Sorry but another healthcare costs rant acomin'... (1 Viewer)

[efil4stnias]

Sorry to hear about your impending bankruptcy. And your achillies -- that too.

You know, when V Chip posted this back in March I chuckled because I thought "no way".

As most of you know, I tore my achilles tendon in March. Had surgery in April to repair. One of my factors in opting for surgery was the out of pocket costs i would incur having the surgery.

So I called my healthcare provider to find out exactly what my policy would cover. I had a $2000 deductible and then 50% co pay for "outpatient surgery" IN NETWORK. My Orthopedic surgeon was "in network". So on 3 separate occasions, my wife ( who takes wonderful notes when speaking to folks in cases like this ) and my self both spoke with the Surgeons asst. who handles the scheduling to get a pretty good idea of what the surgery will ultimately cost so we can determine what WE would pay for.

Surgeon cost - $2528 ( spot on)
Anesthesia - $1200 ( pretty close - $1340 )
Outpatient room charge ( at facility ) - $3000 ( This is where it comes off the rails )

So based on what my health insurance would pay, i would be out of pocket about $4000. Manageable. So we scheduled the surgery. I arrived at the facility at 6:30, filled out ppwk, gave them my health insurance card and waited approx 30 min to be called back. Just before being called back my wife was asked to pay $3042.70. We figured they already calculated what we would owe based on my health insurance. I was prepped for approx 45 min, Surgery took all of 32 min and i spent another 90 or so min in recovery. I was released to go home before noon.

Last night I received a "summary of account" by my healthcare provider. It shows that the Outpatient Facility was OUT OF NETWORK. Therefore, they are not paying them a dime. Furthermore, the Facility charged my healthcare provider $12,171. Thats right. $12,171. That is a looong way off from the $3000 we were told back in March on 3 separate occasions. I called my provider and they explained all of this. They also explained that under my "deductible" there was a $2006.63 charge....this charge is what THEY determined to be a FAIR charge for the facility based on MEDICARE standards. But because this Facility was OUT OF NETWORK for ME, they can basically charge WHATEVER they feel like charging me and I AM GOING TO BE RESPONSIBLE for this.

I plan on making some calls this am. First to my surgeon then to this Facility. I have no problem paying $3-4000 for the service. I have already paid them $3042. I just dont see how this is even legal.

I want to know how my surgeon can be IN NETWORK, yet perform his surgery at a place that is OUT OF NETWORK when his office AND the facility both had my health insurance info and yet never ONCE advise me that the Facility is going to be considered OUT OF NETWORK AND NOT COVERED.

Im so effn mad that im past mad ( if that makes sense ) im rather calm since I realize any yelling, screaming and/or cursing will get me nowhere fast.

 

[zeetes]

ahh yes, health care woes. if you have peoples health, they just dropped a lot of doctors and a few clinics etc.

we are currently fighting with bluecross over an "out of network" test and it is the third (maybe fourth?) time in the last year we've had to appeal a denial/partial payment.

this time is for a specialized cancer diagnosis test, which is supposed to help pinpoint the best course of action and treatment, and is only conducted by one lab in the united states. my wife couldn't even have the test performed the first time she was diagnosed because by their guidelines, it is generally unnecessary. anyway, it was approved by bcbs when she was re-diagnosed, but by the time it went to billing has since been denied, appealed, determined that it is out of network (even though by our own policy that states, and confirmed by a rep, that if it is a test only performed out of network, then it is treated as if it is in network). we are currently in the appealment process yet again.

 

[dtc]

You know, when V Chip posted this back in March I chuckled because I thought "no way".

As most of you know, I tore my achilles tendon in March. Had surgery in April to repair. One of my factors in opting for surgery was the out of pocket costs i would incur having the surgery.

