Crazy health care surprise... glad I have insurance

[gmoney]

Going to a new doc who wanted to run some detailed blood work on me... they took about a quart and a half it seemed and sent it off. I received no warning as to the cost of the tests.

I just got a statement from my insurance co showing 24 separate tests (3 pages), and the "Total charged" for the bloodwork was $5,023.68!!

Now, the crazy/fortunate part is that my insurance "repriced" the tests to... $289.54 -- more than I particularly wanted to pay, but only 5.7% of the "original" amount. The $5,023 does not go towards my deductible, only the $289, but I'd be willing to bet the $5,023 counts against my max lifetime benefit.

What kind of system has 94% "wiggle room" between retail and wholesale prices? One test had a 97.6% markdown from repricing ($377 to $9.22).

This indicates that the system is broken, and the pricing is all some fantastical "aim for the stars" racket. Does someone ever actually PAY these list prices? Does MEDICARE or MEDICAID pay retail?

I'm also told that if I were to walk into the lab, say that *I* wanted these tests performed (not on doctor's orders) it would cost dramatically less than going through my doctor. Maybe not 94% less, but it would be within the realm of reality. How fucked is that?

Again, I'm pleased to be "only" on the hook for $289, but this is another symptom of our health care problems, and I don't hear many people addressing it.

[HereSince1628]

1. Could it be that they take it as a business loss?

Thus creating near $5K of loss to use against earnings?

Jes wonder'n

[gmoney]

2. Could be...

the RW talking point is that health insurers "only have a profit margin of 2 or 3 percent" -- that may be one way to keep reported profits low?

[matt819]

3. The people who pay this?

If you didn't have insurance, you'd be on the hook for the full amount. And therein lies the utter obscenity of the health care system.

And if the hospital wants to come after you, then you'd be one of the increasingly number of Americans declaring bankruptcy due to medical care costs.

The other poster raises an interesting point. How do the hospitals account for these transactions and what impact does that have on profitability, shareholder value, taxation, etc.

[pitohui]

21. dirty little secret -- the uninsured subsidize health care for the insured

if you are uninsured and have a house, sooner or later, these thieves will get it from you

it went to trial many years ago in louisiana, where an uninsured lady was charged $30K for a procedure that costs the insured $3K

the court ruled in favor of the hospital and they got the lady's house

they might as well have just gone ahead and let her die because she was too old to start over

[truedelphi]

30. people in Marin County are fighting things like this

An insured person gets one high priced bill from the Marin General Hospital business office; the uninsured another.

And the other thing, having been uninsured now and again - you are treated like scum for being uninsured. Even though often you're required to pay in cash, and to pay the significantly higher prices!

[frazzled]

4. This is why published rates are part of the health care bill, I think

I recall reading that hospitals and labs will have to publish their rates for standard procedures so that consumers will have some comparative ideas. I don't have the exact part of the bill that deals with this, so I'll have to double-check that.

It would be best, of course, if the government could set standard rates in various markets (I assume it's more expensive to do things in some areas than in others), but this could be a start to more transparency as well as cost reductions. Of course everyone will go to the lab that charges $289 rather than $5,023.

I had to have foot x-rays a few years ago. It took five minutes or so and I carried the x-rays back to my foot doctor's office, as he requested. So there was no analyst's fee: the doctor himself was looking for the bone problem. My bill for these two x-rays amounted to about $800. I had to pay that as part of my deductible, in full. That's when we decided to switch to the HMO plan (which would have covered it all) rather than the PPO we currently had under the same insurer for my husband's employer. Curiously, the HMO, which uses the same doctors and labs as far as I have encountered so far, has lower premiums and no deductibles.

[Warpy]

5. I'm making an educated guess here

but I'm guessing the hospital unbundled the tests in order to pad the bill. I've caught hospitals trying to pull that shit on me and I've turned them in for trying it.

