Fun with health care billing (RANT)

[Puckstop31]

My primary care DR chose the Allergist,
not me. Why would they pick an out of network provider? Seems
to me they made the error, & they should therefore cover the bill.

How is it their responsibility to pick a provider that is covered by YOUR insurance?

Ill give you that maybe they SHOULD care.... But only from a good customer service point of view.


I think we can see one of the causes of high health care costs here.... Nobody questions anything with their doctor it seems, especially when it comes to payment. "Somebody else" pays it, so who cares? Until, of course, "I" have to pay it and not "somebody else".

[Lady's Human]

Puck, perhaps it's like the health care provider I use......99.9% of their docs are covered under my ins. plan as the big umbrella "charitable" org that runs they system is normally completely covered by my ins., however, particularly if there's a new specialist involved, they might not be in the PPO list. I only get a PPO list once a year, and I'm fairly certain the list changes more often than that.

[lizbud]

Puck, perhaps it's like the health care provider I use......99.9% of their docs are covered under my ins. plan as the big umbrella "charitable" org that runs they system is normally completely covered by my ins., however, particularly if there's a new specialist involved, they might not be in the PPO list. I only get a PPO list once a year, and I'm fairly certain the list changes more often than that.

You're right LH, that's how it works. My primary care Dr works for the (my)Insurance group.

[Grace]

My primary care Dr works for the (my)Insurance group.

That's how it is for me, also. And my private insurance is excellent. When I need a referral, they never go out of network unless it's absolutely necessary. They're very aware of the insurance coverage problems.

Considering the 'network' consists of physicians in a major med school, we're pretty much assured of quality care without having to leave.

[Puckstop31]

Puck, perhaps it's like the health care provider I use......99.9% of their docs are covered under my ins. plan as the big umbrella "charitable" org that runs they system is normally completely covered by my ins., however, particularly if there's a new specialist involved, they might not be in the PPO list. I only get a PPO list once a year, and I'm fairly certain the list changes more often than that.

Perhaps it is? How does that make it the responsibility of the provider to ensure that a referral participates in the patients insurance plan?

We use the Lancaster General system as our provider... Every provider we see is part of that umbrella. I still always check when we have to see a new provider (mostly for Hannah's vision needs), just to be sure.

I'm not trying to start a ruckus. (Really ) I simply wish people paid more attention to what this stuff costs, even if the insurance company is paying the bill directly. I think Liz's shock at having to pay for something is an example of assuming the provider worries about such things. Thats all....

[Lady's Human]

Puck, it is most certainly the provider's responsibility when they make a statement that "Hospital/Care group A is now 100% PPO's for Insurance Plan B"

Then you get a bill from said insurance plan for the aforementioned group that, surprise surprise, there's a Doc within the care provider's group who is NOT a PPO for your health plan.

Not my fault, it's called false advertising in any other field. In healthcare, it's called too bad, you owe us.

[Puckstop31]

Puck, it is most certainly the provider's responsibility when they make a statement that "Hospital/Care group A is now 100% PPO's for Insurance Plan B"

OK... So the provider said that... They told the consumer, right?

Then you get a bill from said insurance plan for the aforementioned group that, surprise surprise, there's a Doc within the care provider's group who is NOT a PPO for your health plan.

Not my fault, it's called false advertising in any other field. In healthcare, it's called too bad, you owe us.

I reckon this might sound harsh and I can certainly see how less than honest providers might take advantage of people who would not understand the system... But, "let the buyer beware".

OR, to put it another way... IMO, the only real way we can get the cost of healthcare to become more reasonable, short of draconian regulation by governments that would just cause the quality of care to go down, is for the consumer to question EVERYthing. "Why does service X cost such and such. I called provider B and they will do it for x...." Even if your health plan will cover it, question the costs anyway. Its what we did when Tanya was pregnant. I had to pay for all of her care out of my pocket. We shopped around and found a WAY better provider that cost more than 50% less than the "big" women's hospital here. Better care for a lot less money.

In Liz's case... Yes, her doctor said use Allergist X. Why not look for other Allergists? I don't take a mechanics word as gold when my car needs fixed, I shop it around.... In non-emergency instances of health care, why not do the same?

[Lady's Human]

Puck, easy for you to say.

However, when the best docs in the area work for a provider with less than ethical practices, but they're shielded by the bureaucracy.........

The buyer CAN'T beware.

You keep making excuses for the businesses who are operating on the fringes of the law. I'd expect a slightly different response form you, frankly. Look, I'm an intelligent person, and I cannot figure out how their billing system works, and frankly, don't have the time to spend to do so. Again, anywhere but healthcare, they're in court for false advertising, doing business under false pretenses, and a host of other issues. But because they're a charitable org. doing healthcare, it's all good, and you're defending them? I just cannot for a second see how those are ethical business practices.

[Puckstop31]

Puck, easy for you to say.

However, when the best docs in the area work for a provider with less than ethical practices, but they're shielded by the bureaucracy.........

The buyer CAN'T beware.

You keep making excuses for the businesses who are operating on the fringes of the law. I'd expect a slightly different response form you, frankly. Look, I'm an intelligent person, and I cannot figure out how their billing system works, and frankly, don't have the time to spend to do so. Again, anywhere but healthcare, they're in court for false advertising, doing business under false pretenses, and a host of other issues. But because they're a charitable org. doing healthcare, it's all good, and you're defending them? I just cannot for a second see how those are ethical business practices.

I did not say it was ethical, nor was I trying to imply that Liz was wrong for being upset... I know that the industry has a lot (a LOT) of holes in it. All the more reason to ask a lot of questions and to NEVER take their word on anything.

I am NOT defending them. Its sucks and we all know it. We deal with vendors who try to pull fast ones ALL the time. I run a small business dude.... I know how these games get played.

What is the answer though? MORE laws? A government monopoly in the health care business? How does that help make care more affordable or of a higher quality? Because that is what I want... I want the individual consumer (and their families) to be more involved in the process of their care.


I see how this can devolve into reasoning for more central control of businesses... Be careful what you wish for.

[RICHARD]

It's a big enough umbrella, but it's always me that ends up getting wet.

-Sting




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The way that a hospital/HMO bills is not exactly kosher.

When I did the stats for the Operating Room, they billed a surgery based on pre-packaged surgery kits they ordered from a sugery supply company.

There has been a trend to go ahead and to try and pre pack a 'kit' that takes care of most of the trends for a particular surgery.

For example?

An appendectomy surgery kit will contain all the items needed for a "standard" surgery. By packaging all the items into a standard kit, they eliminate the need to pull individual items for that surgery.

In essence it becomes a One-Size-Fits-All kit.

The patient is charged for everything in that kit.

Even if it is not used. There are many things that go into the trash, taken home or stashed for another surgery.

Other times kits are cannibalized for parts and the missing parts are taken off the shelf - to complete the kit - and the patient is charged for a total kit.

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In the 'old days' billing was done on a per item basis, Now billing is done by computer and everytime a hospital stay goes into a data base, the patient is charged based on an average of the items used/given.

The reason? Stocking the items used and stafffing costs.

It's far easier to charge based on an average rather than costing out a stay based on EXACTLY what a patient uses/needs.