So I called my healthcare provider to find out exactly what my policy would cover. I had a $2000 deductible and then 50% co pay for "outpatient surgery" IN NETWORK. My Orthopedic surgeon was "in network". So on 3 separate occasions, my wife ( who takes wonderful notes when speaking to folks in cases like this ) and my self both spoke with the Surgeons asst. who handles the scheduling to get a pretty good idea of what the surgery will ultimately cost so we can determine what WE would pay for.

Surgeon cost - $2528 ( spot on)
Anesthesia - $1200 ( pretty close - $1340 )
Outpatient room charge ( at facility ) - $3000 ( This is where it comes off the rails )

So based on what my health insurance would pay, i would be out of pocket about $4000. Manageable. So we scheduled the surgery. I arrived at the facility at 6:30, filled out ppwk, gave them my health insurance card and waited approx 30 min to be called back. Just before being called back my wife was asked to pay $3042.70. We figured they already calculated what we would owe based on my health insurance. I was prepped for approx 45 min, Surgery took all of 32 min and i spent another 90 or so min in recovery. I was released to go home before noon.

Last night I received a "summary of account" by my healthcare provider. It shows that the Outpatient Facility was OUT OF NETWORK. Therefore, they are not paying them a dime. Furthermore, the Facility charged my healthcare provider $12,171. Thats right. $12,171. That is a looong way off from the $3000 we were told back in March on 3 separate occasions. I called my provider and they explained all of this. They also explained that under my "deductible" there was a $2006.63 charge....this charge is what THEY determined to be a FAIR charge for the facility based on MEDICARE standards. But because this Facility was OUT OF NETWORK for ME, they can basically charge WHATEVER they feel like charging me and I AM GOING TO BE RESPONSIBLE for this.

I plan on making some calls this am. First to my surgeon then to this Facility. I have no problem paying $3-4000 for the service. I have already paid them $3042. I just dont see how this is even legal.

I want to know how my surgeon can be IN NETWORK, yet perform his surgery at a place that is OUT OF NETWORK when his office AND the facility both had my health insurance info and yet never ONCE advise me that the Facility is going to be considered OUT OF NETWORK AND NOT COVERED.

Im so effn mad that im past mad ( if that makes sense ) im rather calm since I realize any yelling, screaming and/or cursing will get me nowhere fast.

The whole freaking thing is a giant scam. It's set up and designed to screw the patient and maximize income for the doctors and providers. It's impossible to understand or navigate the myriad billing intricacies unless you're a medical billing pro and it's the result of decades of refusal to do anything about it. Legislatures and government are sold to the highest bidder and that's the providers and insurance companies rather than the patients.

Good luck and just be thankful it wasn't something expensive like cancer or heart surgery.

Everybody hates the lawyers, but a couple hundred mass tort suits against providers for deceptive billing practices and malfeasance in their estimates of cost might be good if they wouldn't just jack up prices further to cover it.

 

[efil4stnias]

ahh yes, health care woes. if you have peoples health, they just dropped a lot of doctors and a few clinics etc.

we are currently fighting with bluecross over an "out of network" test and it is the third (maybe fourth?) time in the last year we've had to appeal a denial/partial payment.

this time is for a specialized cancer diagnosis test, which is supposed to help pinpoint the best course of action and treatment, and is only conducted by one lab in the united states. my wife couldn't even have the test performed the first time she was diagnosed because by their guidelines, it is generally unnecessary. anyway, it was approved by bcbs when she was re-diagnosed, but by the time it went to billing has since been denied, appealed, determined that it is out of network (even though by our own policy that states, and confirmed by a rep, that if it is a test only performed out of network, then it is treated as if it is in network). we are currently in the appealment process yet again.

Im sorry you are having to deal with that.

I cannot fathom having to deal with the stresses of just the diagnosis and then top that off with having to deal with the stress of medical bills/will or wont my health insurance pay for this or that.
I am a firm believer that the mind plays a large role in many instances for recovery. There is no way folks in your position can carry a clear mind to focus on recovery when dealing with unnecessary external factors like EFFN MEDICAL BILLIN/COVERAGE.

