Ugh, health insurance networks.

We have truly excellent health insurance through the PPO plan at the hospital my wife works at and if we have services within the tier 1 network the costs are negligible even for extended hospital stays.

Well it is all my fault but we got zapped for $800 by using a surgery center that is in a building right next to the hospital but not in the tier 1 network. We have used up out fairly low out of pocket maximum for the tier 1 network so if she had minor foot surgery at the hospital itself it would have cost us zero. The confusion for me was that her doctor/surgeon are in the tier 1 network but not the surgery center he uses which is covered as in the tier 2 BCBS network. I should have asked or looked into it myself.

At least I learned this before I schedule my colonoscopy this fall which I will do at the hospital and not at my GI doctor's office who now has their own on site facility.

Bottom line is that it pays to double check everything and anything you are going to have done health wise to make sure you are maximizing benefits with your health insurance company. The doctor's office may say that your insurance covers you but you want to find out exactly what network tier they are in and also realize that what they use for labs, surgery, imaging, referrals, etc may not be in the same network tier.

This can also apply during a hospital stay. In 2012 I was in the hospital for a week due to very high fever caused by unknown infectious disease and the infectious disease specialist doctor in my network sent my numerous lab workups to a DIFFERENT HOSPITAL. We got lab bills for several thousands of dollars. When we questioned it the hospital and doctor apologized saying that should not had happened and we ended up paying our tier 1 network for the labs that amounted to a few hundred dollars.

I have been on both sides. Being a patient is bad enough without having to navigate the byzantine system of healthcare. Even when you work in the field there are problems such as this. Hospitals, the government and insurance companies dictate most of this foolishness. It is about money not care.

Having said that, doctors often set up their own centers not just for revenue but for having appropriate patient care. A good friend who is an anesthesiologist set up his own surgery center so he could make the appropriate calls, not a hospital bureaucrat. Depending on the contractual agreement, the surgery center could offer to charge you the same amount as the hospital.

If you have ever had a CAT scan or MRI at a freestanding center you know what I am talking about. Scheduled appointments, no waiting, coffee in the lobby and out in less than an hour. Hospital schedule is be there at 5:00 am to fill out paperwork, sit around for six hours with a full bladder, and get in the mile long line. Whole day is gone and two weeks for the results.

 
If you are on Medicare, beware if you are asked to sign an "ABN" (advanced benefit notification). It means basically that Medicare will not cover this procedure, and subsequently, your complement/supplement coverage will not touch it either. Many times it is due to the person ordering the procedure keyed in the wrong code, so go back there and try to get it corrected first, otherwise you may be on the rack for some charges.
 

quote:

Originally posted by ZSMICHAEL:
I have been on both sides. Being a patient is bad enough without having to navigate the byzantine system of healthcare. Even when you work in the field there are problems such as this. Hospitals, the government and insurance companies dictate most of this foolishness. It is about money not care.

Having said that, doctors often set up their own centers not just for revenue but for having appropriate patient care. A good friend who is an anesthesiologist set up his own surgery center so he could make the appropriate calls, not a hospital bureaucrat. Depending on the contractual agreement, the surgery center could offer to charge you the same amount as the hospital.

If you have ever had a CAT scan or MRI at a freestanding center you know what I am talking about. Scheduled appointments, no waiting, coffee in the lobby and out in less than an hour. Hospital schedule is be there at 5:00 am to fill out paperwork, sit around for six hours with a full bladder, and get in the mile long line. Whole day is gone and two weeks for the results.

Interesting about the CT scan. My doctor office moved to a new facility and they now do CT/MRI and at a much better price than the hospital. I talked to my oncologist about using it and he was fine with it as long as they got access to my last CT scan so a comparison can be done. He said in some cases I may need to get and bring them a DVD of my last one. I have to say that getting it done at my hospital has always been a good experience where I am done within half an hour of my scheduled time. Typically I get results from my doctor within 2-3 days. The one time I had a CT scan for a more urgent matter I got the results within 3 hours.

We will never have "affordable" healthcare in this country without some controls on the insurance companies. As it is now, whether it is Obamacare or Trumpcare, they get to decide how much they are going to charge, as well how much they are going to pay out. What a deal ! Of course it will never change, as long as they continue to be major contributors to the politicians.

quote:

We will never have "affordable" healthcare in this country without some controls on the insurance companies.

+1

Simple solution is to remove insurance companies from the pricing decision. Doctors, hospitals, clinics charge what they want but one & the same price for everyone. This is how it was before HMO's, PPO's & assO's got involved.

quote:

Originally posted by Anush:

quote:

We will never have "affordable" healthcare in this country without some controls on the insurance companies.

+1

Simple solution is to remove insurance companies from the pricing decision. Doctors, hospitals, clinics charge what they want but one & the same price for everyone. This is how it was before HMO's, PPO's & assO's got involved.

