4 ms·

Honest question. If I ask a doctor "will I be billed for this procedure," and they straight-up can't or won't answer me, what's going on? Whose fault is that?

riahi 7y ago
It entirely depends on if they are independent and work for themselves, and therefore know their contracted rates with the insurance companies. If the physician in question is an employee or a member of a large health organization, it's entirely possible someone else does those negotiations on the person's behalf, so they would have literally no idea. By law, we can only charge one price to all payors. We cannot charge variable numbers; however, you can accept less money than charged. Medicare will pay what they pay; they don't care what my charge is. However, other payors (private insurance) will pay various amounts which are usually higher than Medicare. If I set my top price too low, I'm leaving money on the table. However, I cannot "enter the negotiation" even with a cash-paying-patient legally without charging the top-line price. These top line charges are called "Chargemaster" rates. I can probably get a hold of my institution's charge master schedule and figure out what they'd charge you, but as one of literally 200 radiologists in my current practice, I have no say in those rates at all.
- subhobroto 7y ago
  > However, I cannot "enter the negotiation" even with a cash-paying-patient legally without charging the top-line price. Yes, this is true and if you try and settle with a cash-paying-patient who's insured, the insurance company can drop you as well as pursue breach of contract damages. > By law, we can only charge one price to all payors What law is it? because this is absolutely untrue in a country that does not follow an all payer rate set system and the U.S. ain't one. In the U.S. the VA pays one rate, Medicare another, private another, Indian Health Service (IHS) and Tribal Health another and so on. Here's a helpful chart for you that shows all the different parties each of who pays different rates for the SAME CPT CODE: https://qph.fs.quoracdn.net/main-qimg-72f33aa55c71c439fc4660b23333c55b-c https://qph.fs.quoracdn.net/main-qimg-72f33aa55c71c439fc4660... Infact a lot of avarice ridden providers refuse to treat Medicare patients, who need the most help, precisely because Medicare pays less than private party care. > one of literally 200 radiologists in my current practice, I have no say in those rates at all Oh yes you do. Most radiologists dont even attach themselves to a network because they can bill OON. Which is why 35 percent of adults have surprise bills for imaging services: https://www.radiologybusiness.com/topics/healthcare-economics/surprise-billing-imaging-services-survey https://www.radiologybusiness.com/topics/healthcare-economic... Let me quote another article: http://www.ncsl.org/research/health/counteracting-surprise-medical-billing.aspx http://www.ncsl.org/research/health/counteracting-surprise-m... > As an example, a woman seeks care for a broken limb. She is careful to go to a hospital that is in her health insurance plan’s network. She remits her copayment and receives an X-ray. Several days or weeks after the visit, the woman receives a bill for hundreds, possibly thousands, of dollars. Even though the patient was seen at an in-network hospital, the radiologist who read her X-ray was not in her insurance network. Still, the patient is responsible for picking up the out-of-network cost. No one is forcing a radiologist to be OON - it's their own decision and they do it exactly to have a say in their rates. It's fine to want to make money. Whats the big deal with all this smoke and mirrors? Here's how a business transaction outside healthcare in the U.S. goes: Party A: Hey B, you have X, which I need Party B: Yes. I have X, and I want $Y from you Party A: OK, but can you try and do it for a bit less, say $Z? Party B: Yes. Here's how a business transaction in healthcare in the U.S. goes: Party A: Hey doctor, you have X, which I need Doctor: Yes. I have X, and I accept your insurance! Party A: OK, here I am. $30 co pay, right? Doctor: Yup! Doctor (3 months later): Oh, turns out you owe me $250 for the local anesthetic and $1700 for use of the camera I shoved down your throat 3 months ago. Also the thing I did was surgery because I went inside your body so it's not a $300 in office visit but a $750 one. If you don't know what endoscopy is, it's your fault you ignorant slob. It's your fault you didn't know all of this. I didn't go to medical school for nothing, now pay up or I will repo your house and garnish your wages. The pain is showing now. People are really upset about how they have been and continue to be taken advantage of
- ben_jones 7y ago
