I recently had a skin biopsy come back as a melanoma, and discovered this morning (one day before I go under the knife to have it removed) that one of the tests my dermatologist ordered was denied...
I recently had a skin biopsy come back as a melanoma, and discovered this morning (one day before I go under the knife to have it removed) that one of the tests my dermatologist ordered was denied by my insurance company--to the tune of $8500, which (assuming none of the appeal paths I plan on pursuing go anywhere) I have to pay out of pocket and won't even count towards my deductibles. It stemmed from the phone conversation where I was given my diagnosis, during which my dermatologist suggested "I think we should run XYZ test to help determine how concerned we should be about metastasis and recurrence, is that OK?" and me, having just learned I have cancer, saying "yeah, that sounds like a good idea."
That bill is going to sting a lot, but I'm privileged enough that it shouldn't hurt my day-to-day quality of life too much (just erase a pretty significant percentage of my savings). I can't say for certain I would have said no if I understood the cost of the test and that there was a chance I'd have to foot it myself, but I definitely would have put more thought and research into it before just shrugging and nodding. I think it's absurd that:
a) private insurance companies with a strong financial incentive to deny coverage get to second-guess decisions that the actual medical providers make in the best interest of their patients; and
b) patients who are potentially already feeling overwhelmed by whatever medical issue they're facing also have to parse every treatment and testing decision that they or their doctor makes through the lens of "what is the likelihood my insurance will cover this and how f***ed am I if not?"
I don't know what the solution is, but it needs to address those problems at least. Anyway, I just wanted to vent a bit. I truly loathe the state of the American health care system.
For starters, there's likely no good reason that test costs $8500. That's not what the insurance will pay if they have to cover, and that's not what anyone else in the world likely pays for these...
For starters, there's likely no good reason that test costs $8500. That's not what the insurance will pay if they have to cover, and that's not what anyone else in the world likely pays for these things.
The whole system is supremely fucked up because of this exact point, and it's why I found the ACA to be mostly toothless. Until we can actually start charging companies, doctors, etc for what this is (out and out fraud), the system will never be fixed.
And yes equally as important is that insurance should NEVER be able to second guess a doctor. Ever. End of discussion. It's horrific it's even allowed.
Correct, it is not what the insurance would pay, it's just what the provider billed them for. @Rudism, IF all, and I mean every single possible avenue of appeal including sending a letter to the...
For starters, there's likely no good reason that test costs $8500. That's not what the insurance will pay if they have to cover, and that's not what anyone else in the world likely pays for these things.
Correct, it is not what the insurance would pay, it's just what the provider billed them for. @Rudism, IF all, and I mean every single possible avenue of appeal including sending a letter to the insurance stating you're also sending a copy to your state board of insurance regarding the medical necessity of the procedure, fail and you end up having to pay for it, you'll want to request the "self pay rate" for the procedure. It will be the cash price as if you never had insurance, will be much lower, and either the same or less than what insurance would pay. It's also entirely possible that the biller at your provider's office simply billed it wrong. Medical billing, largely because of what is discussed further below, is a threading the needle game of cat and mouse.
[Of the very long list of occupations I've had in my many years it includes: medical billing, running physician offices, writing medical billing software, and more in this shit of a healthcare industry we have in the US[
And yes equally as important is that insurance should NEVER be able to second guess a doctor. Ever. End of discussion. It's horrific it's even allowed.
Not to defend insurance companies at all, I utterly despise them from both an intelligent human and having spent far too much time in the industry standpoint, but rampant fraud exists at the provider level as well which leads to requiring second guessing the medical necessity of what is billed. Even Medicare and Medicaid do so with thousands of policies dictating what can and cannot be billed for various reasons. When fraudsters stop billing every single test under the sun for a stubbed toe or head cold the payors will stop second guessing providers.
They're simply operating in the system created by the insurance companies. In order to maximize the payout of a visit, they just shotgun blast the insurance co with every possible code and let the...
When fraudsters stop billing every single test under the sun for a stubbed toe or head cold the payors will stop second guessing providers.
They're simply operating in the system created by the insurance companies. In order to maximize the payout of a visit, they just shotgun blast the insurance co with every possible code and let the insurance sort it out. If the insurance company doesn't want that happening the could stop it by publishing clear rules. But that's not in their interest either.
Not to be that guy, but if you don't actually understand the point you're trying to make, don't attempt to make it. Clear and exact medical necessity rules are published by every insurer. Signed,...
could stop it by publishing clear rules. But that's not in their interest either.
Not to be that guy, but if you don't actually understand the point you're trying to make, don't attempt to make it. Clear and exact medical necessity rules are published by every insurer.
Signed, the guy that wrote the program that probably decided what diagnosis and procedures matched the medically necessity rules that your provider used to bill insurance the last time you went to see him/her.
Please help me understand then. If the guidelines are as clear as you say, and the fraud is so obvious and rampant, why is it allowed to continue? Shouldn't the perpetrators of the fraud face some...
Please help me understand then. If the guidelines are as clear as you say, and the fraud is so obvious and rampant, why is it allowed to continue? Shouldn't the perpetrators of the fraud face some kind of penalty, like a fine or jail time?
Well that's not a very productive answer. As an expert in this field, would you say it's due to misaligned incentives, penalties that are not severe enough to deter bad behavior, or something else?
Well that's not a very productive answer. As an expert in this field, would you say it's due to misaligned incentives, penalties that are not severe enough to deter bad behavior, or something else?
Correct, you mentioned "rampant fraud exists at the provider level". If it is rampant, i.e. everywhere, then the parties responsible for stopping it are either complicit, incompetent, or...
Correct, you mentioned "rampant fraud exists at the provider level". If it is rampant, i.e. everywhere, then the parties responsible for stopping it are either complicit, incompetent, or non-existent otherwise it wouldn't be allowed to continue, right? I'm having trouble wrapping my head around how this industry has become overrun with fraud to the point that it's having trouble functioning.
Because the system is designed, much like this site, to assume good faith and that the provider is billing for medically necessary procedures, is performing the procedures being billed, etc. Much...
Because the system is designed, much like this site, to assume good faith and that the provider is billing for medically necessary procedures, is performing the procedures being billed, etc. Much like speeding, theft, tax evasion, murder, or any other crime, it takes more effort to find and prosecute than it does to commit the crime itself. All of those things are rampant. Does that mean the the police, IRS, or other enforcement agencies are "complicit, incompetent, or non-existent"? No.
There's also a matter of what is worth prosecuting. Most of this fraud is not, but that doesn't mean it goes unfound or penalized. Verifying fraud occurred isn't a simple matter. It requires pulling medical records and comparing those to the procedures billed, checking for forgery of the record, talking with patients about care they've likely long since forgotten, and every other aspect of an investigation . Typically, what we'll refer to here as petty fraud, is met with clawbacks by retroactively denying a claim or procedure and deducting the amount paid for it from a future claim or fines instead of pursuing criminal investigations as the headline grabbing cases linked above do.
Thank you for humoring me in this thread. I wonder what the tipping point is, in terms of societal harm, where it becomes beneficial to begin a broader effort to go after fraud? We both recognize...
Thank you for humoring me in this thread.
I wonder what the tipping point is, in terms of societal harm, where it becomes beneficial to begin a broader effort to go after fraud? We both recognize this an issue on some level. This isn't profitable to go after this fraud from a monetary perspective, at least not on a one-to-one basis, but the effect of this fraud is that it drives costs up not just because they're stealing from the system, but because of the increased scrutiny on all claims and the associated administrative overhead that comes along with it. So when does the system get so bad that something has to be done?
I have complicated feelings about this, but I think it comes down to this: I get the emotional impetus that drives you to cry 'fraud' here. But I don't think it's accurate or really fair to assert...
Until we can actually start charging companies, doctors, etc for what this is (out and out fraud),
I have complicated feelings about this, but I think it comes down to this: I get the emotional impetus that drives you to cry 'fraud' here. But I don't think it's accurate or really fair to assert that companies, doctors, etc, are all committing fraud. I also don't think it's all that effective. Much better to instead point out that the complex system we've created is leading to unexpected negative outcomes, and we need to fix it.
It's more than just quibbling over language. Empirically, we know that when people feel accused, they tend to dig in their heels ("I'm not committing fraud!"). If we say instead "this is nobody's fault, but it needs to be fixed," we're much more likely to get broad buy in and support.
Simplified, the problems with the US healthcare system aren't about the US healthcare system, but the US insurance system and regulations regarding financial responsibility. I think that's why...