Its a shame. it truly is and I hope that your wife keeps a positive attitude ( as do you ) and makes a full recovery.

 

[RazorOye]

EFFN MEDICAL BILLIN/COVERAGE.

This thread reminded me of a post over at reddit from someone who works in the industry. A long, but topical read, I think.

here's the article that spurned the comment:

One hospital charges $8,000 and another charges $38,000

and here's the comment:

badengineer comments on One hospital charges $8,000 - another, $38,000: for the first time, medicare has released the average costs of the 100 most common procedures at different hospitals

I work for a major medical center doing business stuff, so I'm at least aware of how the various hospitals in my state are doing, how pricing works and what the market dynamics are. There are a few things that should be pointed out....

First, you're right. The charge rate certainly doesn't correlate to quality metrics.

The charge rate listed in the data (available as an 11MB excel file at CMS.gov) has nothing to do with anything. It's not a real price. It doesn't correlate to the price anyone pays except for the extremely rare millionaire who doesn't have insurance. Medicare doesn't pay it, 95% of uninsured people can't pay it, insurance companies don't pay it.

It's primarily a negotiating trick, with some accounting tricks thrown in for good measure.

People need to understand how pricing works, because it's the cancer at the heart of healthcare.

At any given hospital, there are a hundred different prices for any given procedure. Medicare and Medicaid pay all hospitals the same amount for Procedure X. Most hospitals lose 20% (or more) on that Medicare price and make it up on the private companies.

Every single private health insurance company pays a different price, very often 150% of what Medicare is paying. Each plan negotiates prices all on its own, in secret. They have no idea what other insurance companies pay. It's in no one's interest to share that price. It hurts hospitals' future negotiations if their lowest negotiated price is public and it hurts payers negotiations if it gets out that they overpay some hospitals.

The hospital says "X costs us $50K, Y costs $60K, $Z costs $20K."

The insurance company they're negotiating with says "we normally pay $25K, $35K and $9K for those procedures. How about we give you 50% of your charge rate?"

The hospital says "OK".

As a result, at a single hospital there can literally be 100 plans paying different prices for your gall bladder removal. Multiply that by 3,000 hospitals in the country. There are maybe 3,000,000 different prices for that surgery out there. All completely secret. You can imagine how that might create problems.

So basically, this charge rate is nothing more than a bit of insight into a hospital's chosen negotiating tactics. They either price high and discount a lot, or price low and discount a little.

Uninsured people are screwed no matter what. If you're uninsured and land in the hospital, you're likely going bankrupt. It's almost irrelevant whether it's a $200K bill or a $100K bill. You're going bankrupt. You might think this pricing was designed to extract money from that uninsured population, but hospitals get so little money from them that most don't think about trying to squeeze them more using this charge rate. A vast majority of that care is just written off.

If the charge rate doesn't correlate to real prices, it definitely doesn't correlate to quality. There's very often an inverse relationship between cost and quality to begin with. Medical errors are expensive and the places that reduce them save a ton of cash in lawsuits, readmissions (in cases where they're penalized for them), etc. For example, we're an awesome hospital you've heard of, but some organ transplants cost 35% less at the best-of-the-best place, because they do it so frickin' well. That's real cost. Not fake charge book cost. Usually, the better the care, the cheaper it is.

The odd thing about this story is that it isn't new. Dartmouth Health Atlas has been publishing similar data for decades. It's great to see it being covered, because it's insane and a clear symptom of a deeper problem, but I was surprised to see it on the front page of the Times.

And every time I write something about this, I have to add: neither insurance companies nor hospitals are (on the whole) getting particularly rich off of this. As crazy as it sounds, this is not the result of unusual greed or a morally corrupt industry. It's a historical artifact more than anything. Non-profit hospitals (which is almost all of them) earn an average of 2.5% operating margin and that's shrinking. I dunno about for-profit hospitals, but they're still not raking it in like people think they are. Health insurance plans earn more like 3.5% on average. If you chart the most profitable sectors of the economy, that puts them pretty far down the list. Drug companies, in comparison, are deep into double digit margins.