  > By law, we can only charge one price to all payers My last visit to one medical for a pretty average checkup netted my a bill of ~$450. I checked their website, and saw a price for the same “procedure” for 100. When I called up they said that was the price for uninsured patients who had that procedure and that because I was insured, they were legally compelled to charge me $450. Ultimately the support agent hinted at me to say some magic line about financial hardship so she could lower it to ~250. As a patient all the doctors and admins are pointing at the insurers and all the insurers are pointing at the doctors and admins. It’s hard to trust any of you.
  - riahi 7y ago
    Any place that accepts insurance is bound by the terms of the insurance contract, which usually includes a most favored nation clause, meaning that you won't accept cash payment for less than the negotiated reimbursement from the carrier. Similarly, you cannot charge less than you accept from Medicare/Medicaid. What we can do is bill you, then write off whatever is equal to the highest contract we have. People in private practice approve this not infrequently; but corporate and mega groups have removed individual decision making and stripped us from pricing discretion. These are the pains of 3rd party payers. I advise everyone who has an HDHP or no insurance to find a reasonable cost direct primary care. The subscription is often much cheaper than you'd think.
- smsm42 7y ago
  > If the physician in question is an employee or a member of a large health organization, it's entirely possible someone else does those negotiations on the person's behalf, so they would have literally no idea. They personally might not, but their organization certainly does. If they are large hospital, they won't negotiate rates with each person anew, they already have everything figured out. If the doctor can't access it with a couple of clicks on their PC, it's an organizational failure. And if the doctors don't raise a stink about it every day but shrug and tell the patient "you'll see when we send you 20 separate bills, 20 line items each, all coded with internal codes you have no access to" - then it becomes their failure too. I can appreciate they are part of a large organization, but they are not totally powerless and if they really pushed for it they probably could do something. Maybe not one radiologist, but if every radiologist would ask the billing to implement that system, I think they'd think about doing it sooner or later.
SkyPuncher 7y ago
> they straight-up can't or won't answer me, what's going on The answer is they probably don't know. Or if they do know, they can't be 100% in their answer. ----- There are literally thousands and thousands of insurance combinations. Aetna might approve one thing while Blue Cross won't. Even within the same provider network, your specific medical history (or even your claim processor) can affect if you'll be covered for a specific procedure. Even if the doctor contacts insurance, it won't guarantee something will be covered. You have to wait until things get billed to resolve specifics.
- yazaddaruvala 7y ago
  Lol if it’s too difficult for an MD to know. For all their capability of understanding and working as a professional to answer a simple question about costs, then something is wrong. If doctors were obliged to answer this question, I bet we would have a simpler system because the physicians would put pressure on the system to simplify.
  - SkyPuncher 7y ago
    If MD's controlled billing, they'd absolutely be able to answer. You see this with doctors that have switched to entirely cash pay. They can provide quotes and estimates much like automotive maintenance or general contracting.
- PhasmaFelis 7y ago
  > The answer is they probably don't know. Or if they do know, they can't be 100% in their answer. So whose fault is that? It's inexcusable to be forced to accept a service before being told how much it costs. If the doctor really is completely helpless, I want to know who's forcing them to go along. "That's just the way things are" is not an acceptable answer.
  - SkyPuncher 7y ago
    >"That's just the way things are" Unfortunately, that's what it comes down to in practice. ----- It really comes down to insurance companies. Some doctors are switching to private pay only (i.e. you pay out of pocket). This allows them to operate much more closely to a traditional business, like auto repair or general contracting. They have easily itemized costs for materials and a standard labor rate. When insurance comes in, absolutely all of that goes out the window. * Insurance never wants to commit to exact costs. Doing so removes their leverage to minimize bills. * You remove the incentive for high efficiency (which simply becomes an issue in every aspect of health care). * Patients never even attempt to shop around for costs. * Patient satisfaction scores are completely at odds with billing efficiency. You either do too much to minimize visits or risk loosing money if you choose to tackle something iteratively. ----- In general, I think the entire health system would be drastically better if health insurance took the approach of automotive insurance. Insurance is only for catastrophic events. Standard care and maintenance is an expected cost that comes out of pocket.

