A few years ago, my wife's previous primary care physician gave up her practice rather than deal with ObamaCare.

Wife went to a new primary care doc. He was rather brusque, seemed a bit disorganized, did not address a couple of questions that she asked.

The doc told her she needed a shingles shot. My wife did not question this and she did get the shot.

Shortly thereafter she received a bill from the practice for the shot: Five Hundred Dollars!

I was in Publix yesterday, at the pharmacy to pick up a prescription. There was a sign on the counter announcing the availability of shingles shots. I asked the pharmacist what the cost was, self-pay, no insurance. Two shots, at forty-seven bucks each.

Needless to say, my wife will not be using that doctor again.

There's always going to be a huge difference between "charge" and "payment" whether you are on Medicare or some commercial insurance, so you're getting amped up about apples and oranges unless you are actually uninsured. A base fee schedule of 3-5X Medicare is completely normal, hospitals usually closer to 10X.

If you ARE uninsured, you already know you have to get pricing before you have anything done. If you're insured/covered in any way I suspect there is zero chance your doctor is actually billing you a balance due of $500, is there?

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Originally posted by Georgeair:
There's always going to be a huge difference between "charge" and "payment" whether you are on Medicare or some commercial insurance, so you're getting amped up about apples and oranges unless you are actually uninsured. A base fee schedule of 3-5X Medicare is completely normal, hospitals usually closer to 10X.

If you ARE uninsured, you already know you have to get pricing before you have anything done. If you're insured/covered in any way I suspect there is zero chance your doctor is actually billing you a balance due of $500, is there?

Per the doctor's office, everything else for that visit was covered by insurance, but the shingles shot was NOT covered. The bill was for Five Hundred Bucks for that shot. My wife went back to the office, asked them to verify, she was told yes, that was what she actually owed. She paid it.

As I said, I asked the Publix pharmacist what the cost of the shot would be at Publix if it was self-pay. Forty seven bucks.

As far as asking about cost in advance, yes, I always do that. My wife did not ask in this case, but she will in the future.

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There's always going to be a huge difference between "charge" and "payment"

And that's one of the biggest problems with our healthcare system. There needs to be a "price". This isn't some third world bodega. We should know what the cost is, and that cost should be reasonably similar to the cost that others pay for the same service.

She on Medicare Part D? Does not sound right. Typically Medicare drug plans cover the majority of the cost of Shingrex. Unlike other vaccines I believe it is under Part D, not Part B. If you have a Medicare Advantage plan it may be a different story.

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Originally posted by ZSMICHAEL:
She on Medicare Part D? Does not sound right. Typically Medicare drug plans cover the majority of the cost of Shingrex. Unlike other vaccines I believe it is under Part D, not Part B. If you have a Medicare Advantage plan it may be a different story.

Office was adamant in their statement that this was NOT covered by Part D Rx, nor by Part B, nor by United HealthCare supplement.

I did not get involved, she handles her own health care, but it sounds like a pure (outrageous) profit item to me. She paid it. Had it been me, I would have raised hell.

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And that's one of the biggest problems with our healthcare system. There needs to be a "price". This isn't some third world bodega. We should know what the cost is, and that cost should be reasonably similar to the cost that others pay for the same service.

+1

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Office was adamant in their statement that this was NOT covered by Part D Rx, nor by Part B, nor by United HealthCare supplement.

I am acquainted with Medical billing. Since it is five hundred bucks I would call the insurer and appeal the denial. Folks here in Mississippi have copays of around 68 dollars for each injection at the pharmacy with a prescription from an MD. That is with Part D Medicare. Good luck.

Sounds fishy enough that I wouldn’t stop investigating yet.

1) Check EOBs for all coverages for what was billed vs paid.

2) Obtain a properly coded billing statement from the doc. He should be using ICD-10 by now and be able to provide you with the statement on a CMS 1450 or 1500 form.

See if he turns white when you throw those terms around. Tell him you’re going to try to resubmit the bill yourself for reimbursement. If he balls, file a written complaint with your state licensing board and CMS.

CMS hates billing fraud and loves to audit.

-Rob

This is what happens when we let .gov get in between service/goods providers and the consumers.

Free market and health care in the USA need to be reacquainted.

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Originally posted by a1abdj:

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There's always going to be a huge difference between "charge" and "payment"

And that's one of the biggest problems with our healthcare system. There needs to be a "price". This isn't some third world bodega. We should know what the cost is, and that cost should be reasonably similar to the cost that others pay for the same service.

Amen. Preach it brother. I get peeved I have to check Goodrx everytime I get a scrip refilled. I don't expect the price to be exactly the same everywhere but 2 and 3 times difference is inexcusable.

Reminds me of Sage Dental, I'm sure you've sen them as they're all around here. Always recommending work that coincidentally is never covered under insurance. I said I wanted a cleaning and they said they couldn't do it because I had too severe of buildup. I would need a deep cleaning and that would require a different set of antibiotics, blah blah blah. I passed and went to my regular dentist and it was covered under my 1 cleaning annually.

