One (weak) way to fight back against high medical costs.

Thread Starter

WBahn

Joined Mar 31, 2012
25,750
Stop blindly signing the Agreement to Pay forms.

These forms, which are pretty universal (in the U.S.), generally state that you are agreeing to pay the bill if, for any reason, the insurance company denies the claim.

On the surface this sounds quite reasonable, but as a direct consequence of the distorted way in which medical billing is done, it is far from reasonable and people need to stop signing these damn things.

Here's a case in point from my personal experience yesterday.

I have a partially torn rotator cuff and I need a physical therapy evaluation (followed by quite a bit of physical therapy). The evaluation typically takes a half hour to an hour (which I know for a fact since I had a similar injury several years ago on the other shoulder). So when I show up for the appointment they want me to sign the form and so I ask them how much the cost will be if insurance denies. As expected, they have no idea -- they want me to sign a blank check saying that I agree to pay whatever amount they choose to BILL the insurance company (as opposed to the amount they expect to actually get PAID by the insurance company). So I refuse to sign unless they give me a number. They finally give me the phone number for their billing estimates department, who tell me that they are going to bill the insurance company $471. Sound a little excessive for an evaluation that will take less than an hour? Yeah, by quite a bit. So I told them that, if insurance refuses to pay, I would agree to pay whatever insurance WOULD have paid. They didn't bite, so I told them to cancel the appointment and I would take my business elsewhere.

I then contacted two other physical therapy places and asked them what their cash-pay price for an evaluation was. The first place was $120 and the second was $75.73. The front desk person at both places were able to immediately give me that price without any need for anyone (them or me) to call anyone else. The first place gave me an appointment for the 7th of October and, since I would like to get seen before then, I went to the second and they were able to get me in on the 1st. When I told them that I was not going to sign their standard Agreement to Pay form but that I would sign one that stipulated that I would agree to pay their cash-pay price if insurance refused to pay, they both agreed (rather reluctantly, but I think the fact that they had already given me their cash-pay price had them boxed into a corner). Later I called up the first place and asked them what their cash pay price was (something I just didn't think to do when I was there earlier) and was told that it was $85.

So the first place was going to bill my insurance for nearly six times (5.8x) the amount they would have accepted in cash and they wanted me to agree to pay that over-inflated amount if anything went wrong. HAD I signed the Agreement to Pay at the first place and HAD the insurance company refused to pay, they WOULD have come after me for the full $471 and I would have had to fight tooth and nail to get it resolved for anywhere near a reasonable amount. I know this because it has happened to me twice.

A number of years ago I had some labs done and the insurance denied the claim saying that the same tests had been done too recently, so the lab came after me for $818. However, the EOB (Explanation of Benefits) that I received denying the claim included the allowed amounts (i.e., the amount that the lab was willing to accept as payment in full from the insurance company per their contract with them) which totaled to $75. It took well over a year to get that resolved and I ended up paying about $150 when the dust settled.

If you look at your EOBs, you will discover that massive overbilling is the norm. My most recent statement for lab work totals $336, of which the allowed amount is $26.63. A review of my many EOBs over the last couple of years shows very few where the bill amount isn't at least 2x the amount actually paid, that most were around 5x, that diagnostic labs and prescriptions are seldom less than 10x, and that emergency room related bills are often in the 20x range.

Remember, the amount that the insurance allows is the amount that these providers agreed to accept IN ADVANCE as part of becoming part of that network. These represent amounts that constitute acceptable payments that cover all expenses plus whatever profit is deemed acceptable for goods and services rendered. No provider is going to join a network in which they lose money on every transaction.

So why the endemic overbilling?

It's actually fairly simple. Each provider has a single billing system and they bill the same amount for a given service no matter who is footing the bill. Not only is this make the system easy, but it provides cover because they can't be accused of charging different people different rates -- the fact that they give different groups different discounts is much more hidden and can be plausibly explained away pretty easily. Most of their billing goes to either Medicare or a private insurer and in either case the amount actually paid is predetermined by the contract and will be the lesser of the contracted rate or the billed amount, so there is no risk associated with overbilling, but if they bill for less than the contracted rate they will, of course, only get the amount billed. So they definitely want to bill at least as much as the highest contracted rate will be.

It's been my experience that the contracted rates paid by insurance companies are within spitting distance (on either side, but not without occasional exceptions) of the cash-pay rate that they will accept from someone without any insurance at all. So why aren't the billed amounts within, at least, say a factor of two of the cash-pay price?

Again, it's pretty simple. If you ask for the moon, you will sometimes get it.