riahi 7y ago

It entirely depends on if they are independent and work for themselves, and therefore know their contracted rates with the insurance companies. If the physician in question is an employee or a member of a large health organization, it's entirely possible someone else does those negotiations on the person's behalf, so they would have literally no idea. By law, we can only charge one price to all payors. We cannot charge variable numbers; however, you can accept less money than charged. Medicare will pay what they pay; they don't care what my charge is. However, other payors (private insurance) will pay various amounts which are usually higher than Medicare. If I set my top price too low, I'm leaving money on the table. However, I cannot "enter the negotiation" even with a cash-paying-patient legally without charging the top-line price. These top line charges are called "Chargemaster" rates. I can probably get a hold of my institution's charge master schedule and figure out what they'd charge you, but as one of literally 200 radiologists in my current practice, I have no say in those rates at all.

subhobroto 7y ago
> However, I cannot "enter the negotiation" even with a cash-paying-patient legally without charging the top-line price. Yes, this is true and if you try and settle with a cash-paying-patient who's insured, the insurance company can drop you as well as pursue breach of contract damages. > By law, we can only charge one price to all payors What law is it? because this is absolutely untrue in a country that does not follow an all payer rate set system and the U.S. ain't one. In the U.S. the VA pays one rate, Medicare another, private another, Indian Health Service (IHS) and Tribal Health another and so on. Here's a helpful chart for you that shows all the different parties each of who pays different rates for the SAME CPT CODE: https://qph.fs.quoracdn.net/main-qimg-72f33aa55c71c439fc4660b23333c55b-c https://qph.fs.quoracdn.net/main-qimg-72f33aa55c71c439fc4660... Infact a lot of avarice ridden providers refuse to treat Medicare patients, who need the most help, precisely because Medicare pays less than private party care. > one of literally 200 radiologists in my current practice, I have no say in those rates at all Oh yes you do. Most radiologists dont even attach themselves to a network because they can bill OON. Which is why 35 percent of adults have surprise bills for imaging services: https://www.radiologybusiness.com/topics/healthcare-economics/surprise-billing-imaging-services-survey https://www.radiologybusiness.com/topics/healthcare-economic... Let me quote another article: http://www.ncsl.org/research/health/counteracting-surprise-medical-billing.aspx http://www.ncsl.org/research/health/counteracting-surprise-m... > As an example, a woman seeks care for a broken limb. She is careful to go to a hospital that is in her health insurance plan’s network. She remits her copayment and receives an X-ray. Several days or weeks after the visit, the woman receives a bill for hundreds, possibly thousands, of dollars. Even though the patient was seen at an in-network hospital, the radiologist who read her X-ray was not in her insurance network. Still, the patient is responsible for picking up the out-of-network cost. No one is forcing a radiologist to be OON - it's their own decision and they do it exactly to have a say in their rates. It's fine to want to make money. Whats the big deal with all this smoke and mirrors? Here's how a business transaction outside healthcare in the U.S. goes: Party A: Hey B, you have X, which I need Party B: Yes. I have X, and I want $Y from you Party A: OK, but can you try and do it for a bit less, say $Z? Party B: Yes. Here's how a business transaction in healthcare in the U.S. goes: Party A: Hey doctor, you have X, which I need Doctor: Yes. I have X, and I accept your insurance! Party A: OK, here I am. $30 co pay, right? Doctor: Yup! Doctor (3 months later): Oh, turns out you owe me $250 for the local anesthetic and $1700 for use of the camera I shoved down your throat 3 months ago. Also the thing I did was surgery because I went inside your body so it's not a $300 in office visit but a $750 one. If you don't know what endoscopy is, it's your fault you ignorant slob. It's your fault you didn't know all of this. I didn't go to medical school for nothing, now pay up or I will repo your house and garnish your wages. The pain is showing now. People are really upset about how they have been and continue to be taken advantage of
ben_jones 7y ago
> By law, we can only charge one price to all payers My last visit to one medical for a pretty average checkup netted my a bill of ~$450. I checked their website, and saw a price for the same “procedure” for 100. When I called up they said that was the price for uninsured patients who had that procedure and that because I was insured, they were legally compelled to charge me $450. Ultimately the support agent hinted at me to say some magic line about financial hardship so she could lower it to ~250. As a patient all the doctors and admins are pointing at the insurers and all the insurers are pointing at the doctors and admins. It’s hard to trust any of you.
- riahi 7y ago
  Any place that accepts insurance is bound by the terms of the insurance contract, which usually includes a most favored nation clause, meaning that you won't accept cash payment for less than the negotiated reimbursement from the carrier. Similarly, you cannot charge less than you accept from Medicare/Medicaid. What we can do is bill you, then write off whatever is equal to the highest contract we have. People in private practice approve this not infrequently; but corporate and mega groups have removed individual decision making and stripped us from pricing discretion. These are the pains of 3rd party payers. I advise everyone who has an HDHP or no insurance to find a reasonable cost direct primary care. The subscription is often much cheaper than you'd think.
smsm42 7y ago
> If the physician in question is an employee or a member of a large health organization, it's entirely possible someone else does those negotiations on the person's behalf, so they would have literally no idea. They personally might not, but their organization certainly does. If they are large hospital, they won't negotiate rates with each person anew, they already have everything figured out. If the doctor can't access it with a couple of clicks on their PC, it's an organizational failure. And if the doctors don't raise a stink about it every day but shrug and tell the patient "you'll see when we send you 20 separate bills, 20 line items each, all coded with internal codes you have no access to" - then it becomes their failure too. I can appreciate they are part of a large organization, but they are not totally powerless and if they really pushed for it they probably could do something. Maybe not one radiologist, but if every radiologist would ask the billing to implement that system, I think they'd think about doing it sooner or later.