Of course, that's relatively small profit on a truly mind-boggling amount of money (17% of the american economy) so it has a gigantic effect. It also tends to concentrate a lot of pain on people who can't afford to pay it.

Anyway, that low profit margin gets at why no one breaks out and tries to be more transparent. A tiny downtick in your reimbursement rates will sink you. As our contracting guy says, last time our main payer got slightly miffed and decided to throw some business across town, we laid off 500 people the next year.

This is just how the system works. It's not a conspiracy. It's a perfect example of how a a bad system forces a bunch of rational actors to do absolutely bat**** crazy things. Everyone could stand to earn and do a lot more if things were rationalized and we did away with this system of invisible prices. That's the tragedy of the commons for you.

All hospitals and insurers are forced to play this game. Whether that's a big 100-facility for-profit chain, a gigantic charity-oriented catholic system, an academic research center or your community hospital. This is how money moves in the system. Any real fix stands to hurt so many players that it's pretty unlikely we'll see change from a political standpoint. I'm kind of hoping the whole thing just collapses under it's own weight and something better can arise from the ashes.

 

[efil4stnias]

The whole freaking thing is a giant scam. It's set up and designed to screw the patient and maximize income for the doctors and providers. It's impossible to understand or navigate the myriad billing intricacies unless you're a medical billing pro and it's the result of decades of refusal to do anything about it. Legislatures and government are sold to the highest bidder and that's the providers and insurance companies rather than the patients.

Good luck and just be thankful it wasn't something expensive like cancer or heart surgery.

Everybody hates the lawyers, but a couple hundred mass tort suits against providers for deceptive billing practices and malfeasance in their estimates of cost might be good if they wouldn't just jack up prices further to cover it.

D,

thats it.

I have already told my wife that if we do not get resolution to this, I will call my attny and start proceedings. I truly dont want to because my surgeon is not only a really nice guy, he is really good at what he does. Yet he will be drug thru the muck, well because thats what attorneys do. He isnt the target. Its this Facility. Thats where my true anger lies (with). The fact that they can bill with NO ITEMIZATION is beyond nuts.

I am truly blessed in that I have the means to pay this. But my thought process went immediately to "what if I made $80,000/ yr....this would certainly break me". And there are COUNTLESS numbers of families in that income range. This fight isnt just for me....but for those that may not have the means/wherewithall to fight this.

Again, im hopeful that the Facility bill to my insurer was just their way of attempting to get as much as they can and when they see it denied, they will just say "ok we tried...lol" and accept my $3042 as sufficient payment. But I just dont think it will go down this way.

Something has to give. Like i said, i am hopeful a few phone calls will lead to an amicable resolution. But if it doesnt, then just as Wyatt said on the train platform in Tombstone "tell em Im comin...and hells comin with me".

 

[zeetes]

The whole freaking thing is a giant scam. It's set up and designed to screw the patient and maximize income for the doctors and providers. It's impossible to understand or navigate the myriad billing intricacies unless you're a medical billing pro and it's the result of decades of refusal to do anything about it. Legislatures and government are sold to the highest bidder and that's the providers and insurance companies rather than the patients.

Good luck and just be thankful it wasn't something expensive like cancer or heart surgery.

Everybody hates the lawyers, but a couple hundred mass tort suits against providers for deceptive billing practices and malfeasance in their estimates of cost might be good if they wouldn't just jack up prices further to cover it.

yep.

Im sorry you are having to deal with that.