A very common way in which this happens in the medical coverage on your automotive insurance. This does NOT involve negotiated rates and this coverage has a cap that is almost always fairly low (I think $5k is the default in Colorado). Since this coverage is primary and has no deductible in the event of an auto accident, this insurance gets billed first and exhausted quickly. Because there are no negotiated rates in place, the auto insurance has little choice but to pay the full billed amount and, since the caps are relatively low, they know they will hit the cap on most accidents and so they don't really care whether they pay out $5000 on a claim that should have been closer to $500, or pay out $5000 on ten more rational claims -- in fact, the fewer claims it takes to hit the cap, the less paperwork they have to deal with.

Now consider where most bills related to auto accidents originate from, at least initially. The emergency room and diagnostic labs. Is it any surprise that these providers have the highest multipliers on their billed rates? They DO collect those outrageous billed amounts when they are able to get first in line on submitting a claim against an auto insurance policy's medical coverage.

Now, while I have all kinds of ideas for simple changes to how billing is done that would bring the billed amount much more in line with the actual amounts that are paid, we as individuals don't have any direct control over that.

What we DO have at least SOME control over is the ability to make it known to providers that we are aware of the game and that we do NOT have to play by their rules -- we DO have the ability to take our business elsewhere and to make them very much aware of the fact that it is their unrealistic billing practices that are driving it.

Oh -- and about an hour after I made the appointment with the second place, the original place called me back and agreed to let me sign a modified agreement in which I was only held accountable for the cash-pay price. So clearly that ARE sensitive to the issue WHEN it is resulting in a loss of business. I told them that they should have agreed to that when I offered it and that it was too late -- that I would not only take this appointment elsewhere, but that all of my physical therapy appointments would be with another provider, that I had personally blacklisted them and would only do business with them in the future as a last resort, and that I had every intention of telling as many people as I could to avoid them in the future.
 

jpanhalt

Joined Jan 18, 2008
9,391
When I first saw WBahn's post, I was concerned that it would devolve into a political discussion, not unlike the "gift economy" one awhile back that got closed, based on the current political slogan of "Medicare for all." Medicare and Obamacare are simply taxes. They act to redistribute wealth just like income tax does.

As for the question, "So why the endemic overbilling?" There is a history to that. You hit on some of the elements of how that evolved. Medicare was passed into law in approximately 1966. Ted Kennedy was a major sponsor of the enabling legislation. It is not really insurance in the sense of other insurance that existed at the time. It is a tax, and anyone on Medicare should be aware of that. Today, the Social Security Administration assesses a fixed tax (regardless of age) called "IRMA" (income-related Medicare adjustment) on those covered. Medicare is classified as "subsidized" insurance. How much is subsidized is variable and can be less than zero (i.e., one might find cheaper private insurance). The income amount that is used taken from your US 1040 form and adjusted upward to eliminate certain non-taxed items to give the MAGI (Medicare adjusted gross income) by which the IRMA is determined.

Back to the history... Originally, Medicare paid a percentage of charges, just as commercial insurers did at the time. As the system was abused, focus was shifted to controlling cost. The percentage reimbursement was ratcheted down, and in response, providers ratcheted up charges. The ratio of charges to actual reimbursement went from a little more than 1.1:1 (e.g., reimbursement was 90% of charges ) to more than 3:1 or 4:1 in the late 1980's. It was really a silly game. A Harvard professor of economics was enlisted to develop a list of procedure codes with fixed reimbursements ("CPT codes", Current Procedural Terminology). Those codes failed to cover a lot of things, but have been the basis for payment -- not charges -- ever since. That led to a division in billing between facility charges, which are hard to relate to CPT codes and provider charges (physicians and other direct-billing providers, "physicians"). The argument used for making that distinction was that physician charges could be related to average time (i.e., direct cost) per procedure and reasonable compensation. Whereas, it is much more difficult to do the same analysis for facilities that have almost unlimited indirect costs, as well as direct costs.*

Are current charges reasonable? No. I have known a lot of physicians and have been peripherally aware of facility charges. Since the inflation period described above, I have never met a physician who thought the ratio between charges and reimbursement was reasonable or even ethical. Facilities are much happier as they tend still to get cost-based reimbursement.

Why not simply reduce charges to be closer to reimbursement? That is far easier said than done. A typical medical practice in the US is about 33% Medicare, 30% to 40% private insurance, 10% to 20% Medicaid (welfare), and <10% uninsured "self-pay". Unfortunately "self-pay" includes two very different groups of patients. The larger group (in most practices) is "no pay." The smaller group actually pays the list prices. In Ohio, we have a have a large Amish population. They, unfortunately, fall into the uninsured, self-pay group who actually do pay.