Simplified, the problems with the US healthcare system aren't about the US healthcare system, but the US insurance system and regulations regarding financial responsibility.
I think that's why cries against hospitals/health care workers ring so hollow for me: That's not what any of this is about, which means fixing the healthcare system isn't about fixing the healthcare system at all. The care is world class, but it's just inaccessible to many of those who should have access due to the stupid financial organization.
I really appreciate you saying that. Being lumped in with fraudsters is a hard one to take when I'm increasingly overwhelmed with rising performance targets and administrative needlework. The...
I really appreciate you saying that. Being lumped in with fraudsters is a hard one to take when I'm increasingly overwhelmed with rising performance targets and administrative needlework. The incentives are misaligned at every level of the US healthcare system, but the those misalignments are wildly in disproportionate favor of private insurers and drug/device manufacturers. The moral injury clinicians and patient-facing staff endure for the sake of continuing to practice is real and should at least count as evidence that individual contributors are not pulling the strings.
And I do realize that there's no need for me to take what other users have said as a personal attack...but I guess I'm running low from the different forms of anti-doctoring that have been rampant.
Agreed, but I'd add the for profit hospital system (almost half of hospitals) and the for profit drug industry. It's sort of an unholy trinity. 100% that none of the fault is with practicing...
Simplified, the problems with the US healthcare system aren't about the US healthcare system, but the US insurance system
Agreed, but I'd add the for profit hospital system (almost half of hospitals) and the for profit drug industry. It's sort of an unholy trinity.
100% that none of the fault is with practicing physicians or other on the ground staff.
A huge number of other types of practices are being bought by or are merging into larger for profit firms, too. I read this article a while back about private equity in Anesthesiology, and I...
A huge number of other types of practices are being bought by or are merging into larger for profit firms, too. I read this article a while back about private equity in Anesthesiology, and I believe it's also happening elsewhere.
I've read about that too, both related services like you mentioned and whole hospitals. It's approaching 10% of US hospitals owned by private equity. If what happened in the housing market is any...
I've read about that too, both related services like you mentioned and whole hospitals. It's approaching 10% of US hospitals owned by private equity. If what happened in the housing market is any indication, that number is going to grow quickly. What private equity firm doesn't love a heavily subsidized non discretionary industry?
For profit (basic) healthcare is a monumentally bad idea.
Except it absolutely is just that. This is not normal market economics. NO ONE is paying that price except the consumer, and even then, if you actually call your doctor/hospital they will almost...
Except it absolutely is just that.
This is not normal market economics. NO ONE is paying that price except the consumer, and even then, if you actually call your doctor/hospital they will almost certainly give you a discount. When a hospital is charging $25 for a single aspirin in the US, and no other country does that, what are they funding?
They're funding the risk of being sued, and care in all cases they're required to give care even if people can't pay. I have relatives that practice medicine. Around a third of their annual income...
They're funding the risk of being sued, and care in all cases they're required to give care even if people can't pay.
I have relatives that practice medicine. Around a third of their annual income goes to paying malpractice insurance.
And then hospitals are for-profit because healthcare isn't universal or government-run, but still in part government funded. The whole system is bonkers. This means that even more of the money goes to profits of the 'medical insurance and litigation business', and 'owning-healthcare providers' business. These are very lucrative businesses.
The threat of non-payment or calling out overpricing isn't worth not lowering the price to see what you can get away with. It's also a system where you for some reason have to barter, and the same procedures can cost hugely different sums depending on which hospital was closest when one neede emergency care.
Healthcare cannot be market economics, because as we approach death or serious permanent harm, the willingness to pay approaches infinity, going somewhere else often isn't practically possible and financial ruin is viewed as an acceptable outcome.
Plenty of other countries have these situations and do not charge $25 for aspirin. If that were the case they wouldn’t let the insurance and any patient who pushes back pay less. I too know people...
They're funding the risk of being sued, and care in all cases they're required to give care even if people can't pay.
Plenty of other countries have these situations and do not charge $25 for aspirin.
If that were the case they wouldn’t let the insurance and any patient who pushes back pay less.
I too know people who practice medicine. Malpractice insurance is a part of it but the US it’s not unique there and yet somehow our prices are
I cannot think of a different country where the system of litigation and rules for going to court are the same as they are in the US. It's not normal that there are billboards along roads for...
I cannot think of a different country where the system of litigation and rules for going to court are the same as they are in the US.
It's not normal that there are billboards along roads for accident lawyers, or that you need to have labels and signs warning against using a hairdryer in a tornado, or that using the pool is at your own risk.
Rules relating to liability are out of whack in the US. This has effects throughout society. Malpractice insurance being so incredibly costly is one of those things.
My local doctor's union advises their members to lie that they're not doctors in the US and not to help in any way if they're on the scene of a medical incident. But that advice is only for the US and a small number of other developing countries.
It's my opinion that the US is unique with relation to courts and risks of getting sued in the medical field.
Taxes. If they maintain it costs $8500 but you call and say you can't pay above $1000 for services rendered, then they can mark the $7500 as a straight-up loss.
For starters, there's likely no good reason that test costs $8500.
Taxes. If they maintain it costs $8500 but you call and say you can't pay above $1000 for services rendered, then they can mark the $7500 as a straight-up loss.
On the contrary, that's not their job nor should they know it. A patient shouldn't be concerned with what a medically necessary procedure costs, nor should a provider; their concern is the health...
The doctors themselves often don’t know what the procedure they’re recommending costs. I think that’s pretty messed up.
On the contrary, that's not their job nor should they know it. A patient shouldn't be concerned with what a medically necessary procedure costs, nor should a provider; their concern is the health of their patient. Should every conversation with your provider go something along the lines of:
Provider: You need ABC done to stop your XYZ condition.
Patient: Great, let's get that done.
Provider: How much money do you have?
Patient: Huh?
Provider: Well, your insurance might not cover it, and it'll be $25k if they don't.
Patient: I don't have that kind of money.
Provider: Sucks to be you, champ. How much is relief from that XYZ condition worth to you?
---or---
Provider: [thinking internally] Patient needs ABC to stop XYZ, but they look like they can't afford it, so I might as well not even suggest it to get their hopes up.
Provider: [speaking to patient] How about some pain meds?
Yes, healthcare shouldn't work this way, but it does in this fucking country.
Okay, let me rephrase that. Given that the patient might actually have to pay for it, it’s fucked up that they aren’t told what it would cost in advance, and doctors, who are running or work for a...
Okay, let me rephrase that. Given that the patient might actually have to pay for it, it’s fucked up that they aren’t told what it would cost in advance, and doctors, who are running or work for a business and are the ones actually talking to the customers, don’t know what they charge and don’t talk about it. What other business works that way? Dentists, opticians, and hearing aid providers don’t work that way.
On the other hand, for emergency services, it does make sense that they should simply be provided and paid for by the government. When a house is on fire, nobody asks how much the firefighters charge to put it out, nor should they.
Some healthcare things are more like emergencies and some are things you could shop for if given a chance. Unfortunately there often isn’t a clear distinction between them.
Handling costs are what the provider's supporting staff are for, when I ran physician offices we provided estimates for all procedures performed and what they'd cost at the self pay rate if...
Handling costs are what the provider's supporting staff are for, when I ran physician offices we provided estimates for all procedures performed and what they'd cost at the self pay rate if insurance denied coverage. The physicians that owned the practices didn't keep track of prices for procedures, what insurance paid, or anything financial as there was and should be a separation between the medical and financial side of things. A provider's only concern should be the wellbeing and best course of care for their patient, period.
Outside of very small practices, providers don't generally keep up with the costs of procedure. Dentists, opticians, and audiologists are usually in that category; largely because their practices are very rigid. They're the fast food of healthcare where it's a numbers game. They know it's X number of cleanings/eye exams/hearing aids needed to pay the bills. An oncologist isn't going into practice with the thought "if I can get 40 poor souls per month with cancer I can get that new Ferrari F80 by spring."
Providers typically don't want to keep up with the costs either, it's not what they went to school for, and is one of the many "selling points" that private equity/hospital groups has latched onto and caused the mass consolidation of healthcare.
On the other hand, for emergency services, it does make sense that they should simply be provided and paid for by the government. When a house is on fire, nobody asks how much the firefighters charge to put it out, nor should they.
And so they can run up whatever charges they want for their customers? You're basically excusing fraud because it's "not their department." Doctors are businesspeople and need to understand what...