There are some tests that are run by machine and run as a whole panel of tests, so charging for them individually makes no sense except to pad the bill. Examples are liver function, thyroid function, basic metabolic panel, complete metabolic panel, and basic blood count. Unbundling them says they drew them one at a time and ran them one at a time and this is just not the case.

Some exotic immune panels can get costly, but it seems that only unbundling a lot of routine labs could possibly have generated 3 pages of charges. If you'd been a private pay patient with no medical knowledge, you'd have been stuck. The insurance company is wise to that trick, so that's why their payment was so much less.

[gmoney]

10. It wasn't a hospital situation with me.

But maybe my new doc or the lab is playing games?

[safeinOhio]

12. Ask the doc to use a different lab

and have your insurer recommend a lab for all of your work.

[Warpy]

19. Could be the lab

In any case, your insurance company seems to have spotted it.

[laughingliberal]

25. Right. I just posted down thread: unbundling of lab tests was the basis for the conviction of HCA

for the biggest case of Medicare fraud in history.

[tularetom]

6. Medicare definitely does NOT pay retail

If had a lot of medical bills in the past six months in conjunction with cataract surgery in both eyes, so I've received a lot of documentation from both Medicare and the supplemental insurance company.

Medicare immediately disallows a hefty portion of the amount billed. For example, the surgeon billed them $2,500 for his work on one eye. They threw out roughly $1,800 of it. Of the remaining balance they paid about $560 and the supplement paid $140.

If I'm calculating correctly in my head that's 72% disallowed and 80% of the remaining 28% paid by Medicare.

Wonder if that's any indication of what medical professionals would charge if I had no insurance.

[mmonk]

8. No. They put the rate high so that they can be reimbursed

at a rate they can operate by.

[SoCalDem]

13. Probably not these days.. Remember how doctors used to function?

Maybe you are too young to know this, but doctors used to "hang out their shingle" at a rather hum-drum office..often a converted house or rather mundane office in a strip mall.. They had a person..ONE PERSON.... at the counter.. she (it was always a woman..possibly even his wife).. She scheduled appointments, took phone calls and did the billing. He had a nurse..ONE NURSE..she took blood samples and they did basic analysis right there in the office..for things like UTIs..

In the early 80's, I took all three of my boys to the pediatrician and never paid more than $45.00 for the visit, which often INCLUDED any shots they needed... a prescription for Benadryl or some other cold med would usually be about $10, and the amount was always enough to treat all 3 (they always got sick together)...

We had 80-20 coverage...with a $5K family deductible at that time, and we just put all the receipts in an envelope and sent them off at the end of every month.. The insurance co sent us a monthly statement, showing how close we were to the deductible, and a check for 80% of what we had spent (once the deductible was met).. It was not tricky..

(disclaimer..we always had our deductible met early, since our oldest spent weeks and weeks in the hospital every year)

There were NOT the massive clinics we now have, and doctors were in business for themselves, so there was real competition..

[tularetom]

27. I can top that - I played sports in HS and had to get a physical every year

My mom would take me to the doctor for this "fog up the mirror" type physical and it was exactly as you describe, in the downstairs of a two story house, except the nurse was also the receptionist. When we were done, my mom would pay the doctor, IN CASH, for the cost of the visit. And after I got my driver's license I drove myself one year and paid the receptionist/nurse for the physical, $5.

One time I stepped on a rusty nail and went in for a tetanus shot and it took 5 minutes, 15 minutes for the same doc to burn a wart off the back of my hand.

And we had no insurance. I'm not even sure there WAS such a thing.

So yes, I'm old enough to remember this. I graduated from HS in 1959, so this had to be back in the mid to late fifties.

The care, I'm sure, is equal to or better than it was then, but the process sucks by comparison.

[SoCalDem]

28. In my high school, the doctor came TO the school and gave the jocks their physicals

FREE!

[Pithlet]

29. Your first example, of how doctors use to be? That is exactly how my doctor's office is.

I remember thinking it was odd the first time I went there. I've since gotten used to it and I rather like it now.