The law clearly requires that physicians and facilities cannot charge Medicare more than the list prices offered to any other payer. So, charges are kept high, because some rare insurers do pay much higher than Medicare actually pays. Unfortunately, those who really do self-pay get hurt. I find that ethically unacceptable. However, the law does allow negotiation of how much will be paid after the charges have been assessed, but the patient must initiate those discussions. That is what WBahn did.** There are other ways around that blatant unfairness too, but not all providers do it.

Is there a solution? In theory, yes, but it is extremely unlikely that our politicians will take the necessary action. It is far more likely for them to add layers and increase control, rather than decrease it. Most important, remember that individual providers have very little leverage compared to mega-insurers like Anthem and United Healthcare. From the insurers perspective, the discordance between charges and actual payments benefit the insurers by adding perceived value.

John

*My direct experience with billing is about 10 years out of date. I believe the same elements still apply based on a recent personal experience.
**You can also challenge the legitimacy of any charge. Facilities will often back down when faced with the need to document such things as timely physician signatures on verbal orders. The EMR/EHR (electronic medical/health record) may have closed that loophole. Almost all providers and facilities will refer unpaid bills to collection agencies. One can get a cease and desist letter sent that offers some protection. Physicians rarely actually sue for reimbursement as a countersuit for malpractice may result if they do. Facilities are more likely to sue, but have enormous incentive to negotiate.


EDIT: There is also what's called "pre-authorization." The situations needed for that vary considerably depending on your insurance and circumstances. What it does is ensure your insurance will cover a bill that it might not normally cover. One example, if you are in an HMO or any other restricted plan and have a legitimate reason to go outside the plan, you can ask the provider to get pre-authorization. Be sure that request is documented (recorded or written). Legitimate reasons can be a lot of things, including but not limited to prior experience with a particular provider and location.
 
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Thread Starter

WBahn

Joined Mar 31, 2012
25,750
When I first saw WBahn's post, I was concerned that it would devolve into a political discussion, not unlike the "gift economy" one awhile back that got closed, based on the current political slogan of "Medicare for all." Medicare and Obamacare are simply taxes. They act to redistribute wealth just like income tax does.
Let's be careful to keep the politics out of the discussion. The why and how we got to this point is immaterial as far as THIS discussion is concerned. As are the broader questions of how we might deal with it on a national level -- there's NO way to have that discussion without delving into the politics in a big way, so let's just not do it. I'm only talking about things that individuals can do to help them deal with the their immediate situations as they exist today. Yes, those options are limited and are far from a magic bullet, but there are at least SOME options that can have an effect SOME of the time, and every bit helps.

I wish we were still under a high-deductible/HSA plan, but that's not an option available to us right now. Back when I had an HSA I had a LOT more bargaining power. Providers knew that I was effectively cash-pay for most services (my first HSA plan paid for absolutely nothing until the $7000 deductible was hit and then it paid for 100% of everything -- which is personally the way I think that insurance is supposed to be; I'm responsible for all of my routine and low-end, high-probability emergent health care costs and I have insurance to cover the high-end, low-probability catastrophic events). As a result, when I would set an appointment I would tell them that I had an HSA and was no where near my deductible and they would usually immediately quote me a price that was at least 50% off what it started out at and sometimes quite a bit more. That was when I first became aware of the routine overbilling because they would still file the claim with my insurance and I would still get the EOB showing the allowed amount and it was almost always very close to what the cash-pay price the provider had given me. When the EOB had a lower amount that was the amount I actually paid (per the provider/insurer contract) and when it was a higher amount I only paid the cash-pay price (per the provider/patient prior agreement). Now that I don't have an HSA it is a lot harder for me to play that card.

I've also had the reverse happen to me. I had a surgery about seven years ago that had a $15,000 cap on my coverage. Since this surgery was often not covered at all by many insurance companies (at the time, it's covered much more broadly now as both the chronic and acute health benefits have become more widely known), the surgeon had a sheet showing ALL of the prices charged by all of the various providers, including the hospital, printed up. The total cost was going to be around $19,000 so I was expecting to have to cover about $4,000 of it myself. The surgeon's price was $3,000 ($1,500 for the actual surgery and $1,500 for twelve months of follow-up care) and the surgeon's assistant was $470. As it turned out, despite being very explicit about the need for everyone involved to be in my network, they used a surgeon's assistant that was out-of-network and that billed my insurance for $5,000. Had they been in network, the allowed amount was $510 dollars (very close to the upfront cash-pay price), but because there was no contract with them, they simply paid the full amount as much as they could under the procedure cap, which meant that they paid them about $3,500. So that was $3,000 above what the assistant has agreed to be paid and, worse, that was money that did NOT go to the hospital which increased my direct costs by that same $3,000. Plus, the assistant's office sent me a bill for the remaining $1,500 (since they could balance-bill owing to the lack of a contract preventing it). They quickly agreed to accept the amount received as payment in full (gee, how generous of them, they had to sacrifice and only take 7x what they had agreed to take!). The hospital, in turn, was able to balance bill me because the insurance hit the cap and denied payment of the amount above it. In a still-infuriating loop-hole in contract, they not only got to bill me for the allowed amount that was in excess of the actual payment, they got to bill me for the excess billed amount and so sent me a bill for over $96,000. I demanded an itemized list of the charges, which they provided, and it was almost funny to read -- $900 for each liter of saline IV, $6 for each baby aspirin. It took a year of negotiating, but I eventually got them to settle for about $6,000, which combined with the other providers I paid for directly, brought my total out-of-pocket to around $8k, which was still in shouting distance of the $4k expected plus $3k due to the out-of-network snafu. The hospital, at the end of the day, ended up without about $1k more than they would have had they just settled for the agreed upon amount and it took them a year and who knows how many man-hours of time to get it.