I cannot fathom having to deal with the stresses of just the diagnosis and then top that off with having to deal with the stress of medical bills/will or wont my health insurance pay for this or that.
I am a firm believer that the mind plays a large role in many instances for recovery. There is no way folks in your position can carry a clear mind to focus on recovery when dealing with unnecessary external factors like EFFN MEDICAL BILLIN/COVERAGE.

Its a shame. it truly is and I hope that your wife keeps a positive attitude ( as do you ) and makes a full recovery.

thanks, though i know it could probably be heart-attack inducing to come home and open a 12k bill. we (she especially) have a very good support network, even from antipop and wdf. the prognosis is very positive and as cliche as it sounds, we just go by a day at a time. she is so much stronger than i am because i wouldn't be able to cope with it.

as for healthcare, like dtc said, it is one giant scam. what will be covered once, even twice, may not be covered the third time. my mother-in-law works as a claims reviewer for one of the insurance companies, so it hasn't been too bad for filing the appeals. we mostly let her expose the bs for us it is just the pain in the *** of having to file the appeals.

i would totally appeal the 12k bill. i wouldn't even hesitate to get in touch with someone because chances are, the first few people you speak to will either be clueless or not willing to help. i've learned not to blame them so much since they are generally following procedures.

 

[efil4stnias]

This thread reminded me of a post over at reddit from someone who works in the industry. A long, but topical read, I think.

here's the article that spurned the comment:

One hospital charges $8,000 and another charges $38,000

and here's the comment:

badengineer comments on One hospital charges $8,000 - another, $38,000: for the first time, medicare has released the average costs of the 100 most common procedures at different hospitals

oye

saw that last week here where someone posted the link to CMS.gov for the MEDICARE costs.

what gets me is that these costs are for Hospitals. Facilities that have enormous amounts of overhead costs.

Im speaking about an "outpaitent surgery facility"- owned by a several of Docs ( this particular one is owned, in part, by the ANESTHESIOLOGIST that administered my Anesthesia - so not only is he charging for his service, he owns the doggone facility! ) - a facility that is designed for lower-end surgeries that do not require the "hospital" setting due to their relative "less dangerous" aspects. This one is prolly 4000 sq ft. probably $400,000 to build, another $300,000 to outfit and Voila!, they are in business. Charging Hospital rates, yet carrying 1/5 of Hospital costs.

 

[RazorOye]

oye

saw that last week here where someone posted the link to CMS.gov for the MEDICARE costs.

what gets me is that these costs are for Hospitals. Facilities that have enormous amounts of overhead costs.

Im speaking about an "outpaitent surgery facility"- owned by a several of Docs ( this particular one is owned, in part, by the ANESTHESIOLOGIST that administered my Anesthesia - so not only is he charging for his service, he owns the doggone facility! ) - a facility that is designed for lower-end surgeries that do not require the "hospital" setting due to their relative "less dangerous" aspects. This one is prolly 4000 sq ft. probably $400,000 to build, another $300,000 to outfit and Voila!, they are in business. Charging Hospital rates, yet carrying 1/5 of Hospital costs.

ah... sorry about that

thanks for the clarification

 

[zeetes]

oye

saw that last week here where someone posted the link to CMS.gov for the MEDICARE costs.

what gets me is that these costs are for Hospitals. Facilities that have enormous amounts of overhead costs.

Im speaking about an "outpaitent surgery facility"- owned by a several of Docs ( this particular one is owned, in part, by the ANESTHESIOLOGIST that administered my Anesthesia - so not only is he charging for his service, he owns the doggone facility! ) - a facility that is designed for lower-end surgeries that do not require the "hospital" setting due to their relative "less dangerous" aspects. This one is prolly 4000 sq ft. probably $400,000 to build, another $300,000 to outfit and Voila!, they are in business. Charging Hospital rates, yet carrying 1/5 of Hospital costs.

ahh my wife was billed separately from the louisiana anesthesiology group or something for her last surgery. that reminds me, i've been meaning to look into whether or not he works for the hospital as well.