A provider's only concern should be the wellbeing and best course of care for their patient, period.
And so they can run up whatever charges they want for their customers? You're basically excusing fraud because it's "not their department."
Doctors are businesspeople and need to understand what business they're in. They should understand where their patients are coming from, including their financial situation. They should get informed consent, including financially, not just medically.
Doctors spend money. Lots of money. Healthcare doesn't exist in a money-free zone.
Not in the slightest. Doctors aren't idiots and are well aware of what tests should be done to diagnose and what treatment should be performed to alleviate the illness. I said best course of care...
Not in the slightest. Doctors aren't idiots and are well aware of what tests should be done to diagnose and what treatment should be performed to alleviate the illness. I said best course of care not run-every-test.
Doctors are not businesspeople, some go into independent practice yes, but that doesn't make them businesspeople as a group and therefore responsible for knowing the financial situation of patients any more than a software developer should know the financial situation of the end user so they don't waste time at their job, driving up the cost of development, eventually being passed on to the consumer.
I think software developers who are independent contractors and work directly with customers (building a custom website, for example) do need to understand what business they’re in, what they...
I think software developers who are independent contractors and work directly with customers (building a custom website, for example) do need to understand what business they’re in, what they charge, and avoid recommending inappropriate solutions? There’s also a question of how to charge - hourly or fixed cost? Though I was never an independent consultant myself, I’ve paid some attention to this because there were times when I thought about it.
Many doctors are often working directly with individual customers (patients).
I would take “it all depends” as an answer, and maybe someone else in the organization can help with this. But as a customer, I’m absolutely interested in both medical and financial advice about the expensive services that doctors propose.
The conclusion you drew from their statement is a complete non-sequitor. To the point that I'm having a hard time even figuring out how you misunderstood them. The doctor not being the person who...
The conclusion you drew from their statement is a complete non-sequitor. To the point that I'm having a hard time even figuring out how you misunderstood them. The doctor not being the person who understands the financial aspect doesn't mean the practice functions as though no one does and the patients don't speak to anyone about it. There should be more clarity and understanding than there is, but it's not the way you painted it at all.
To be clear most practices cannot give you the cost of procedures nor can/will hospitals. They don't know what insurance will cover/charge in advance or if say a surgery, the procedure, the...
To be clear most practices cannot give you the cost of procedures nor can/will hospitals. They don't know what insurance will cover/charge in advance or if say a surgery, the procedure, the aftercare, the surgeon and the anesthesiologist may all charge separately and you have essentially no control over who's running anesthesia that day and if they're in your network. Or how many bandages you need. That's why the doctor or the person on the phone can't answer at least, the real answer is most hospitals are not in compliance with the law requiring it.
To be clear, my issue is not with the complaint that pricing is unclear or that patients aren't able to get proper information before consenting to medical procedures. That's an absolutely valid...
To be clear, my issue is not with the complaint that pricing is unclear or that patients aren't able to get proper information before consenting to medical procedures. That's an absolutely valid complaint. My issue is with the implication that a significant part of this problem is that the doctor is not personally abreast of the financial situation, rather than having it handled by someone else at the practice. Specifically this part:
And so they can run up whatever charges they want for their customers? You're basically excusing fraud because it's "not their department."
Even if doctors had no ballpark, no clue whether a procedure was going to cost $1 or $1 million, you don't just do all of the suggested procedures on one day in one appointment without any scheduling or consent from the patient. Theoretically in the time allotted for an appointment there are a small number of charges they could "run up", but if the doctor is willing to commit fraud then the doctor knowing what those charges are makes no difference. The doctor knowing what the charges are also has zero bearing on their willingness or capability to commit said fraud. It's not relevant.
In the rest of @skybrian 's comment, if the word "doctor" had been replaced with the word "practice" I would actually agree. The doctor does not need to personally know, but the information should be available to patients from the practice before any services are rendered. Absolutely. The bit I quoted, however, is honestly just baffling to me.
Thanks for clarifying. I think I agree in the sense that it’s important to get an estimate, not necessarily who does it. But, if these estimates were available, it seems like that might feed back...
Thanks for clarifying. I think I agree in the sense that it’s important to get an estimate, not necessarily who does it. But, if these estimates were available, it seems like that might feed back into making alternative medical recommendations sometimes?
Maybe? I think that would depend a lot on the specifics. As it is, doctors usually recommend the least invasive, safest thing that is still likely to be effective. Doctors might not know exact...
Maybe? I think that would depend a lot on the specifics. As it is, doctors usually recommend the least invasive, safest thing that is still likely to be effective. Doctors might not know exact nickle and dime amounts, but they usually have an idea of ballparks. Speaking from what I've seen in Orthopedics, NSAIDs are likely to be less expensive than physical therapy, especially if you go over-the-counter, but they tend to mask the problem rather than solve it. MRIs are more expensive than several sessions of physical therapy, but doctors already tend to recommend PT first because MRIs don't actually solve any problem, they just determine if surgery would help. There aren't usually two options where the only difference is cost. You'd need to sacrifice effectiveness, safety, or something else. It's definitely possible that there are areas of medicine that I'm not aware of where two similarly safe and effective options have wildly different costs and the doctors aren't aware of that cost, but I would be surprised.
For a contrasting example, here in Germany, I had an elective surgery recently that was covered by my public health insurance, but I had to pay $10 per day I spent in the hospital. I was warned...
For a contrasting example, here in Germany, I had an elective surgery recently that was covered by my public health insurance, but I had to pay $10 per day I spent in the hospital. I was warned about this more than once beforehand and I believe it was in the admissions paperwork I signed too.
I've had to pay out of pocket for a handful of medical tests and things in the past, and I have always been informed in advance what it would cost -- and it's always been a ludicrously small sum from an American perspective, I think my largest bill was around 100€ tops -- because there are a lot of very strict rules about how much doctors can charge for things. There are ways they can get more money out of private insurance (since we have it alongside public insurance here for those who make enough or are self-employed), but even these are scaled based on a multiplier of what public health insurance pays. On public insurance there's basically no upfront payment for anything except for a tiny copay for prescriptions.
Meanwhile, my dad back in the States drove himself to the hospital for what turned out to be a pulmonary embolism. Everything worked out well for him, luckily, but surely a society where that's a rational decision to make is not what we want. The US has no shortage of other countries' systems to imitate here -- even countries that don't have full-on nationalized healthcare. There's just apparently not enough political will. It's very sad, and this is honestly by far the biggest reason I won't consider moving back to the States anytime soon.
When I lived in Iceland, I found a lump. I had no idea how to navigate finding a doctor, so I went to our show's production manager.
Me: I found a lump. Can you help me find a doctor?
PM: Just go to the cancer center.
Me: Okay. How do a get a referral?
PM: What's a referral?
After I explain what a referral is, he looks baffled.
PM: Just go to the cancer center.
Me: But...referral?
He shrugs and hands me the phone number to the cancer center. I call and explain.
CC: A lump, ah yes. You should come in.
Me: Don't I need a referral?
CC: A what?
Having accepted that I don't need a referral, I say, "How do I make an appointment?"
CC: An appointment? Yes, we can do that if your schedule is very busy, otherwise just come in.
Me: I don't need an appointment?
CC: You found a lump! You know your body, yes? Come in.
So I go. The nurse checking me in apologizes because, since I'm not Icelandic, I'll have to pay for the visit.
I do always manage to get a little chuckle from the German medical staff if they apologize for the price of something and I respond by just saying "I'm American" lol. It's very validating.
I do always manage to get a little chuckle from the German medical staff if they apologize for the price of something and I respond by just saying "I'm American" lol. It's very validating.
Correct, we can only give an estimate based on the fee schedule, the patient's insurance contract, and some other information that we get from the insurance companies. The issue is with the face...
Correct, we can only give an estimate based on the fee schedule, the patient's insurance contract, and some other information that we get from the insurance companies. The issue is with the face that we, the administrative staff, are unable to get clarity on this issue from the insurance company. The fact that the doctor isn't the person who has or does not have the information is not the problem. It's at worst irrelevant, and at best, still a benefit to their medical advice.
I was just attempting to clarify for the discussion that access to that information is not granted to the patient often, because the practice also can't get it. I did forget it is your line of...
I was just attempting to clarify for the discussion that access to that information is not granted to the patient often, because the practice also can't get it. I did forget it is your line of work, but I wanted to add that the transparency is not a given from the practice about further procedures either.