But I learned a valuable lesson that I've been able to pass on to others in similar situations (in this case, members of a support group that are considering this same surgery). When you have insurance that has a cap on a given procedure, negotiate a cash-pay price with all of the players you can ahead of time and for most of them pay them directly and don't even have them bill insurance at all; it won't matter as far as your deductible or annual out-of-pocket max is concerned because any amount above a cap doesn't count toward either of those (but check with your insurance to be sure since policies do vary). Keep the insurance amount available for the one or two big ticket items and try like hell (you may or may not be successful) to get something in writing from them saying that they will accept the allowed amount, via a combination of insurance and personal payment, as payment in full for the agreed-to listed services.
 

Hypatia's Protege

Joined Mar 1, 2015
3,219
Are current charges reasonable? No. I have known a lot of physicians and have been peripherally aware of facility charges. Since the inflation period described above, I have never met a physician who thought the ratio between charges and reimbursement was reasonable or even ethical. Facilities are much happier as they tend still to get cost-based reimbursement.
Buy that man a "Nail's":D:) --- To wit: wholeheartedly agreed -- and then some!:cool:

Very best regards
HP
 

jpanhalt

Joined Jan 18, 2008
9,391
I've also had the reverse happen to me. I had a surgery about seven years ago that had a $15,000 cap on my coverage. Since this surgery was often not covered at all by many insurance companies (at the time, it's covered much more broadly now as both the chronic and acute health benefits have become more widely known), the surgeon had a sheet showing ALL of the prices charged by all of the various providers, including the hospital, printed up. The total cost was going to be around $19,000 so I was expecting to have to cover about $4,000 of it myself. The surgeon's price was $3,000 ($1,500 for the actual surgery and $1,500 for twelve months of follow-up care) and the surgeon's assistant was $470. As it turned out, despite being very explicit about the need for everyone involved to be in my network, they used a surgeon's assistant that was out-of-network and that billed my insurance for $5,000. Had they been in network, the allowed amount was $510 dollars (very close to the upfront cash-pay price), but because there was no contract with them, they simply paid the full amount as much as they could under the procedure cap, which meant that they paid them about $3,500. So that was $3,000 above what the assistant has agreed to be paid and, worse, that was money that did NOT go to the hospital which increased my direct costs by that same $3,000. Plus, the assistant's office sent me a bill for the remaining $1,500 (since they could balance-bill owing to the lack of a contract preventing it). They quickly agreed to accept the amount received as payment in full (gee, how generous of them, they had to sacrifice and only take 7x what they had agreed to take!).
I had a similar thing happen to me last year for an out of network procedure where the physicians got the pre-authorization and were paid (Anthem), but the inept business office of the facility didn't. Of course, Anthem denied facility charges. Facility appealed and said I told them I thought they were in network. Of course, that appeal was denied. I then took the unusual step of making a second appeal. I provided medical justification, pointed out that the physicians had gotten prior-authorization based on information that could only have been communicated to them by the facility, and pointed to the facility's telephone recordings. Anthem and the facility knew where that was headed, since the facility clearly misrepresented what I had told it. Of course, I did not make such a threat nor mention my own recordings in that second appeal. Shortly thereafter, I got a letter from Anthem notifying me that an independent appeal team had approved my appeal, and the bill had been settled entirely. The facility even waived a small co-pay it could have charged. It's a jungle.

While some physicians are certainly guilty of abuse, in my experience over many years, facility charges are the greatest abusers (e.g., $6 for an aspirin). My 30-minute precautionary stay in recovery (I had no sedative or anesthesia prior to or during the procedure) was charged at much more than the total of physician charges.