[dysfunctional press]

14. "Wonder if that's any indication of what medical professionals would charge if I had no insurance."

yes, it is.
i had several simple procedures when i was uninsured, and the bills were astronomical.

[gtar100]

7. I get billed by these labs and doctors for the difference between what the insurance company pays

and what they charge. It's absolutely disgraceful on the part of the medical community to do this. I've been charged $150 to $200 just for an office visit - that's after my $25 co-pay and what the insurance company paid. The insurance company refused to pay the exorbitant prices so they turned it back on me.

My office visit was a matter of taking my blood pressure and temperature, listening to my breathing, looking in my ears and nose and telling me I had a nasty virus and possibly a sinus infection (no tests to confirm). I left with a piece of paper for some prescription drugs and the clinic was done. That was 15 minutes of service for $200. The doctor was with me for about 5 minutes. What makes them think they are worth $800 an hour?!!

And, by the way, no one said a word about this extreme cost to me. I asked if they took my insurance, they said yes. I paid my co-pay and that should be the end of it, right? Nope.

[havocmom]

9. They don't think they are worth $800 an hour. They do have to pay for all the office workers

Takes payroll hours to jump through all the different hoops of all the different Insurance Vampires. THAT is a big chunk of all our bills for 'health care'.

[gtar100]

11. haha - Rube Goldberg hard at work!

[havocmom]

20. Check out how many MDs have thrown in the towel

Why? They aren't making a living comiserate with their education and hours if they have a private practice. They have to hire more staff to do paperwork. Not more MEDICAL staff, more clerical staff. That is not health care enhancement.

If they work as employees in big corporate clinics, they don't get to 'practice' medicine, they just have to herd people through to rack up billing units for the boss.

Get rid of the hoard of insurance vampires, with their varied maze of paperwork and the $$ going to HEALTH CARE can be spent on health care.

Go to single payer. It is the ONLY way we will really get health care functioning for the population.

[gtar100]

23. I agree. Single payer is the *only* correct solution to the problem.

Profit on health care is immoral and a damning judgment on the values of American society. Doctors, nurses and their supporting staff, on the other hand, do deserve to make a very good living based on their contribution to the well-being of people. Can't say how that could be measured but it is they, not the insurance industry, that deserve to do well. I didn't mean to come down on them as much as the profiteers who work the system, which does sometimes include those who call themselves 'doctors' these days. But we need healers and they should be revered. Given our population numbers, it's become essential we all pool together to make a working system. The meme about needing "competition" to make everything right is only another symptom of the stranglehold that capitalism has on our mindset. Sometimes cooperation is far more effective and when it comes to the basic necessities of life, which includes health care near the top of the list, it's a matter of our collective survival.

[Paper Roses]

32. My daughter is a Doctor. She tells me the horror stories of

dealing with Medicare and insurance companies. (Never tells me about any patient stuff).

Whether the Doc in the office spends 15 minutes of 2 hours with a patient, Medicare reimburses them $96.00. Try running a practice--all that overhead-- on that. Most of her patients are elderly. Some have other insurance, but many have only Medicare.

If you ask me, and this has nothing to do with my daughter, the Medicare reimbursement to Doctors is very inadequate. Just the staff required to handle the mountains of paperwork costs a fortune. They are buried with insurance forms and other paperwork. Time also spent doing the referral thing, calls to pharmacies for prescriptions, countless jobs you might not think too much about. Medicare thinks it is all worth $96.00.

The problems we blame on the Doc's should really be blamed mostly on the labs, big Pharma, Hospitals etc.

Just my opinion.

[laughingliberal]

26. I'd check with my insurance company first

This could have changed but most do not allow deficiency billing. IOW a provider contracts with them to provide services for a particular rate and they are not allowed to bill the difference between the contracted rate and their regular rate to the patient outside your co-pay or percentage you are responsible for. May not be the case with your policy but it's worth a phone call to clarify.