Yes. That must be the solution. Make it illegal for people to freely enter into contracts or form associations that do so on their behalf.

I'm going to give you the benefit of the doubt and assume that you just don't know what you're talking about, rather than the other option - that you're a fucking socialist.

No time to give a long explanation this evening, but I'll be happy to educate you in the morning if others haven't jumped in by then.

-Rob

quote:

Originally posted by henryaz:
 
If you are on Medicare, beware if you are asked to sign an "ABN" (advanced benefit notification). It means basically that Medicare will not cover this procedure, and subsequently, your complement/supplement coverage will not touch it either. Many times it is due to the person ordering the procedure keyed in the wrong code, so go back there and try to get it corrected first, otherwise you may be on the rack for some charges.
 

Lab Corp in Tucson zapped me for $400 in blood testing by my signing a mandatory waiver form requiring me to pay for procedure if Insurance failed to pay.

Of course Lab Corp fucked up the paper work by entering the wrong code to Insurance Co. I told Lab Corp to simply correct code input and they said they couldn't do it, saying it was my responsibility.

I told them where to go and called my insurance provider to explain screw up.

That was in 2005 and I never heard from Lab Corp again. Of course I never went back, either.

quote:

That must be the solution. Make it illegal for people to freely enter into contracts or form associations that do so on their behalf.

I'm going to be halfway between him and you.

People should be free to enter into contracts or associations. But if you're going to offer your products or services to the public, there should be "a price".

I can't charge an Asian person more or less because they're Asian. I can't charge a Male more or less because they aren't female. So why can the medical community charge 30 different prices, for the exact same product/service, based on who you are?

When I go into a store milk is the same price for everyone. When I go to a movie, it's the same price for everyone. When I go to my mechanic I'm paying the same hourly rate that everyone else pays. There are some minor deviations. Sometimes there's a senior discount, or a bulk rate. Even then, it's still in the "ball park". It's not $5 for you, and $150 for the next guy.

I don't care what a medical provider charges. I just want to know upfront what it is, and to know that generally everybody else gets the same deal. I think it's BS that the medical providers can essentially toss a dart at a board with random prices and then bill you that amount.

quote:

I'm going to give you the benefit of the doubt and assume that you just don't know what you're talking about, rather than the other option - that you're a fucking socialist.

No time to give a long explanation this evening, but I'll be happy to educate you in the morning if others haven't jumped in by then.

Wow! and coming from a Burton cousin too! A doctor told me that BlueCross/BlueShield is so dominant in TN that his clinic can not charge anyone less than BC/BS pays, or they will lose BC/BS per contract as a payer. Is that a free market, or a monopoly?

quote:

Originally posted by Anush:
A doctor told me that BlueCross/BlueShield is so dominant in TN that his clinic can not charge anyone less than BC/BS pays, or they will lose BC/BS per contract as a payer. Is that a free market, or a monopoly?

Neither - that is a contractual term. Fairly standard "most favored nations" clause...found in lots of commercial contracts.

quote:

Originally posted by Anush:

quote:

I'm going to give you the benefit of the doubt and assume that you just don't know what you're talking about, rather than the other option - that you're a fucking socialist.

No time to give a long explanation this evening, but I'll be happy to educate you in the morning if others haven't jumped in by then.

Wow! and coming from a Burton cousin too! A doctor told me that BlueCross/BlueShield is so dominant in TN that his clinic can not charge anyone less than BC/BS pays, or they will lose BC/BS per contract as a payer. Is that a free market, or a monopoly?

Interesting. Here in Illinois BCBS is huge too but my doctor office also has cash prices too, at least for some things. I heard the dialogue between a patient and front desk about it.

quote:

Originally posted by Anush:

quote:

I'm going to give you the benefit of the doubt and assume that you just don't know what you're talking about, rather than the other option - that you're a fucking socialist.

No time to give a long explanation this evening, but I'll be happy to educate you in the morning if others haven't jumped in by then.

Wow! and coming from a Burton cousin too! A doctor told me that BlueCross/BlueShield is so dominant in TN that his clinic can not charge anyone less than BC/BS pays, or they will lose BC/BS per contract as a payer. Is that a free market, or a monopoly?

By definition, unless BC/BS has some sort of artificially elevated bargaining position (think government interference like w/ labor unions & NLRB, etc.), then it's obviously the result of BC/BS leveraging it's size to make sure it's getting the best deal.

Sounds more like an oligarchy to me, assuming BC/BS isn't the only insurer in TN, but that can also be the result of free market forces.