As you point out, "balance billing" is another gotcha.
 

dl324

Joined Mar 30, 2015
10,731
These forms, which are pretty universal (in the U.S.), generally state that you are agreeing to pay the bill if, for any reason, the insurance company denies the claim.
That's not likely to work. If you don't agree to the provider's terms, they don't have to provide service.
 

Thread Starter

WBahn

Joined Mar 31, 2012
25,750
That's not likely to work. If you don't agree to the provider's terms, they don't have to provide service.
Agreed. I never said they did, nor do I expect or demand them to. They have NO obligation to do business with you, but the point is that, more often than not, YOU don't have to do business with THEM, either. There ARE alternatives and you DO have SOME leverage in the deal, since they don't get paid anything for services they don't provide. If they won't agree to accept a commitment to pay their cash-pay price if insurance denies, then take your business elsewhere. It won't always work -- never said it would. But virtually no one even tries and people would be surprised how often you CAN get them to agree to a reasonable commitment IF you walk in with the information in hand and are willing to make the effort (and there IS some effort involved, to be sure) to use it.
 

Thread Starter

WBahn

Joined Mar 31, 2012
25,750
I had a similar thing happen to me last year for an out of network procedure where the physicians got the pre-authorization and were paid (Anthem), but the inept business office of the facility didn't.
One area that is getting better (on a state-by-state basis, anyway) is the morass of in-network and out-of-network billings that is particularly common in emergent care situations. One thing I pushed for whenever I could (with no real expectation that it would actually change) was to have the in/out decision be based on the initial point of contact. If you go to a facility that is in network, then that facility should have agreements in place with every provider that works out of that facility stating that they will accept in-network amounts for any work they perform in that facility. I got burned back in 2008 when I had my stroke. I made the effort specifically to go to an emergency room that was in network, but several of the physicians and some of the diagnostic tests (all of which were performed on-site) were "independent contractors" and were out-of-network. So I got hit with tons of inflated balance-billing amounts that I had to fight through. In all but one case I was able to get them reclassified as in-network by having the provider rebill the insurance using the hospital's address as the office location (and all but one of the providers worked with me to make that happen). One of them I couldn't get to do that and ended up paying about $800 extra as a result.

Today (in Colorado) this is a lot better. When I went to the emergency room (on a Saturday morning) for my gallbladder near-explosion I called the insurance company ahead of time to ascertain which hospital I should go to and they told me that the hospital I inquired about was in-network, but of course added the caveat that the information could be out of date and so it was no guarantee and that I needed to check with the facility to confirm. When we got to the emergency room the first thing I asked was whether they were in-network and, as I fully expected, they said that I needed to call my insurance company or contact the hospital business office on Monday. Sure enough, it turned out that they were actually NOT in network and neither were the majority of the providers I saw, which I found out after I got home from a six-day hospital stay and got the benefits determination letter in the mail stating that all benefits were out-of-network and that I was not only subject to the much higher deductible and co-insurance but also to balance billing. I was absolutely livid -- I had done everything I possibly could, despite being in extreme pain, to ensure that I used an in-network facility. Needless to say, I was not in a good mood when I called the insurance company the next morning. But they informed me that Colorado law now requires that (at least for emergent care, I don't know exactly how broad the law is) emergency room care provided at the nearest available facility be treated as in-network AND that all related care be treated as in-network. So as long as the surgery and hospital stay and services were billed in conjunction with the emergency room visit, it would all be treated as in-network. They even said that I didn't need to file an appeal of the benefits determination, that they would do that for me in house. Somewhat to my surprise, that's exactly what happened and all of the inflated balance billing charges simply went away. I even called up one provider to pay the in-network allowed amount that was on the EOB and their updated statement and they told me to hold off because the insurance company had informed them that it was being reviewed. I ended up not owing them anything because I had met the in-network out-of-pocket max and so the insurance company went back and paid that and two other claims that I had already paid, so I got credits from those two.

I'm not really sure how this actually works. If I'm a provider that is not in some insurance company's network, how can I be forced to accept the payment terms as if I were? The only thing I can think is that it is something like what I was always pushing for and that it was now a required part of the contract between a facility and their independent providers.
 

jpanhalt

Joined Jan 18, 2008
9,391
One thing I pushed for whenever I could (with no real expectation that it would actually change) was to have the in/out decision be based on the initial point of contact. If you go to a facility that is in network, then that facility should have agreements in place with every provider that works out of that facility stating that they will accept in-network amounts for any work they perform in that facility.
That may work where you live, but in Cleveland and in most large American cities, each major player offers everything. In Cleveland, the two major players are the Cleveland Clinic (CCF) and University Hospitals (Case Western Reserve University Hospitals, CWRU). I can assure you that no such agreement existed between those two. Years ago, a joint venture building was built between the two (physically between the two University Circle campuses) . It is the so-called Walker Center. CWRU elevators did not stop on the CCF floors, and visa versa. Maybe that has changed. Google seems to indicate that CCF owns the entire building now.
 