[TreasonousBastard]

15. Quite few have, including Obama, but they've been...

drowned out by the shrieking masses from teabaggers who don't want any change to single payer advocates and the like who will only accept their version of change.

It is possible that the medical practice owns the lab, or has some interest in it, and came up with that outrageous pricing for some additional profit.

You might note that it was the evil, bloodsucking insurance company that saved you all that money, even if they didn't have to. (and, yes, it could be to their advantage eventually, but they still saved you thousands)

[grasswire]

16. time for a SPECIAL PROSECUTOR

This is obviously a RICO matter. Send in the U.S. Marshals to seize the books and the computers. There is a giant racket being perpetrated on citizens, and perpetrated DOUBLY. First, a citizen is taxed for Medicare. And then the citizen is gouged and victimized by fraud.

This is criminal!! Stand up, America!!

[davsand]

17. That is called a "negotiated rate."

What your insurance actually pays is usually less than what the clinics and hospitals bill. They refer to that as a "negotiated rate" between your insurance company and the hospital or clinic that billed it. Essentially, your insurance has gotten you a "deal" on that service.

There is a "chargemaster" that sets a standard for what stuff should cost. That is supposed to be adjusted for location, (however, I couldn't BEGIN to explain it because I don't understand fully how it all works...) and that is used by Medicare and other programs to determine what amount gets paid for services. From what I understand, the rates charged any given insurance company will probably be higher than what government programs pay.

If you want to consider something really f***ed up, a lot of hospitals will bill the uninsured MORE than anyone else in an attempt to make up the shortfalls.



Laura

[seleff]

18. Received an unexpected bill yesterday

In July I had rotator cuff surgery after a prolonged attempt to avoid it through physical therapy. Of course there was needed PT after surgery, all of which was prescribed by the surgeon. I have a PPO and tried to get info up front from my insurer regarding how much PT they would agree was medically necessary. No dice, all I could do was follow Dr's an d the PTs advice and submit for coverage. Although i still have limited use and pain with some movements with my shoulder, I stopped going to the PT the day my prescription ran out, and i chose not to push the surgeon into writing another script, which i and my PT believed that i would greatly benefit from. Months have passed and i now received a bill from my PT's office that coverage for the last 5-6 visits were denied and that I owe $1150. The office is asking for $600 as a courtesy. This happened also in January of 09 when I was doing PT after an ultrasound guided aspiration of a cyst that wsa causing the shoulder trouble. It is so aggravating to be told that you have coverage and then for someone in the insurers office randomly deny coverage for no reason that I will ever get explanation for. The PT's office is not encouraging regarding winning an appeal as they say they have been through two rounds of appeals already.

This stuff has happened to us probably 10 times for different reasons in the past 5 yrs. My experience is that they figure you won't fight. Sometimes we have and won, sometimes its been more time and effort wasted. And often it is time wasted at work when their offices are open.

[NNN0LHI]

22. Who is going to draw and analyze blood WITHOUT a doctor's orders?

Do some places do that?

Am I missing something here?

Don

[laughingliberal]

24. Part of the scheme that got HCA convicted of the biggest Medicare fraud in history

involved the 'unbundling' of lab tests. Your post reminded me of that.

[upi402]

31. "What kind of system has 94% 'wiggle room' "

I think the mafia is green with envy.

[Vinca]

33. If I - an uninsured person - had the same tests,

I would be on the hook for the whole $5,000+. Your "wiggle room" story is why health costs are so high. The provider bills, big insurance tells them what percentage they'll pay and the provider agrees. Next time around, the provider has already jacked up the price so he'll do better on the percentage. Eventually, big insurance renegotiates the numbers, the provider raises the rates yet again, and so it goes. It's been "going" since the 1960's and it's finally landed in hell.

[dkf]

34. Yup the pricing is out of whack with reality.

Which goes to show there's a scam in there somewhere that is completely unexposed and unfixed.