copayment would be $50 a month with your insurance, or I could prescribe Oomphimexx and you can get it for $3 at Wal-Mart for 30 days, but I've found people tend to get more stomach upset. What are your thoughts?" Or, I'd like to do a test to rule out arthritis and it will cost $500 with your insurance."


The data exists. It's just in multiple computers and multiple systems. We'd have to get many people, including competitors, playing nice together.


But wouldn't it be worth it?

for at least prescriptions it could also be checked on someones smart phone, as most pharmacy benefit managers tend to have that online, in particular they like to show you how much you would save by getting your drugs thru their mail order outfit.
Actually if the info was consolidated anyone with a smart phone could login to their insurance companies site, and given the procedure code and the provider be told what the cost would be with no complications.
No need for the physician to do the checking.