The good news is that BC/BS is a third party in this equation and not the provider of services. At some point, BC/BS pays X for service Y or the providers stop providing. BC/BS TN goes out of business because there are no doctors and everyone has to leave the state to receive any kind of health care. In the meantime, everyone essentially has the opportunity to bargain down to the lowest price for service Y, which because of BC/BS size, has already been done for them.

Insurers who pay providers more than X will out of necessity charge more in premiums, which makes them less competitive - unless there are other factors that come into play. Perhaps they cater to a different risk pool that demands different services. Perhaps they run more efficiently than BC/BS and can mitigate against higher reimbursement rates vs. premiums in that way.

There are a lot of factors that come into play here, but it's an absurdly myopic view to lay this mess at the feet of insurers. They're only acting in their own best interest, as should the providers, as should the patients.

The real question is where this artificial market started? How does BC/BS know where to begin negotiating its contract?

I hate to break it to you - or your doctor friend - but CMS is the big fish. CMS sets the baseline for reimbursement. There will be no truly free market in health care (aside from concierge practices, of course) until/unless the federal government gets out of the game completely. Abolish CMS and wait for the sea change.

-Rob

The real issue is transparency. Ask any of the medical providers how much it is going to cost for a procedure and try to get a straight answer.

You will not get one, and if you try to shop around beforehand, well good luck.

Change the system so that people can make informed decisions and health care costs should go down.

quote:

Originally posted by bwl5:
The real issue is transparency. Ask any of the medical providers how much it is going to cost for a procedure and try to get a straight answer.

You will not get one, and if you try to shop around beforehand, well good luck.

Change the system so that people can make informed decisions and health care costs should go down.

I would certainly be in favor of state-level statutes/regulations/etc. (because it should all be state level) requiring medical providers of any kind to publish their cash price for services.

Of course, that won't solve too many problems, really. The fee schedule would still have to be listed per ICD-10 codes and most people would still have a hard time figuring that out. If there's an easier alternative, I can't figure it out.

Or would cash patients' treatment have absolutely no connection to current billing standards at all? That could create a hell of a lot of work for the providers, depending on what we're talking about.

Simple office visits? Probably doable. Anything interventional? Likely much more difficult.

-Rob

quote:

Originally posted by bwl5:
The real issue is transparency. Ask any of the medical providers how much it is going to cost for a procedure and try to get a straight answer.

You will not get one, and if you try to shop around beforehand, well good luck.

Change the system so that people can make informed decisions and health care costs should go down.

That's really the key. There's no competition. Consumers cannot compare prices, so there's no incentive to compete.

quote:

I hate to break it to you - or your doctor friend - but CMS is the big fish. CMS sets the baseline for reimbursement. There will be no truly free market in health care (aside from concierge practices, of course) until/unless the federal government gets out of the game completely. Abolish CMS and wait for the sea change

Yes. CMS is a major problem. Not only in pricing but also in dictating standards of care, and pushing the idea of "evidence based care." Under new guidelines physicians will be compensated based upon a checklist, rather than for procedures performed. Physicians are now filling out computer checklists, and spending less time interacting with patients.

quote:

Originally posted by NK402:
We will never have "affordable" healthcare in this country without some controls on the insurance companies. As it is now, whether it is Obamacare or Trumpcare, they get to decide how much they are going to charge, as well how much they are going to pay out. What a deal ! Of course it will never change, as long as they continue to be major contributors to the politicians.

Mouth full well said and well said mouth full. I have had my Ins. Co. dictate to me three or four times which medication they wanted me to use and which Blood Glucose monitor they wanted me to use. I get ill just thinking about it.

quote:

Originally posted by GWbiker:

quote:

Originally posted by henryaz:
 
If you are on Medicare, beware if you are asked to sign an "ABN" (advanced benefit notification). It means basically that Medicare will not cover this procedure, and subsequently, your complement/supplement coverage will not touch it either. Many times it is due to the person ordering the procedure keyed in the wrong code, so go back there and try to get it corrected first, otherwise you may be on the rack for some charges.
 

Lab Corp in Tucson zapped me for $400 in blood testing by my signing a mandatory waiver form requiring me to pay for procedure if Insurance failed to pay.

Of course Lab Corp fucked up the paper work by entering the wrong code to Insurance Co. I told Lab Corp to simply correct code input and they said they couldn't do it, saying it was my responsibility.

I told them where to go and called my insurance provider to explain screw up.

That was in 2005 and I never heard from Lab Corp again. Of course I never went back, either.

I learned my lesson the hard way, too. The ABN is presented to you before the procedure. The first time I saw one, I didn't understand the implications of it, and had to do like you and deal with the billing department, which is typically unwilling to budge since they have the "code". At a later date, for lab work, I was presented with an ABN and simply refused to have the blood drawn. I walked back across the street to the clinic and talked to the nurse who ordered the procedure. She found a more precise billing code that did not result in an ABN.