Fun with health care billing (RANT)

[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.

[Bonny]

A person wonders if they couldn't just run off a copy of what they have done & the cost right then & there for the patient? Then you would have what you need to fight the insurance companies. They seem to get the itemized list instead of us.

Then they could also get you mixed up with someone else & send their bill to you or vice versa.

I was told you have to be your advocate but if you are sick & feeling lousy that is hard to do.

[pomtzu]

Even tho I don't have to pay any of my doctor or hospital bill and my insurance covers it all, I still scrutinize my bills when I get them, and complain loudly when something is amiss. When I had back surgery last Dec, I was in the hospital for 4 days. When I got my printout from the hospital, I was charged for 4 days of physical therapy. I don't think so!!!!! The therapist finally came in on the 3rd day after I complained, since I couldn't get out of bed until the therapist cleared me to do so. She walked me down the hall, had me climb 4 steps, and then walked me back to my room. That was the extent of my therapy, and I was told since it was the weekend, therapy works with a reduced staff and that's all I would get. Well guess what - that's all my insurance has to pay for. There were also other charges on the bill that I had removed. It's amazing what these hospitals are getting away with, since most people never question the charges.

[Pembroke_Corgi]

I HATE insurance companies!! It seems like with all the money the employee and employer pay for insurance, there should be no co-pays / deductibles!

When I was pregnant with Lyra, I had a blood test to check for cystic fibrosis at a routine office visit that was covered by my insurance. Yet, I got a bill months later for over $300. The reason, I found out after requesting my itemized bill, was because they had charged me for THE SAME TEST 186 times. Yes, I counted. It took months to sort out.

Why wasn't something like this caught by someone?

[Lady's Human]

A conversation with my doc prior to minor surgery:

So, how much is this going to run?

We don't know.

Huh? It's a simple procedure, local, slice, a couple stitches, done.

Well, it all depends on your insurance co, the anesthesiologist who's used, the nurse who's used, we can't tell until it's all done how much it's going to cost.

__________________________________________________ ___________________________

And therein, boys and girls, lies the problem.

A mechanic in NY state has to post their hourly rate prominently in their customer area, and has to tell you up front how many billable hours a repair is going to be.

The health care industry is under no such restrictions, even for simple exams and procedures.

[RICHARD]

A conversation with my doc prior to minor surgery:

So, how much is this going to run?

We don't know.

Huh? It's a simple procedure, local, slice, a couple stitches, done.

Well, it all depends on your insurance co, the anesthesiologist who's used, the nurse who's used, we can't tell until it's all done how much it's going to cost.

__________________________________________________ ___________________________

And therein, boys and girls, lies the problem.

A mechanic in NY state has to post their hourly rate prominently in their customer area, and has to tell you up front how many billable hours a repair is going to be.

The health care industry is under no such restrictions, even for simple exams and procedures.

There is a 'set' price list for healthcare procedures!

This is how it works.

There are two costing 'guides' that are used.

One is called the International Classification of Diseases and the other is called a Diagnosis Related Group.

The ICD is a coding guideline that is used to classify a disease/illness into a numeric format.

The DRG deals with the average cost/stay/care of a hospital stay.

Back in the late 70's an appendectomy/birth of a child was a minumum
3-4 day hospital stay. Now? I have seen appy's discharged after an overnight stay- some new moms have been sent home the same day-hours after delivering a baby.

In an HMO setting, some med centers actively discourage physicians/docs/surgeons from keeping patients past a certain time frame.

A DRG is the averaging of any hospital stay or illness.

The guvmint uses those averages to pay back the centers/facilities for services rendered.

If an appy surgery costs 10k and two days in the hospital and the patient stays in for 5 days because they had an unforseen illness/condition?

The provider has to justify the extra days/care in order to get the money from the guvmint.

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During the years I worked in the industry? I saw many cases where a patient suffered because of cost cutting measures, worries about being paid and the ineptness of staff.

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The next time anyone has a problem with billing, costs, care and other shiat in the HC industry?

Look no farther than the industry itself.

The system is set up to maximize the profits and needs a reform like no one's business. The Health Care Initiative is a joke and the prez of the US should be ashamed of passing that bowel movement and making us believe that it's for the common good.

The system needs to be dismantled, there has to be caps on malpractice insurance and jury awards .