Thread Starter

WBahn

Joined Mar 31, 2012
25,750
That may work where you live, but in Cleveland and in most large American cities, each major player offers everything. In Cleveland, the two major players are the Cleveland Clinic (CCF) and University Hospitals (Case Western Reserve University Hospitals, CWRU). I can assure you that no such agreement existed between those two. Years ago, a joint venture building was built between the two (physically between the two University Circle campuses) . It is the so-called Walker Center. CWRU elevators did not stop on the CCF floors, and visa versa. Maybe that has changed. Google seems to indicate that CCF owns the entire building now.
If you are dealing with facility that does everything in house, then it is a non-issue.

Here the problem wasn't (isn't) work done collectively between large players, it was (and still is, at least in normal situations) that the large players (the hospitals) farm out a lot of the services, even ones that are performed on site, to a host of individual small players. The emergency room doctors are seldom employees of the hospital, instead they have separate practices and they contract with the hospital to provide services there, but they are separate entities from a business/billing aspect. The surgeons and the anesthesiologists are separate practices and bill separately. The same with most of the diagnostic lab services. The X-ray, CAT scan, and MRI folks were ALL separate companies that billed separately. I don't know who owned the physical machines or what the arrangements actually are -- I could easily see a variety of lease arrangements either for basic space or for furnished labs that would keep them as separate business entities. For this last stay, the hospital provided nursing and operating room support personnel only. They did SOME of the blood work in house. They also submitted bills that, to my eye, seemed to be directly duplicating some of the bills that the independent providers had submitted. I had no way of knowing if they were actually billing for the same service, similar services performed separately at different times, or they each provided a part of a single service and were billing just their portion. I brought the concern to the attention of the insurance company but it turned out they were already on it and most of those charges were allowed for one party (almost always the independent provider) and disallowed for the other (which tells me that they were double billing hoping to get away with it and that the insurance companies are well aware of the practice and routinely prevent it, though I'm sure they miss some from time to time and the provider gets their piece of the moon).

While I have ideas that could address these issues on a broader scale, this isn't the place to discuss them. Here I'm just bringing up some things that, if people are aware of them, they might be able to use in the reality that they face as individuals. Certainly these are things whose applicability is going to vary greatly from location to location and situation to situation; but I think that being aware of potential tools that might be at your disposal can only make you a more informed consumer.
 

jpanhalt

Joined Jan 18, 2008
9,391
@WBahn

You have to separate what may appear on paper, and the reality of the situation. Most states have laws prohibiting the "corporate" practice of medicine. That is, a hospital per se cannot bill for physician-provided services (i.e., it may bill for the technical component, but not the professional component). The fact that pathology and other "hospital-based practices" bill separately may well represent that fact. In reality, insurance contracts for those practices are negotiated by the facility, and that facility retains control of those practices.

Most universities have "clinical practice" plans that appear separate and allow such separate billing. Non-hospital-based practices may differ (e.g., orthopedic surgery, Wills Eye Hospital), but in reality, the hospital/university retains a good deal of control via credentialing which decides who can admit patients and provide services within the hospital. Economic credentialing (i.e., not credentialing qualified physicians because of competition) has been deemed legal.

Fully integrated practices, such as the Mayo Clinic and Cleveland Clinic have salaried physicians, are physician run, and differ.
 

Thread Starter

WBahn

Joined Mar 31, 2012
25,750
@WBahn

You have to separate what may appear on paper, and the reality of the situation. Most states have laws prohibiting the "corporate" practice of medicine. That is, a hospital per se cannot bill for physician-provided services (i.e., it may bill for the technical component, but not the professional component). The fact that pathology and other "hospital-based practices" bill separately may well represent that fact. In reality, insurance contracts for those practices are negotiated by the facility, and that facility retains control of those practices.

Most universities have "clinical practice" plans that appear separate and allow such separate billing. Non-hospital-based practices may differ (e.g., orthopedic surgery, Wills Eye Hospital), but in reality, the hospital/university retains a good deal of control via credentialing which decides who can admit patients and provide services within the hospital. Economic credentialing (i.e., not credentialing qualified physicians because of competition) has been deemed legal.

Fully integrated practices, such as the Mayo Clinic and Cleveland Clinic have salaried physicians, are physician run, and differ.
Oh, there is no doubt whatsoever that the number of possible combinations and complications in the whole practice of medical billing is enormous. It has arisen that way for a variety of factors and the current situation is largely a result of the various players simply trying to find a way to navigate the world that they operate in and get on with their business. The result is a complicated mess that virtually no one actually understands and that leaves open the door for all kinds of gamesmanship, some of it unethical or even illegal and some of it neither.