I understand the rest of your disagreement. The doctor shouldn't have that information in their head, though a world where it's just a click away for them too would be nice.
On that, we completely agree. Should the practice have that information? Absolutely. Should the doctor, specifically, have it? Probably not. If the doctor doesn't personally have it, will that in...
On that, we completely agree. Should the practice have that information? Absolutely. Should the doctor, specifically, have it? Probably not. If the doctor doesn't personally have it, will that in any way enable or encourage fraud or frivolous billing on the part of the doctor? Absolutely not, without question.
The doctor is still the person recommending treatment and they should understand what they're recommending. Financial considerations are part of that. They should know what things cost, just like...
The doctor is still the person recommending treatment and they should understand what they're recommending. Financial considerations are part of that. They should know what things cost, just like other people providing services, whether professionals or contractors working in the trades know what things cost. When you take your car in to get work done you get an estimate, and doctors are often recommending things that cost a lot more than that.
For example, many doctors prescribing medications will often know whether there's a generic drug that's equivalent. This is pretty central to what they do.
Also, there are no guarantees when it comes to treatment for mental conditions, but a psychiatrist or other mental health professional will at least tell you what they charge per hour, and this is often negotiable.
(I don't think they necessarily need to understand insurance, but they should know what things cost without insurance.)
As @DefinitelyNotAFae points out, this is often not what happens. But it's one of the ways that some parts of the healthcare system (like hospitals in particular) are screwed up.
As both a patient, and a person who works in exactly this aspect of healthcare, I am absolutely fine with walking to a separate counter to get the financial information from the person who handles...
As both a patient, and a person who works in exactly this aspect of healthcare, I am absolutely fine with walking to a separate counter to get the financial information from the person who handles scheduling and paperwork in order to give my doctor more time to spend on medical questions rather than financial ones. In no way at all does that separate person make it open season for fraud or to run up frivolous charges as you claimed.
The problem, as I also said to @DefinitelyNotAFae is that this information is often completely unavailable to anyone at the practice. The insurance company gives us some information, along with a disclaimer that it's only an estimate and payment cannot be assessed until a claim is received, and even if the claim depicts exactly the same information that we provided over the phone or entered into the provider portal, reimbursement may still be completely different from what they claimed on the phone, and the insurance company calculates the patient's remaining responsibility. We aren't allowed to just bill whatever they don't pay - that's called balance billing, and it's mostly illegal. We have to bill the patient's calculated responsibility as per the Explanation of Benefits provided to us by the insurance company. This is at greatest issue when the services aren't covered at all, despite having a huge team of people dedicated to contacting insurance companies and checking that every service provided every day will be covered.
Collapsed description of the practice that I work at as an example: We have 17 doctors at our practice, and 6 appointments schedulers who each check as they are scheduling patients to make sure that the doctor they are scheduled with is contracted with that patient's insurance. Then we have a team of 4 people who do verifications, that's just ensuring that the patient's information was entered correctly and that the doctor is contracted with the patient's insurance, and that we have the best possible idea of what the visit will cost the patient. We have a physical therapy department that, despite only seeing those patients that have already been checked by two people at this point, has its own verifications person who often gets contradictory information from the insurance company and checks before patients are seen there. The same goes for the MRI department, although people often get PT before they get an MRI so the person doing those verifications is usually checking information on patients that have already been checked three times. We also have a three person referrals team that just deals with patients that have HMOs to make sure all DX and procedure codes will be covered and that we have the best possible idea of what those costs will be.
Despite all of that, we are still unable to guarantee anything to our patients because the insurance companies won't guarantee anything to us. You have to understand, it's not just x service costs y dollars. Doctors would need to be familiar not just with every insurance carrier, but with the contracted rates for every single insurance plan. There are thousands. And the contracted rate is just the start. From there it will depend on if the service is covered or not, if it's included in the co-pay, if your deductible is met, which will depend on if previous services were deemed covered and we may not have received an EOB by the time you need the next service. It will depend on if the plan gives us the correct information for obtaining a prior authorization - these are often handled through third parties and we have been given the wrong third party information before. If I get a prior auth from Cohere but it actually needed to go through American Specialty Health (random third parties as examples) it won't cover the service, and the third parties can't or won't always tell you if they don't actually handle prior auths for the plan that you're calling about. Those teams of people that I described are busy, all day, every day.
Despite the fact that it would put me out of a job, it should not be this complicated. It's ridiculous that it is. The answer is not to take all of this complication and make it an additional responsibility of the doctor.
The fact that the doctors are not the people personally handling any of this is not the problem, and if they were the people personally handling any of this, they would see way fewer patients.
Although the cost after taking insurance into account might be what many patients care about, I think that making cost estimates just based on costs, assuming the customer isn’t going to use...
Although the cost after taking insurance into account might be what many patients care about, I think that making cost estimates just based on costs, assuming the customer isn’t going to use insurance, is something that should be a lot easier? Or at least it would be, if health providers didn’t charge different prices based on who’s paying, which is another way healthcare is screwed up. It’s another example of how the system has been corrupted so that prices are not real.
Are you referring to charging different amounts to different insurances? Those are contracted rates, and healthcare providers don't have the option to not do that. In order to be "in network", you...
if health providers didn’t charge different prices based on who’s paying, which is another way healthcare is screwed up.
Are you referring to charging different amounts to different insurances? Those are contracted rates, and healthcare providers don't have the option to not do that. In order to be "in network", you have to negotiate a contract with the insurance company, and since they're negotiated individually they will of course be different. That's not the fault of providers. It is screwed up, though.
making cost estimates just based on costs, assuming the customer isn’t going to use insurance, is something that should be a lot easier?
At our practice, this is extremely easy. I can't speak for anywhere else, but our self-pay rates are much lower than we bill to the insurance, but higher than most co-pays or co-insurances would end up being. I can give the self-pay cost to any patient for any service at any time, it's all in one spreadsheet. For something like 80% of patients, though, that price would be more than they would pay if they went through their insurance, especially if they're going to be seeing us for a lot of stuff.
At our practice you have to agree to self-pay before the service is provided. That means we save a significant amount of time and resources in terms of prior authorizations and billing the insurance, so we can afford to charge less than we would charge the insurance. Once you have agreed that we will perform the service and bill your insurance, however, you've agreed to pay what your insurance deems you will be responsible for. We can't just offer the self-pay price after the fact if your insurance determines that you're responsible for more than that, because we've already had to spend a significant number of man hours interacting with your insurance. At that point we're losing money.
You're not wrong that it's screwed up and the prices aren't real, and again, I can only speak for the single practice that I have experience with, but as far as I can tell, knowledge of self-pay prices are also not the problem.
It seems this knowledge isn’t shared with the customers often enough, though? That is, going by the complaint that started this conversation off? Maybe self-pay prices should be publicly posted.
It seems this knowledge isn’t shared with the customers often enough, though? That is, going by the complaint that started this conversation off?
Our self-pay prices are posted on our website. I would be extremely surprised to find out that even 10% of our patients ever see our website, but the self-pay prices are all there. They're even...
Our self-pay prices are posted on our website. I would be extremely surprised to find out that even 10% of our patients ever see our website, but the self-pay prices are all there. They're even sorted into packages so you can see what multiple services that you're likely to need together will cost (for example, if you get tendon repair surgery, you will almost certainly need a custom made splint, but those are technically two different services).
I don't know if that's common. I pretty much never go to doctor's websites.
Edit: again, though, those prices are a lot higher than the vast majority of patients with insurance would end up paying, if their insurance companies cover their services in the way that we in the office are informed that they will. So if you have insurance, you see those prices and they're more than you could afford, that doesn't necessarily mean that you couldn't afford that care with us. The caveat being that if your insurance has informed us incorrectly, it could cost WAY more than you can afford.
I think the confusion I'm seeing in the conversation is that it started with asking about tests/procedures being ordered by the doc. Many times tests and procedures are done outside of the...
I think the confusion I'm seeing in the conversation is that it started with asking about tests/procedures being ordered by the doc. Many times tests and procedures are done outside of the individual practice and referred to local hospitals or other offices. Those are things primary care providers (or at least the doctor ordering the test) can rarely speak to the costs of and aren't being paid for themselves anyway. Those tend to be the things people are unable to get specifics on - on top of hospitals just not complying with current law requiring them to provide pricing.
@GenuinelyCrooked works in an office with a number of providers and can provide the contracted costs and self pay costs for that practice but probably cannot easily answer how much an MRI will be if ordered by one of the doctors there but not provided onsite. (And GC correct me if I get anything real wrong here)
Where will the patient get the MRI?