SkyPuncher 7y ago

> they straight-up can't or won't answer me, what's going on The answer is they probably don't know. Or if they do know, they can't be 100% in their answer. ----- There are literally thousands and thousands of insurance combinations. Aetna might approve one thing while Blue Cross won't. Even within the same provider network, your specific medical history (or even your claim processor) can affect if you'll be covered for a specific procedure. Even if the doctor contacts insurance, it won't guarantee something will be covered. You have to wait until things get billed to resolve specifics.

yazaddaruvala 7y ago
Lol if it’s too difficult for an MD to know. For all their capability of understanding and working as a professional to answer a simple question about costs, then something is wrong. If doctors were obliged to answer this question, I bet we would have a simpler system because the physicians would put pressure on the system to simplify.
- SkyPuncher 7y ago
  If MD's controlled billing, they'd absolutely be able to answer. You see this with doctors that have switched to entirely cash pay. They can provide quotes and estimates much like automotive maintenance or general contracting.
PhasmaFelis 7y ago
> The answer is they probably don't know. Or if they do know, they can't be 100% in their answer. So whose fault is that? It's inexcusable to be forced to accept a service before being told how much it costs. If the doctor really is completely helpless, I want to know who's forcing them to go along. "That's just the way things are" is not an acceptable answer.
- SkyPuncher 7y ago
  >"That's just the way things are" Unfortunately, that's what it comes down to in practice. ----- It really comes down to insurance companies. Some doctors are switching to private pay only (i.e. you pay out of pocket). This allows them to operate much more closely to a traditional business, like auto repair or general contracting. They have easily itemized costs for materials and a standard labor rate. When insurance comes in, absolutely all of that goes out the window. * Insurance never wants to commit to exact costs. Doing so removes their leverage to minimize bills. * You remove the incentive for high efficiency (which simply becomes an issue in every aspect of health care). * Patients never even attempt to shop around for costs. * Patient satisfaction scores are completely at odds with billing efficiency. You either do too much to minimize visits or risk loosing money if you choose to tackle something iteratively. ----- In general, I think the entire health system would be drastically better if health insurance took the approach of automotive insurance. Insurance is only for catastrophic events. Standard care and maintenance is an expected cost that comes out of pocket.