 

[Doug5984]

I got food poisoning in Las Vegas and that was my first real hospital experience. I learned from this mistake- I'm not going back to a Dr unless I'm on death's door. It's sad that it has come to this in our society. That I pay $X / month just to be able to pay the hospital a few grand in the off chance I have to go in for a few hours just once.

 

[V Chip]

Sorry for Predicting!

Seriously though, the reason it is a little funny is because there is a big grain of truth to it. There are many hands grabbing into a pot of potential cash trying to get as much of it as they can while trying to remain as concealed as possible and maintaining the tiniest bit of plausible deniability to be able to say "sorry, it's not MY fault." But it is. It definitely is the fault of all of them.

This is anathema to all the free market fundamentalists, but this is an area where we all would be better off taking the idea of making a profit out of the equation altogether.

It's also anathema to the "less government/less regulations" ideologues but it's also an area that would benefit from strict regulations on pricing and the requirement that all prices be public and agreed to up front, as well as regulations regarding providers owning and operating side ventures (like the facility you mentioned, or imaging facilities, or other profit-making ventures) that get business steered to them by the very doctors who own them.

 

[Norwajun]

I just had total knee replacement surgery. For the surgery and a 2 day hospital stay the bill was over $76000. And that doesn't include the surgeon's fees. My total out of pocket so far is somewhere around $2000.00. The insurance company (BCBS of Texas) has paid about $19k. I'm sweating bullets right now because Louisiana does not have a law against balance billing for out of network providers. I made damn sure everyone was in network well before my surgery date, but there is always that one forgotten detail...

 

[BuffaloSaint]

I tried to get an accurate number before I went in for surgery to get a cyst taken off of my vocal cord. I was unable. It didn't hit me too bad though I think it ended up being about 2k out of pocket with another 1.5k kicked in by the insurance. Met my deductible for the first time in 6 years though so my chiropractor visits are only costing 18 dollars now. I'd be curious what the man hours wasted on arguing between insurance companies and the medical industry is in any given year.

 

[efil4stnias]

Sorry for Predicting!

Seriously though, the reason it is a little funny is because there is a big grain of truth to it. There are many hands grabbing into a pot of potential cash trying to get as much of it as they can while trying to remain as concealed as possible and maintaining the tiniest bit of plausible deniability to be able to say "sorry, it's not MY fault." But it is. It definitely is the fault of all of them.

This is anathema to all the free market fundamentalists, but this is an area where we all would be better off taking the idea of making a profit out of the equation altogether.

It's also anathema to the "less government/less regulations" ideologues but it's also an area that would benefit from strict regulations on pricing and the requirement that all prices be public and agreed to up front, as well as regulations regarding providers owning and operating side ventures (like the facility you mentioned, or imaging facilities, or other profit-making ventures) that get business steered to them by the very doctors who own them.

and that plausible deniability ( which i have heard now twice...once from insurer and now from dr office ) - Its up to you to make sure that every aspect of your services are IN NETWORK- YET neither my DR NOR Insurer ( both of whom i had spoken with a few times PRIOR to surgery ) EVER mentioned this to me. So it stood to reason that if my Surgeon was IN NETWORK, the place he performed his surgery WOULD BE TOO!

I just had total knee replacement surgery. For the surgery and a 2 day hospital stay the bill was over $76000. And that doesn't include the surgeon's fees. My total out of pocket so far is somewhere around $2000.00. The insurance company (BCBS of Texas) has paid about $19k. I'm sweating bullets right now because Louisiana does not have a law against balance billing for out of network providers. I made damn sure everyone was in network well before my surgery date, but there is always that one forgotten detail...

This was my first exp with any sort of "major medical procedure" ever. I will know going fwd for sure, but I would expect, at the very least, that the Dr. should either remind/advise patient or give the patient some sort of notification that just because he is IN NETWORK doesnt mean the place where the surgery will be performed is. Something. Anything. This is totally misleading.