Do they take the patient's insurance and at what tier?
Does the patient need a pre-auth
Whats the copay
Is the scan charged separately from the specialist doctor who interpret's the scan's time? Is that doctor out of network? Was the doctor supposed to be in network but was out on Tuesday so now it's the Out of Network one instead?
Oh and have you met your deductible?
Etc.
Thats why some of those imaging centers and such also are shit about transparency. Though they, and the hospitals, should be able to do it, and the reasons they're not are rarely the person on the phone's fault. But it's definitely not GC who is going to know all of those variables.
The system is shit, and some policymakers in the system are even worse but it really isn't the PCP's office's fault for not having all that info given that.
They actually did used to do this! You can still see "fire marks" on old buildings in London that show which firefighters were responsible for it. Much like private healthcare in the US, it was a...
When a house is on fire, nobody asks how much the firefighters charge to put it out, nor should they.
They actually did used to do this! You can still see "fire marks" on old buildings in London that show which firefighters were responsible for it. Much like private healthcare in the US, it was a complete shitshow that was bad for society.
Yep, I’m aware of the history. I brought that up to show that there are situations where the government paying for emergency services is common and accepted.
Yep, I’m aware of the history. I brought that up to show that there are situations where the government paying for emergency services is common and accepted.
Fair enough, I just figured the history there might be some nice context for people. These things can change, and I hope future generations find paid emergency services just as ridiculous as paid...
Fair enough, I just figured the history there might be some nice context for people. These things can change, and I hope future generations find paid emergency services just as ridiculous as paid firefighters.
I’m not sure I agree. It’s not always clear what medically necessary means, there isn’t an unlimited supply of care, and there are diminishing returns from testing unlikely conditions. Somebody in...
I’m not sure I agree. It’s not always clear what medically necessary means, there isn’t an unlimited supply of care, and there are diminishing returns from testing unlikely conditions. Somebody in the process needs to be able to do a cost benefit analysis for a proposed procedure.
I’m not sure I agree. It’s not always clear what medically necessary means, there isn’t an unlimited supply of care, and there are diminishing returns from testing unlikely conditions. Somebody in the process needs to be able to do a cost benefit analysis for a proposed procedure.
It seems like the whole issue in this discussion is the disconnect between doctors and insurers. You don't want doctors to be concerned with the cost of procedures, but aren't doctors the ones...
It seems like the whole issue in this discussion is the disconnect between doctors and insurers. You don't want doctors to be concerned with the cost of procedures, but aren't doctors the ones most familiar with the relative benefits of a procedure for a given patient, and therefore the ones most qualified to perform that cost benefit analysis? The alternative is kicking that function down the line to an insurer who is not directly involved in the case.
It seems to me that what we really need is to remove insurers completely, and add epidemiologists at the hospital level who consult with doctors on individual cases to determine what procedures will qualify based on their specific circumstances.
Of course now that would be labelled a "death panel" and would be DOA.
Preaching to the choir. There was some movement back in the Obama years with the ACA about getting people to realize that insurers already have "death panels", will need a very strong push on that...
It seems to me that what we really need is to remove insurers completely,
Preaching to the choir.
There was some movement back in the Obama years with the ACA about getting people to realize that insurers already have "death panels", will need a very strong push on that front to sway the general public back towards single payer.
Yeah, they deal with the medicine side. They just know you need it or it may help. Hospital administrators, however, will try to figure out what they can charge for it. Hospitals are a bit crazy...
Yeah, they deal with the medicine side. They just know you need it or it may help. Hospital administrators, however, will try to figure out what they can charge for it. Hospitals are a bit crazy in how they often move money around to pay for different departments and cover different expenses
In case you're unaware, people have started using LLMs to fight healthcare appeals. One such service can be found at https://fighthealthinsurance.com/. Your doctors are probably fairly familiar...
assuming none of the appeal paths I plan on pursuing go anywhere
In case you're unaware, people have started using LLMs to fight healthcare appeals. One such service can be found at https://fighthealthinsurance.com/. Your doctors are probably fairly familiar with what needs to be done for your basic appeals, but it never hurts to submit your own testimony as well.
For those interested, here's an old healthcare rant thread. Best I can tell from my vantage point, things are still getting worse faster than they're getting better (in the USA specifically).
I recently had a skin biopsy come back as a melanoma, and discovered this morning (one day before I go under the knife to have it removed) that one of the tests my dermatologist ordered was denied by my insurance company--to the tune of $8500, which (assuming none of the appeal paths I plan on pursuing go anywhere) I have to pay out of pocket and won't even count towards my deductibles. It stemmed from the phone conversation where I was given my diagnosis, during which my dermatologist suggested "I think we should run XYZ test to help determine how concerned we should be about metastasis and recurrence, is that OK?" and me, having just learned I have cancer, saying "yeah, that sounds like a good idea."
That bill is going to sting a lot, but I'm privileged enough that it shouldn't hurt my day-to-day quality of life too much (just erase a pretty significant percentage of my savings). I can't say for certain I would have said no if I understood the cost of the test and that there was a chance I'd have to foot it myself, but I definitely would have put more thought and research into it before just shrugging and nodding. I think it's absurd that:
a) private insurance companies with a strong financial incentive to deny coverage get to second-guess decisions that the actual medical providers make in the best interest of their patients; and
b) patients who are potentially already feeling overwhelmed by whatever medical issue they're facing also have to parse every treatment and testing decision that they or their doctor makes through the lens of "what is the likelihood my insurance will cover this and how f***ed am I if not?"
I don't know what the solution is, but it needs to address those problems at least. Anyway, I just wanted to vent a bit. I truly loathe the state of the American health care system.
For starters, there's likely no good reason that test costs $8500. That's not what the insurance will pay if they have to cover, and that's not what anyone else in the world likely pays for these things.
The whole system is supremely fucked up because of this exact point, and it's why I found the ACA to be mostly toothless. Until we can actually start charging companies, doctors, etc for what this is (out and out fraud), the system will never be fixed.
And yes equally as important is that insurance should NEVER be able to second guess a doctor. Ever. End of discussion. It's horrific it's even allowed.
Correct, it is not what the insurance would pay, it's just what the provider billed them for.
@Rudism, IF all, and I mean every single possible avenue of appeal including sending a letter to the insurance stating you're also sending a copy to your state board of insurance regarding the medical necessity of the procedure, fail and you end up having to pay for it, you'll want to request the "self pay rate" for the procedure. It will be the cash price as if you never had insurance, will be much lower, and either the same or less than what insurance would pay. It's also entirely possible that the biller at your provider's office simply billed it wrong. Medical billing, largely because of what is discussed further below, is a threading the needle game of cat and mouse.
[Of the very long list of occupations I've had in my many years it includes: medical billing, running physician offices, writing medical billing software, and more in this shit of a healthcare industry we have in the US[
Not to defend insurance companies at all, I utterly despise them from both an intelligent human and having spent far too much time in the industry standpoint, but rampant fraud exists at the provider level as well which leads to requiring second guessing the medical necessity of what is billed. Even Medicare and Medicaid do so with thousands of policies dictating what can and cannot be billed for various reasons. When fraudsters stop billing every single test under the sun for a stubbed toe or head cold the payors will stop second guessing providers.
They're simply operating in the system created by the insurance companies. In order to maximize the payout of a visit, they just shotgun blast the insurance co with every possible code and let the insurance sort it out. If the insurance company doesn't want that happening the could stop it by publishing clear rules. But that's not in their interest either.
Not to be that guy, but if you don't actually understand the point you're trying to make, don't attempt to make it. Clear and exact medical necessity rules are published by every insurer.
Signed, the guy that wrote the program that probably decided what diagnosis and procedures matched the medically necessity rules that your provider used to bill insurance the last time you went to see him/her.
Please help me understand then. If the guidelines are as clear as you say, and the fraud is so obvious and rampant, why is it allowed to continue? Shouldn't the perpetrators of the fraud face some kind of penalty, like a fine or jail time?
Uhh, they do...
https://www.usatoday.com/story/news/nation/2024/10/10/sophia-shaklian-alex-alexsanian-gold-bar-medicare-fraud/75606402007/
https://www.kentucky.com/news/local/crime/article294413814.html
https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/press-releases/houston-man-guilty-160m-medicare-fraud-scheme
https://www.miamiherald.com/news/local/crime/article292727689.html
https://houstonlanding.org/houston-pharmacy-owner-convicted-on-all-counts-in-140-million-medicare-fraud-case/
So, I'm still not getting it.