The $47 you were quoted sounds like a Med D copay, not self pay. I’ve seen that copay with AARP Med D and Essence Part D. I can’t remember the out of pocket cost for Shingrix, but it’s well over that, at least at Walgreens. You mentioned United Health. If that is the medical plan (vs prescription) the office should be able to bill them. If it truly is only a Medicare supplement, then I don’t think they can.

WOW sorry to hear that. Lesson learned though a relatively expensive one. Lab charges can be outrageous too if one is not careful and checking up front what coverage is and at what tier.

Unless this doctor's office was in Beverly Hills and you drove up in a Rolls Royce, I think the office should have been clear and gotten confirmation from your wife that she is willing to accept the $500 charge.

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Originally posted by Krazeehorse:

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Originally posted by a1abdj:

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There's always going to be a huge difference between "charge" and "payment"

And that's one of the biggest problems with our healthcare system. There needs to be a "price". This isn't some third world bodega. We should know what the cost is, and that cost should be reasonably similar to the cost that others pay for the same service.

Amen. Preach it brother. I get peeved I have to check Goodrx everytime I get a scrip refilled. I don't expect the price to be exactly the same everywhere but 2 and 3 times difference is inexcusable.

I am familiar with medical billing as well, and in the medical billing/insurance world, there is something called “U&C”. Usual and customary pricing, meaning you can’t change the price you charge depending on whether or not it goes to insurance- it must be the same price for everyone. The closest I think one can get to skirting that is to offer a “TOS” time of service discount, to be paid in full at the time of service if you don’t have insurance - and know your provider has a contract with each ins company that obliges them to bill insurance if the patient has insurance- they can’t pick and choose who to bill, and who not. But that U&C is just within that organization. One would think there would be a universal pricing policy on vaccinations and drugs for all.

That a pharmacy would have such a drastically different price than the Dr’s office is a whole nother question, and I know it’s just a vaccine, but I’d feel more comfortable with a nurse giving me an injection, rather than a pharmacy tech? I can’t imagine a pharmacist spends a lot of time giving shots and I question whether a tech has the formal training. Maybe I’m completely wrong here, but I know that various vaccines need to be adminstered in various locations and ways (sq, im, etc), and the training to know the difference makes a difference.
I guess my ignorance must be showing- the only capacity I’ve seen pharmacists in is formulating and compounding drugs, nuclear pharm, etc. not actually administering them. Huh.

ETA: I stand corrected. Apparently pharmacists now give injections, too. Good grief, I think they’d have better things to do..like making sure my meds are right, lol!

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I am familiar with medical billing as well, and in the medical billing/insurance world, there is something called “U&C”. Usual and customary pricing, meaning you can’t change the price you charge depending on whether or not it goes to insurance- it must be the same price for everyone.

I can assure you this isn't the case in real life. I may pay X if I have insurance with company A, X.5 if I have insurance with company B, or 7X if I don't have insurance at all.

If what you're saying is that the "price" is the same for everybody, but the examples shown above demonstrate "discounts", well then we're just playing word games.

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That a pharmacy would have such a drastically different price than the Dr’s office is a whole nother question,

One that I have no problem with. If provider A wants to charge $10 and provider B wants to charge $1,000, I think that is fine. I think both need to be upfront with their prices, and both need to charge all of their customers the same. Provider B shouldn't be charging some people $250 and others $1,000 for the exact same product/service. There are of course exceptions, but it shouldn't be the mess we experience today.

Give the doctor a shit review on google maps, yelp and any other site.

I let a private CT scan provider take me to court over a $30 upcharge after I had paid in full for their services.

They claimed that the price they quoted my insurance company did not account for an unexpected higher cost for the dye at the time of service and my part would be higher after I paid.

The judge just laughed at them and told the idiot attorney stupid enough to take me to court that the collection on my credit better be off by the end of the business day.

Yes, they have a shit review that no matter how much they demand I take down stays.

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Originally posted by a1abdj:

quote:

There's always going to be a huge difference between "charge" and "payment"

And that's one of the biggest problems with our healthcare system. There needs to be a "price". This isn't some third world bodega. We should know what the cost is, and that cost should be reasonably similar to the cost that others pay for the same service.

Insurance companies pay one price. Medical pay another price. Paying with credit cards will get you one price while paying by cash will get you a different price. Visitors to this country also have another price.

Sometimes I think some doctors in this country are nothing more than just crooks. While a small portion uphold the oath that they took to the very end. A very small portion.

I got the first of two Shingrix shingles shots at my pharmacy several weeks ago. My UHC Plan N insurance covered the full cost. It’ll cover the second shot too. Without insurance, both shots are expensive.

Oddly, my GP recommended getting it at a pharmacy, rather than at the clinic – dunno why…