There is a local commercial where a woman tells the story about her husband passing from mesothelioma. Her quote is "the asbestos fell from the sky, like snow..." She goes on to praise the law firm that got her a HUGE settlement.

Lady,
Your husband literally killed himself to give you a house and to feed you while he was alive.

Now you want to make MORE MONEY off his death.

She'll get a nice settlement, the lawyers get paid and the workers get their insurance pulled because the company can't afford to cover the workers.

Brilliant.

[Puckstop31]

A conversation with my doc prior to minor surgery:

So, how much is this going to run?

We don't know.

Huh? It's a simple procedure, local, slice, a couple stitches, done.

Well, it all depends on your insurance co, the anesthesiologist who's used, the nurse who's used, we can't tell until it's all done how much it's going to cost.

I work, everyday, in a business that runs on variable costs.... They can give you an ballpark idea. "My insurance company is X, you tell me who is working the day I am scheduled... Now, tell me how much its going to be. I understand that there area great many variables and im not telling you how to do your job, but what will this cost if everything goes as planned? You don't know? OK, point me to somebody who does." Perhaps I am just one of those pain in the butt customers who does not take no for an answer? I am also fully aware that healthcare is very complex.... Im still not taking their word for it.

The system is not used to the customer caring about such things, so its natural to just BS you. Be polite, but be firm. Maybe im lucky, but my experience has been quite different than yours I suppose.


I guess you are rolling your eyes at me right now. Thats fine. I'm used to it. LOL

Just don't take "I don't know" for an answer, ever. If the person I am working with does not know, somebody does. Find that person. This is a key tenent of my business and it flows over into many other things.

The health care industry is under no such restrictions, even for simple exams and procedures.

Are you saying that you want it to be?

[Lady's Human]

Stores have to put the price on the shelves.

Repair businesses have to put their labor rate in plain view for the consumer to see.

I don't have contractors in to do work without an upfront quote.

I see no reason why healthcare shouldn't have the same rules in place. It would be a great simplification of the current mess relating to billing. Charge whatever you want, but tell me UP FRONT.

[RICHARD]

I don't want to turn this topic into an arguement or fight.

Someone mentioned before that HC has always been a 'the insurance will take care of it" idea.

It's time that the mystery is taken out of insurance/hospital/healthcare costs.

For years we have taken that indusstry for granted and now, more than ever, we need to push back the curtain and really pay attention to the guy pulling the levers and telling us the Great and Powerful Oz is on the up and up.

Medicine isn't an exact science, no matter what the TV says.

As a matter of fact, most of those shows really suck.

I love House.........where else can a drug addicted, crippled doctor buck the system and keep his job?

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Another GIANT change to the HC system is going to happen in 2013.

The ICD codes are going to be revised and the 10th edition will be put into effect and that is going to change the way hospitals collect their money.

The ICD codes are broken into two 'books'. One deals with illnesses and the other deals with operations/procedures.

The procedural revisions are going to be so detailed and in depth, that MCs are going to lose money because the docs are into healing, not keeping books.

An example of this?

A knee surgery? You have to code the 'approach'. Is it an incision or will they use a scope? What kind of surgery? A ligament repair, excision of a meniscus?
is it an exploratory surgery?

Every part of that surgery has a code attached to it and that code equals money - for the costs associated with that procedure.

Plus you have room, anesthesia, personnel, materials and surgeon charges.

It's a complex formula and most of the time, doc doesn't know what the eff he is going to find once they get in.

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The HC system is a frustrating system that for years has been shrouded in mystery and we need to take that out of the equation and make it more 'transparent'. There no real way to cost out a hospital stay.

LH, the idea of a cost guide on the wall of a doc's office is one way of doing business, but I think most of us would not even bother to go thru with a surgery IF WE KNEW THE COSTS.

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One of the saddest stories about HC was one my mom told me about a woman in a pharmacy trying to bargain with the clerk for some prescriptions drugs.

She could not afford the whole bottle, so she tried to buy a few pills until her check (SS, maybe?) came in.

THAT is a story that has bothered me for years.

Imagine that.

A country so powerful and rich, that we have reduced our citizen's to try and barter for their healthcare.

One thing I do advocate is for EVERYONE to pay attention to HC costs and their insurance coverage from now on.

Things are going to get tougher from here on out when it comes to costs and the stupid HCI that out benevolent guvmint has foisted upon us.

Knowledge is power-and that is the only way we will be able to afford HC in the future. We have to know what is going on behind the scenes.