Why does the problem continue?
Because people continue to commit crimes despite the fact that they are illegal?
Well that's not a very productive answer. As an expert in this field, would you say it's due to misaligned incentives, penalties that are not severe enough to deter bad behavior, or something else?
To make sure we're on the same page: Are you asking me why people continue to defraud Medicare/Medicaid/insurance?
Correct, you mentioned "rampant fraud exists at the provider level". If it is rampant, i.e. everywhere, then the parties responsible for stopping it are either complicit, incompetent, or non-existent otherwise it wouldn't be allowed to continue, right? I'm having trouble wrapping my head around how this industry has become overrun with fraud to the point that it's having trouble functioning.
Because the system is designed, much like this site, to assume good faith and that the provider is billing for medically necessary procedures, is performing the procedures being billed, etc. Much like speeding, theft, tax evasion, murder, or any other crime, it takes more effort to find and prosecute than it does to commit the crime itself. All of those things are rampant. Does that mean the the police, IRS, or other enforcement agencies are "complicit, incompetent, or non-existent"? No.
There's also a matter of what is worth prosecuting. Most of this fraud is not, but that doesn't mean it goes unfound or penalized. Verifying fraud occurred isn't a simple matter. It requires pulling medical records and comparing those to the procedures billed, checking for forgery of the record, talking with patients about care they've likely long since forgotten, and every other aspect of an investigation . Typically, what we'll refer to here as petty fraud, is met with clawbacks by retroactively denying a claim or procedure and deducting the amount paid for it from a future claim or fines instead of pursuing criminal investigations as the headline grabbing cases linked above do.
Thank you for humoring me in this thread.
I wonder what the tipping point is, in terms of societal harm, where it becomes beneficial to begin a broader effort to go after fraud? We both recognize this an issue on some level. This isn't profitable to go after this fraud from a monetary perspective, at least not on a one-to-one basis, but the effect of this fraud is that it drives costs up not just because they're stealing from the system, but because of the increased scrutiny on all claims and the associated administrative overhead that comes along with it. So when does the system get so bad that something has to be done?
When the amount of money saved exceeds the cost of enforcement.
I have complicated feelings about this, but I think it comes down to this: I get the emotional impetus that drives you to cry 'fraud' here. But I don't think it's accurate or really fair to assert that companies, doctors, etc, are all committing fraud. I also don't think it's all that effective. Much better to instead point out that the complex system we've created is leading to unexpected negative outcomes, and we need to fix it.
It's more than just quibbling over language. Empirically, we know that when people feel accused, they tend to dig in their heels ("I'm not committing fraud!"). If we say instead "this is nobody's fault, but it needs to be fixed," we're much more likely to get broad buy in and support.
Simplified, the problems with the US healthcare system aren't about the US healthcare system, but the US insurance system and regulations regarding financial responsibility.
I think that's why cries against hospitals/health care workers ring so hollow for me: That's not what any of this is about, which means fixing the healthcare system isn't about fixing the healthcare system at all. The care is world class, but it's just inaccessible to many of those who should have access due to the stupid financial organization.
I really appreciate you saying that. Being lumped in with fraudsters is a hard one to take when I'm increasingly overwhelmed with rising performance targets and administrative needlework. The incentives are misaligned at every level of the US healthcare system, but the those misalignments are wildly in disproportionate favor of private insurers and drug/device manufacturers. The moral injury clinicians and patient-facing staff endure for the sake of continuing to practice is real and should at least count as evidence that individual contributors are not pulling the strings.
And I do realize that there's no need for me to take what other users have said as a personal attack...but I guess I'm running low from the different forms of anti-doctoring that have been rampant.
Agreed, but I'd add the for profit hospital system (almost half of hospitals) and the for profit drug industry. It's sort of an unholy trinity.
100% that none of the fault is with practicing physicians or other on the ground staff.
A huge number of other types of practices are being bought by or are merging into larger for profit firms, too. I read this article a while back about private equity in Anesthesiology, and I believe it's also happening elsewhere.
I've read about that too, both related services like you mentioned and whole hospitals. It's approaching 10% of US hospitals owned by private equity. If what happened in the housing market is any indication, that number is going to grow quickly. What private equity firm doesn't love a heavily subsidized non discretionary industry?
For profit (basic) healthcare is a monumentally bad idea.
Except it absolutely is just that.
This is not normal market economics. NO ONE is paying that price except the consumer, and even then, if you actually call your doctor/hospital they will almost certainly give you a discount. When a hospital is charging $25 for a single aspirin in the US, and no other country does that, what are they funding?
They're funding the risk of being sued, and care in all cases they're required to give care even if people can't pay.
I have relatives that practice medicine. Around a third of their annual income goes to paying malpractice insurance.
And then hospitals are for-profit because healthcare isn't universal or government-run, but still in part government funded. The whole system is bonkers. This means that even more of the money goes to profits of the 'medical insurance and litigation business', and 'owning-healthcare providers' business. These are very lucrative businesses.
The threat of non-payment or calling out overpricing isn't worth not lowering the price to see what you can get away with. It's also a system where you for some reason have to barter, and the same procedures can cost hugely different sums depending on which hospital was closest when one neede emergency care.
Healthcare cannot be market economics, because as we approach death or serious permanent harm, the willingness to pay approaches infinity, going somewhere else often isn't practically possible and financial ruin is viewed as an acceptable outcome.
Plenty of other countries have these situations and do not charge $25 for aspirin.
If that were the case they wouldn’t let the insurance and any patient who pushes back pay less.
I too know people who practice medicine. Malpractice insurance is a part of it but the US it’s not unique there and yet somehow our prices are
I cannot think of a different country where the system of litigation and rules for going to court are the same as they are in the US.
It's not normal that there are billboards along roads for accident lawyers, or that you need to have labels and signs warning against using a hairdryer in a tornado, or that using the pool is at your own risk.
Rules relating to liability are out of whack in the US. This has effects throughout society. Malpractice insurance being so incredibly costly is one of those things.
My local doctor's union advises their members to lie that they're not doctors in the US and not to help in any way if they're on the scene of a medical incident. But that advice is only for the US and a small number of other developing countries.
It's my opinion that the US is unique with relation to courts and risks of getting sued in the medical field.
Taxes. If they maintain it costs $8500 but you call and say you can't pay above $1000 for services rendered, then they can mark the $7500 as a straight-up loss.
They said "no good reason"
The doctors themselves often don’t know what the procedure they’re recommending costs. I think that’s pretty messed up.
On the contrary, that's not their job nor should they know it. A patient shouldn't be concerned with what a medically necessary procedure costs, nor should a provider; their concern is the health of their patient. Should every conversation with your provider go something along the lines of:
Provider: You need ABC done to stop your XYZ condition.
Patient: Great, let's get that done.
Provider: How much money do you have?
Patient: Huh?
Provider: Well, your insurance might not cover it, and it'll be $25k if they don't.
Patient: I don't have that kind of money.
Provider: Sucks to be you, champ. How much is relief from that XYZ condition worth to you?
---or---
Provider: [thinking internally] Patient needs ABC to stop XYZ, but they look like they can't afford it, so I might as well not even suggest it to get their hopes up.
Provider: [speaking to patient] How about some pain meds?
Yes, healthcare shouldn't work this way, but it does in this fucking country.
Okay, let me rephrase that. Given that the patient might actually have to pay for it, it’s fucked up that they aren’t told what it would cost in advance, and doctors, who are running or work for a business and are the ones actually talking to the customers, don’t know what they charge and don’t talk about it. What other business works that way? Dentists, opticians, and hearing aid providers don’t work that way.
On the other hand, for emergency services, it does make sense that they should simply be provided and paid for by the government. When a house is on fire, nobody asks how much the firefighters charge to put it out, nor should they.
Some healthcare things are more like emergencies and some are things you could shop for if given a chance. Unfortunately there often isn’t a clear distinction between them.
Handling costs are what the provider's supporting staff are for, when I ran physician offices we provided estimates for all procedures performed and what they'd cost at the self pay rate if insurance denied coverage. The physicians that owned the practices didn't keep track of prices for procedures, what insurance paid, or anything financial as there was and should be a separation between the medical and financial side of things. A provider's only concern should be the wellbeing and best course of care for their patient, period.