What really knocked me back on my heals was the first time that I realized that the people providing medical services seldom have the faintest idea what their patients are being billed, let alone actually paying, for their services. You just don't see this anywhere else (I'm sure there's some exceptions somewhere, but I don't think at this scale). When I was designing ASICs it didn't take but a couple of months before I could give a prospective customer a pretty good estimate, off the top of my head, what they were looking at to have us design the chip, have the fab house manufacture the chip (either as an engineering run or in production as a full wafer run), the packaging house package the chip, and the testing house test the chip (this one was actually the most uncertain because there were so many options). We didn't do any of this except design the chip and we seldom were involved with the business side of the transactions with any of the other players. Yet it was impossible for me to function as an IC designer without being exposed to what the typical costs to our customers could be expected to be.

The first time I saw this was when I was looking at having the veins in my legs stripped and I asked the surgeon what the cost was going to be. He said that his services were $580. He said I would have to contact the hospital to find out their charges and the anesthesiologist to find out theirs. I assumed that this was because he didn't know what their exact rates were, not that he was absolutely oblivious to them (since he had been performing this surgery for over thirty years). The anesthesiologist's office gave me a price of $4,000 and the hospital gave me a price of $15,000 for the use of the operating room for one hour. I didn't know at the time about the outrageous billing inflation (so I'm sure I could have gotten much lower cash-pay prices) but at the time I was very much under the naive belief that everyone charged a price that they expected to be paid. When I mentioned these to the surgeon, he was visibly taken aback and shocked and speechless for several seconds. He simply didn't know how to respond. I opted not to have the surgery because of the cost I was looking at (I was on an HSA at the time so that would have been $7k out-of-pocket right there). Several years later, when I was on a traditional plan, I had the surgery performed and the total authorized cost of everything came in at the $2k mark, give or take (or right about 10% of the what the original billed amount years earlier would have been). Fortunately, the next time I was on an HSA plan I was aware of the game and was able to much more effectively negotiate my way through the maze.
 

jpanhalt

Joined Jan 18, 2008
9,391
It is not surprising your physicians didn't know what each other charged. Physicians are not allowed to discuss what they charge with other independent physicians, and the FTC has been aggressive in prosecuting violations. There was a case many years ago where two physicians were at a party and just happened to mention fees for a procedure. There was no intentional collusion, nor could the government show that either changed its fee as a result. Nevertheless, they were prosecuted and found guilty.

Here's a more recent example, albeit on a bigger scale: https://www.overlawyered.com/2006/12/ftc-snares-doctors-in-price-fixing-trap/ There are exceptions for group practices and discussion within such groups but not between groups.

That rule, as pointed out in the link, does not apply to facilities and insurers, including Medicare. Here's a link to Medicare: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html
 

Thread Starter

WBahn

Joined Mar 31, 2012
25,750
It is not surprising your physicians didn't know what each other charged. Physicians are not allowed to discuss what they charge with other independent physicians, and the FTC has been aggressive in prosecuting violations. There was a case many years ago where two physicians were at a party and just happened to mention fees for a procedure. There was no intentional collusion, nor could the government show that either changed its fee as a result. Nevertheless, they were prosecuted and found guilty.

Here's a more recent example, albeit on a bigger scale: https://www.overlawyered.com/2006/12/ftc-snares-doctors-in-price-fixing-trap/ There are exceptions for group practices and discussion within such groups but not between groups.

That rule, as pointed out in the link, does not apply to facilities and insurers, including Medicare. Here's a link to Medicare: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html
Knowing in detail what the exact charges are is one thing. Being totally unaware of the order of magnitude of the charges that are common in your field is something completely different. Also, I think there's a difference (at least potentially, I haven't read the law) between two providers of the same service discussing fees and providers knowing what fees are typically charged for related services.

If doctors aren't supposed to know what fees are charged by providers of related services, then how was it that my surgeon (for the surgery discussed previously) had handouts with the list of fees for all of the lab work, consults, pre-op screening, hospital care, surgery (including himself, the assistant, and the anesthesiologist), and post-surgery lab and support work? He had a handout for each of the three variants on the surgery he performed. With the exception of the hospital and the assistant (thanks to the billing morass, more than anything), all of those fees were within $20 of what the price came in at. With the exception of the hospital they were not even specific to a single provider, but rather just generic costs that you can expect. Yet they were quite accurate. I believe it is because, for this type of surgery, there are enough people that have to pay the full-boat or that have insufficient coverage caps that the people he serves are sensitive to the costs and therefore it is in his best interest to be informed of what those costs are.
 