Outside of very small practices, providers don't generally keep up with the costs of procedure. Dentists, opticians, and audiologists are usually in that category; largely because their practices are very rigid. They're the fast food of healthcare where it's a numbers game. They know it's X number of cleanings/eye exams/hearing aids needed to pay the bills. An oncologist isn't going into practice with the thought "if I can get 40 poor souls per month with cancer I can get that new Ferrari F80 by spring."
Providers typically don't want to keep up with the costs either, it's not what they went to school for, and is one of the many "selling points" that private equity/hospital groups has latched onto and caused the mass consolidation of healthcare.
On the contrary...
And so they can run up whatever charges they want for their customers? You're basically excusing fraud because it's "not their department."
Doctors are businesspeople and need to understand what business they're in. They should understand where their patients are coming from, including their financial situation. They should get informed consent, including financially, not just medically.
Doctors spend money. Lots of money. Healthcare doesn't exist in a money-free zone.
Lesson 1 for a doctor like that: don't treat poors, they're unprofitable. Can't get blood from a stone and all.
Some doctors do work in free clinics part time, and it's not like Medicaid pays nothing.
Not in the slightest. Doctors aren't idiots and are well aware of what tests should be done to diagnose and what treatment should be performed to alleviate the illness. I said best course of care not run-every-test.
Doctors are not businesspeople, some go into independent practice yes, but that doesn't make them businesspeople as a group and therefore responsible for knowing the financial situation of patients any more than a software developer should know the financial situation of the end user so they don't waste time at their job, driving up the cost of development, eventually being passed on to the consumer.
I think software developers who are independent contractors and work directly with customers (building a custom website, for example) do need to understand what business they’re in, what they charge, and avoid recommending inappropriate solutions? There’s also a question of how to charge - hourly or fixed cost? Though I was never an independent consultant myself, I’ve paid some attention to this because there were times when I thought about it.
Many doctors are often working directly with individual customers (patients).
I would take “it all depends” as an answer, and maybe someone else in the organization can help with this. But as a customer, I’m absolutely interested in both medical and financial advice about the expensive services that doctors propose.
The conclusion you drew from their statement is a complete non-sequitor. To the point that I'm having a hard time even figuring out how you misunderstood them. The doctor not being the person who understands the financial aspect doesn't mean the practice functions as though no one does and the patients don't speak to anyone about it. There should be more clarity and understanding than there is, but it's not the way you painted it at all.
To be clear most practices cannot give you the cost of procedures nor can/will hospitals. They don't know what insurance will cover/charge in advance or if say a surgery, the procedure, the aftercare, the surgeon and the anesthesiologist may all charge separately and you have essentially no control over who's running anesthesia that day and if they're in your network. Or how many bandages you need. That's why the doctor or the person on the phone can't answer at least, the real answer is most hospitals are not in compliance with the law requiring it.
Patients rarely get this information.
Why Fat Joe advocates for hospital price transparency
The fight for transparent healthcare prices in America
To be clear, my issue is not with the complaint that pricing is unclear or that patients aren't able to get proper information before consenting to medical procedures. That's an absolutely valid complaint. My issue is with the implication that a significant part of this problem is that the doctor is not personally abreast of the financial situation, rather than having it handled by someone else at the practice. Specifically this part:
Even if doctors had no ballpark, no clue whether a procedure was going to cost $1 or $1 million, you don't just do all of the suggested procedures on one day in one appointment without any scheduling or consent from the patient. Theoretically in the time allotted for an appointment there are a small number of charges they could "run up", but if the doctor is willing to commit fraud then the doctor knowing what those charges are makes no difference. The doctor knowing what the charges are also has zero bearing on their willingness or capability to commit said fraud. It's not relevant.
In the rest of @skybrian 's comment, if the word "doctor" had been replaced with the word "practice" I would actually agree. The doctor does not need to personally know, but the information should be available to patients from the practice before any services are rendered. Absolutely. The bit I quoted, however, is honestly just baffling to me.
I track that, sorry for inserting myself on a tangent!
No worries! It helped me pinpoint exactly what was so frustrating about the comment I was replying to.
Thanks for clarifying. I think I agree in the sense that it’s important to get an estimate, not necessarily who does it. But, if these estimates were available, it seems like that might feed back into making alternative medical recommendations sometimes?
Maybe? I think that would depend a lot on the specifics. As it is, doctors usually recommend the least invasive, safest thing that is still likely to be effective. Doctors might not know exact nickle and dime amounts, but they usually have an idea of ballparks. Speaking from what I've seen in Orthopedics, NSAIDs are likely to be less expensive than physical therapy, especially if you go over-the-counter, but they tend to mask the problem rather than solve it. MRIs are more expensive than several sessions of physical therapy, but doctors already tend to recommend PT first because MRIs don't actually solve any problem, they just determine if surgery would help. There aren't usually two options where the only difference is cost. You'd need to sacrifice effectiveness, safety, or something else. It's definitely possible that there are areas of medicine that I'm not aware of where two similarly safe and effective options have wildly different costs and the doctors aren't aware of that cost, but I would be surprised.
For a contrasting example, here in Germany, I had an elective surgery recently that was covered by my public health insurance, but I had to pay $10 per day I spent in the hospital. I was warned about this more than once beforehand and I believe it was in the admissions paperwork I signed too.
I've had to pay out of pocket for a handful of medical tests and things in the past, and I have always been informed in advance what it would cost -- and it's always been a ludicrously small sum from an American perspective, I think my largest bill was around 100€ tops -- because there are a lot of very strict rules about how much doctors can charge for things. There are ways they can get more money out of private insurance (since we have it alongside public insurance here for those who make enough or are self-employed), but even these are scaled based on a multiplier of what public health insurance pays. On public insurance there's basically no upfront payment for anything except for a tiny copay for prescriptions.
Meanwhile, my dad back in the States drove himself to the hospital for what turned out to be a pulmonary embolism. Everything worked out well for him, luckily, but surely a society where that's a rational decision to make is not what we want. The US has no shortage of other countries' systems to imitate here -- even countries that don't have full-on nationalized healthcare. There's just apparently not enough political will. It's very sad, and this is honestly by far the biggest reason I won't consider moving back to the States anytime soon.
Yeah apologies for the Twitter link but Mary Robinette Kowal sharing her story left a big impact on me.
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I do always manage to get a little chuckle from the German medical staff if they apologize for the price of something and I respond by just saying "I'm American" lol. It's very validating.
Correct, we can only give an estimate based on the fee schedule, the patient's insurance contract, and some other information that we get from the insurance companies. The issue is with the face that we, the administrative staff, are unable to get clarity on this issue from the insurance company. The fact that the doctor isn't the person who has or does not have the information is not the problem. It's at worst irrelevant, and at best, still a benefit to their medical advice.
I was just attempting to clarify for the discussion that access to that information is not granted to the patient often, because the practice also can't get it. I did forget it is your line of work, but I wanted to add that the transparency is not a given from the practice about further procedures either.
I understand the rest of your disagreement. The doctor shouldn't have that information in their head, though a world where it's just a click away for them too would be nice.
On that, we completely agree. Should the practice have that information? Absolutely. Should the doctor, specifically, have it? Probably not. If the doctor doesn't personally have it, will that in any way enable or encourage fraud or frivolous billing on the part of the doctor? Absolutely not, without question.
The doctor is still the person recommending treatment and they should understand what they're recommending. Financial considerations are part of that. They should know what things cost, just like other people providing services, whether professionals or contractors working in the trades know what things cost. When you take your car in to get work done you get an estimate, and doctors are often recommending things that cost a lot more than that.
For example, many doctors prescribing medications will often know whether there's a generic drug that's equivalent. This is pretty central to what they do.
Also, there are no guarantees when it comes to treatment for mental conditions, but a psychiatrist or other mental health professional will at least tell you what they charge per hour, and this is often negotiable.
(I don't think they necessarily need to understand insurance, but they should know what things cost without insurance.)
As @DefinitelyNotAFae points out, this is often not what happens. But it's one of the ways that some parts of the healthcare system (like hospitals in particular) are screwed up.
As both a patient, and a person who works in exactly this aspect of healthcare, I am absolutely fine with walking to a separate counter to get the financial information from the person who handles scheduling and paperwork in order to give my doctor more time to spend on medical questions rather than financial ones. In no way at all does that separate person make it open season for fraud or to run up frivolous charges as you claimed.
The problem, as I also said to @DefinitelyNotAFae is that this information is often completely unavailable to anyone at the practice. The insurance company gives us some information, along with a disclaimer that it's only an estimate and payment cannot be assessed until a claim is received, and even if the claim depicts exactly the same information that we provided over the phone or entered into the provider portal, reimbursement may still be completely different from what they claimed on the phone, and the insurance company calculates the patient's remaining responsibility. We aren't allowed to just bill whatever they don't pay - that's called balance billing, and it's mostly illegal. We have to bill the patient's calculated responsibility as per the Explanation of Benefits provided to us by the insurance company. This is at greatest issue when the services aren't covered at all, despite having a huge team of people dedicated to contacting insurance companies and checking that every service provided every day will be covered.
Collapsed description of the practice that I work at as an example:
We have 17 doctors at our practice, and 6 appointments schedulers who each check as they are scheduling patients to make sure that the doctor they are scheduled with is contracted with that patient's insurance. Then we have a team of 4 people who do verifications, that's just ensuring that the patient's information was entered correctly and that the doctor is contracted with the patient's insurance, and that we have the best possible idea of what the visit will cost the patient. We have a physical therapy department that, despite only seeing those patients that have already been checked by two people at this point, has its own verifications person who often gets contradictory information from the insurance company and checks before patients are seen there. The same goes for the MRI department, although people often get PT before they get an MRI so the person doing those verifications is usually checking information on patients that have already been checked three times. We also have a three person referrals team that just deals with patients that have HMOs to make sure all DX and procedure codes will be covered and that we have the best possible idea of what those costs will be.Despite all of that, we are still unable to guarantee anything to our patients because the insurance companies won't guarantee anything to us. You have to understand, it's not just x service costs y dollars. Doctors would need to be familiar not just with every insurance carrier, but with the contracted rates for every single insurance plan. There are thousands. And the contracted rate is just the start. From there it will depend on if the service is covered or not, if it's included in the co-pay, if your deductible is met, which will depend on if previous services were deemed covered and we may not have received an EOB by the time you need the next service. It will depend on if the plan gives us the correct information for obtaining a prior authorization - these are often handled through third parties and we have been given the wrong third party information before. If I get a prior auth from Cohere but it actually needed to go through American Specialty Health (random third parties as examples) it won't cover the service, and the third parties can't or won't always tell you if they don't actually handle prior auths for the plan that you're calling about. Those teams of people that I described are busy, all day, every day.
Despite the fact that it would put me out of a job, it should not be this complicated. It's ridiculous that it is. The answer is not to take all of this complication and make it an additional responsibility of the doctor.
The fact that the doctors are not the people personally handling any of this is not the problem, and if they were the people personally handling any of this, they would see way fewer patients.
Although the cost after taking insurance into account might be what many patients care about, I think that making cost estimates just based on costs, assuming the customer isn’t going to use insurance, is something that should be a lot easier? Or at least it would be, if health providers didn’t charge different prices based on who’s paying, which is another way healthcare is screwed up. It’s another example of how the system has been corrupted so that prices are not real.
Are you referring to charging different amounts to different insurances? Those are contracted rates, and healthcare providers don't have the option to not do that. In order to be "in network", you have to negotiate a contract with the insurance company, and since they're negotiated individually they will of course be different. That's not the fault of providers. It is screwed up, though.
At our practice, this is extremely easy. I can't speak for anywhere else, but our self-pay rates are much lower than we bill to the insurance, but higher than most co-pays or co-insurances would end up being. I can give the self-pay cost to any patient for any service at any time, it's all in one spreadsheet. For something like 80% of patients, though, that price would be more than they would pay if they went through their insurance, especially if they're going to be seeing us for a lot of stuff.
At our practice you have to agree to self-pay before the service is provided. That means we save a significant amount of time and resources in terms of prior authorizations and billing the insurance, so we can afford to charge less than we would charge the insurance. Once you have agreed that we will perform the service and bill your insurance, however, you've agreed to pay what your insurance deems you will be responsible for. We can't just offer the self-pay price after the fact if your insurance determines that you're responsible for more than that, because we've already had to spend a significant number of man hours interacting with your insurance. At that point we're losing money.
You're not wrong that it's screwed up and the prices aren't real, and again, I can only speak for the single practice that I have experience with, but as far as I can tell, knowledge of self-pay prices are also not the problem.
It seems this knowledge isn’t shared with the customers often enough, though? That is, going by the complaint that started this conversation off?
Maybe self-pay prices should be publicly posted.
Our self-pay prices are posted on our website. I would be extremely surprised to find out that even 10% of our patients ever see our website, but the self-pay prices are all there. They're even sorted into packages so you can see what multiple services that you're likely to need together will cost (for example, if you get tendon repair surgery, you will almost certainly need a custom made splint, but those are technically two different services).
I don't know if that's common. I pretty much never go to doctor's websites.
Edit: again, though, those prices are a lot higher than the vast majority of patients with insurance would end up paying, if their insurance companies cover their services in the way that we in the office are informed that they will. So if you have insurance, you see those prices and they're more than you could afford, that doesn't necessarily mean that you couldn't afford that care with us. The caveat being that if your insurance has informed us incorrectly, it could cost WAY more than you can afford.
I think the confusion I'm seeing in the conversation is that it started with asking about tests/procedures being ordered by the doc. Many times tests and procedures are done outside of the individual practice and referred to local hospitals or other offices. Those are things primary care providers (or at least the doctor ordering the test) can rarely speak to the costs of and aren't being paid for themselves anyway. Those tend to be the things people are unable to get specifics on - on top of hospitals just not complying with current law requiring them to provide pricing.
@GenuinelyCrooked works in an office with a number of providers and can provide the contracted costs and self pay costs for that practice but probably cannot easily answer how much an MRI will be if ordered by one of the doctors there but not provided onsite. (And GC correct me if I get anything real wrong here)
Where will the patient get the MRI?
Do they take the patient's insurance and at what tier?
Does the patient need a pre-auth
Whats the copay
Is the scan charged separately from the specialist doctor who interpret's the scan's time? Is that doctor out of network? Was the doctor supposed to be in network but was out on Tuesday so now it's the Out of Network one instead?
Oh and have you met your deductible?
Etc.
Thats why some of those imaging centers and such also are shit about transparency. Though they, and the hospitals, should be able to do it, and the reasons they're not are rarely the person on the phone's fault. But it's definitely not GC who is going to know all of those variables.
The system is shit, and some policymakers in the system are even worse but it really isn't the PCP's office's fault for not having all that info given that.
Yes, you are completely correct. If a patient is referred outside of our practice, I won't be able to tell them anything about costs at all.
They actually did used to do this! You can still see "fire marks" on old buildings in London that show which firefighters were responsible for it. Much like private healthcare in the US, it was a complete shitshow that was bad for society.
Yep, I’m aware of the history. I brought that up to show that there are situations where the government paying for emergency services is common and accepted.
Fair enough, I just figured the history there might be some nice context for people. These things can change, and I hope future generations find paid emergency services just as ridiculous as paid firefighters.
I’m not sure I agree. It’s not always clear what medically necessary means, there isn’t an unlimited supply of care, and there are diminishing returns from testing unlikely conditions. Somebody in the process needs to be able to do a cost benefit analysis for a proposed procedure.
Which is what the insurance company does.
It seems like the whole issue in this discussion is the disconnect between doctors and insurers. You don't want doctors to be concerned with the cost of procedures, but aren't doctors the ones most familiar with the relative benefits of a procedure for a given patient, and therefore the ones most qualified to perform that cost benefit analysis? The alternative is kicking that function down the line to an insurer who is not directly involved in the case.
It seems to me that what we really need is to remove insurers completely, and add epidemiologists at the hospital level who consult with doctors on individual cases to determine what procedures will qualify based on their specific circumstances.
Of course now that would be labelled a "death panel" and would be DOA.
Preaching to the choir.
There was some movement back in the Obama years with the ACA about getting people to realize that insurers already have "death panels", will need a very strong push on that front to sway the general public back towards single payer.
Yeah, they deal with the medicine side. They just know you need it or it may help. Hospital administrators, however, will try to figure out what they can charge for it. Hospitals are a bit crazy in how they often move money around to pay for different departments and cover different expenses
In case you're unaware, people have started using LLMs to fight healthcare appeals. One such service can be found at https://fighthealthinsurance.com/. Your doctors are probably fairly familiar with what needs to be done for your basic appeals, but it never hurts to submit your own testimony as well.
For those interested, here's an old healthcare rant thread.
Best I can tell from my vantage point, things are still getting worse faster than they're getting better (in the USA specifically).