jpanhalt

Joined Jan 18, 2008
9,391
1) I didn't mean to imply your physician was totally unaware of the others' fees. One becomes aware of the community. The issue is whether any physician (absent other circumstances) would want to share that information given the well-demonstrated heavy hand the FTC has taken.
2) There is an exception for group practices in which risk and benefit are shared (e.g., Mayo Clinic, Cleveland Clinic Foundation, many university practice plans).
3) Fee schedules can be published and even advertised. That is distinctly different from a discussion of fees between two or more unaffiliated (risk sharing) practitioners.
4) Without knowing details about the physician you mention, namely whether he/she was salaried, group practice, etc., I cannot comment about those disclosures. The fee schedules handed to you may well have been publicly available. I don't believe that violates FTC. On the other hand, some physicians have ethical concerns about publishing fees, as do some other professionals like lawyers.

The views on physicians are changing. Before the 1950's, it was considered unethical for physicians even to be salaried. In fact, from almost its inception, physicians at the Mayo Clinic were salaried. The American Medical Association considered that unethical. Today, I believe a majority of physicians are salaried. Similarly, advertising was highly shunned. Today we see more and more of that. Here is the AMA's position on advertising: https://www.ama-assn.org/delivering-care/ethics/advertising-publicity

In the past 75 years, we have gone from physicians being regarded individualized providers to being providers of commodity services. There are lots of studies on physician burn out and dissatisfaction with that role. Not all physicians feel that way, however. Some even seek that status.
 

Thread Starter

WBahn

Joined Mar 31, 2012
25,750
1) I didn't mean to imply your physician was totally unaware of the others' fees. One becomes aware of the community.
Ah, but that's the point -- I'm not only implying he was unaware, I'm flat out stating it. When I told him that the anesthesiologist was going to charge $4k and the hospital was going to charge $15k (for one hour use of an operating room for an out-patient procedure) he was completely taken aback and speechless. His eyes got real wide and his mouth opened and he didn't know how to respond. You would think and hope that one becomes aware of the community, but not in the medical industry. Most practitioners that I've talked to aren't even aware of what THEY charge for the services THEY provide, not even a ballpark park figure. I think the only reason that the surgeon that stripped the veins in my legs knew what his office billed for his services was because vein stripping was still often a non-covered procedure when done for cosmetic purposes, so he had a certain level of cash-pay traffic in which the patients wanted to know. That's just not the situation for many practitioners who deal almost exclusively with non-elective procedures. For instance, when I had to have an upper and lower endoscopy I asked the gastroenterologist how much it was going to cost. Not a clue. I asked if we were talking $500, $5000, or $50,000 and she had no idea which of those was more likely. I pressed her a bit (she was willing to discuss things and it looked to me like she was really thinking about it for the first time) and she had to admit that she truly did not know if the total cost that was going to be billed was closer to $500 or $50,000. She simply had no idea -- and I suspect that actually reflected a subconscious awareness of how absurdly ridiculous the billing is which prevented her from ruling out the $50,000 figure out of hand. She didn't even know how much HER portion of the procedure was likely to be. The billing has become completely divorced from BOTH parties -- the provider AND the patient -- to such a degree that NEITHER side has a clue about the costs and either side has to make a concerted effort to dig out any information and what they do dig out is hidden and layered and convoluted nearly beyond any hope of comprehension.
 

danadak

Joined Mar 10, 2018
4,057
If you think about this how did a profession lose complete and almost any
control over their own destiny.

And how did this occur in our nation ? A nation that is supposed to value competition,
one that values excess earnings to be used as capital investment in the future, one
that values fiduciary and financial discipline.

How did this happen ? One word, monopolies ?.

Its astonishing.


Regards, Dana.
 

Thread Starter

WBahn

Joined Mar 31, 2012
25,750
If you think about this how did a profession lose complete and almost any
control over their own destiny.

And how did this occur in our nation ? A nation that is supposed to value competition,
one that values excess earnings to be used as capital investment in the future, one
that values fiduciary and financial discipline.

How did this happen ? One word, monopolies ?.

Its astonishing.


Regards, Dana.
Let's please steer clear of discussing how or why we got here. It's irrelevant for the purpose of this discussion, which is on options of how people can better deal with the situation as it is today.
 

danadak

Joined Mar 10, 2018
4,057
Let's please steer clear of discussing how or why we got here. It's irrelevant for the purpose of this discussion, which is on options of how people can better deal with the situation as it is today.
I concur, I should have started another thread. Yours valuable but 50% of the
issue. The other issue is to get active finding out how we got here and get in
the game of being active to fight and change the system. One w/o the other is
incomplete and a recipe for further abuse of the consumers.

Regards, Dana.
 
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