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I work in healthcare. Here is an exchange I had with a major hospital about standard surgery (one of those deemed "Shoppable services") earlier this year. This

I work in healthcare. Here is an exchange I had with a major hospital about standard surgery (one of those deemed "Shoppable services") earlier this year. This exchange was possible after I was able to get an email recipient, following a 30min conversation. >>>> Hello! I was told by the very helpful Ms. XXX, that you would be able to provide patient responsibility amount , related to CPT codes for XXX procedure. I am attaching front and back of my insurance card (Payor). The member DOB is MM/DD/YY The specific 2 codes in question are : CPT 12345 CPT 01234 Can you please provide the total cost and patient resp. for the CPTs above? ___________________________________________________________ Response: Good morning, >>>>>The hospital does not process estimates for patients with insurance coverage. However, our web portal contains charges under the Hospital Price Transparency link. I have included the link in the subject line for easy access. [comment: This link was broken. After much browsing.. I was able to find an alternate route. The linked file turned out to be a JSON. I couldn't figure that one out] As far as out-pocket responsibility, your insurance company is the best source for that information; they will advise if you have any copay for the encounter. _______ Read the 1st sentence of the reply again. My blood still boils from that...

JohnBjorge 4y ago
This sounds about right. I've worked in the healthcare tech world for about 5 years on both sides (for providers and payors). I totally empathize with how annoying it is that essentially no one processes estimates for patients with insurance. There are some places though that do, and it tends to be small/medium size specialty practices (think orthopedics, ophthalmology, radiology) in forward thinking places (Seattle, Minneapolis, etc). I can give some technical reasons as to "why" they can't/won't give you an estimate. I'm not saying these are legitimate reasons, just stating what I've seen. One reason they may not want to give you an estimate is because depending on what happens during your visit/procedure, the codes that get billed could change quite a bit. Because of this their initial estimate could be wildly different. In addition to the procedure codes changing, there are modifiers/adjustments that can get applied to a procedure code depending on what happens during the procedure (which adds another level of uncertainty). For example, anesthesia often bills based on time and complexity. If the procedure runs long then it will cost more, if something goes wrong and the complexity increases then it will cost more, if a nurse anesthetist (CRNA) does your anesthesia rather than an MD it will cost less, etc. Another reason they may not want to give you an estimate is because they have no idea. This is in my experience the case most of the time. A given clinic/hospital is going to have many many contracts with many payors. There's a ton of nuance in these contracts and they are sometimes extremely complicated. I've read hundreds of these contracts and written software to try to scale price estimate tools for patients. It's really hard, happy to dive into it more if there's interest. I often see comments on hackernews along the lines of "it's just a fee schedule, how hard is it to put it in a database and select amount from feeschedule where procedure = 99215". The big wrinkle here is the contracts. The contracts are often times super complicated, dependent on many many different fee schedules and pricing methodologies. The fee schedules/pricing methodologies may be from the payor, they may be from 3rd party vendors, they may be proprietary, they may be based on medicare, etc. Then there's a whole slew of adjustments/modifiers that can trigger depending on tons of different events and combinations of procedures codes that may appear on a claim. Another reason they may not want to give you an estimate is because it's not straightforward to verify your insurance. There are clearinghouses that aggregate benefits data from major payors, but the data is kind of shoddy. It may return your insurance is active when it really is inactive. It may have bad data on what is covered vs not covered, what your deductible, coinsurance, etc are so given all this data is kind of unreliable then giving an estimate becomes pretty unreliable. Anyway, these were a few reasons off the top of my head. Again, I want to emphasize I'm 100% with you on how annoying it is that we can't get estimates. I spent 3 years literally trying to solve this problem, and we actually made really good progress if it gives you any hope that things will maybe (fingers crossed) get better overtime. I just wanted to give some context / spark some conversation around these contracts and why they are challenging from a technical perspective to automate price estimates.
- IG_Semmelweiss 4y ago
  I had a contribution drafted, but lost it all. In summary: >>>>>>>>>>>>>>>>> One reason they may not want to give you an estimate is because depending on what happens during your visit/procedure, the codes that get billed could change quite a bit. Because of this their initial estimate could be wildly different. This is a common excuse given by industry. Its also BS. I want to put it out there so people know. Would you accept if an airline tried to charge you extra if because of weather they served you extra food? Or took you to a different airport ? No. https://surgerycenterok.com/ https://surgerycenterok.com/ has a price on every procedure. It never changes. How? Because they know that price changes are related to a problem doctor. You can reliably predict a problem doctor due to (a) surprise coding and (b) complications. Good doctors (and pilots) know their cases and plan accordingly. >>>>>> Another reason they may not want to give you an estimate is because they have no idea. This is true. They don't know because no one has bothered to translate a scheduled case into specific CPTs and/or looked up rates rates with insurer. So someone dropped the ball. >>>>>>>>>I often see comments on hackernews along the lines of "it's just a fee schedule, how hard is it to put it in a database. Actually, you are misinformed here. The vast majority of contracts for independent providers are simple affairs that are % of medicare rates. The only excuse they have for not putting those % rates in the open is that they have no incentive to do so. But its lazy. They could say to patients "our contract with X payor is % of medicare" and then even the patient could figure it out. They don't even do that. And patients suffer as a result. ASC and Hospitals have no excuse. Even with complex contracts, they have massive staff that can do the work. >>>>>>>>..Another reason they may not want to give you an estimate is because it's not straightforward to verify your insurance.It may have bad data on what is covered vs not covered, what your deductible, coinsurance, etc are so given all this data is kind of unreliable then giving an estimate becomes pretty unreliable. In my experience, some of the data fields are reliably accurate. For the rest, we are actually working on a solution. But let's not make perfect the enemy of the good. Its not hard to caveat a response like: "Assuming all your procedures are covered by your plan, based on your remaining deductible of X and coinsurance of Y, your patient responsibility for this procedure is Z" Its not rocket science. I do it all the time myself.
  - JohnBjorge 4y ago

JohnBjorge 4y ago

This sounds about right. I've worked in the healthcare tech world for about 5 years on both sides (for providers and payors). I totally empathize with how annoying it is that essentially no one processes estimates for patients with insurance. There are some places though that do, and it tends to be small/medium size specialty practices (think orthopedics, ophthalmology, radiology) in forward thinking places (Seattle, Minneapolis, etc). I can give some technical reasons as to "why" they can't/won't give you an estimate. I'm not saying these are legitimate reasons, just stating what I've seen. One reason they may not want to give you an estimate is because depending on what happens during your visit/procedure, the codes that get billed could change quite a bit. Because of this their initial estimate could be wildly different. In addition to the procedure codes changing, there are modifiers/adjustments that can get applied to a procedure code depending on what happens during the procedure (which adds another level of uncertainty). For example, anesthesia often bills based on time and complexity. If the procedure runs long then it will cost more, if something goes wrong and the complexity increases then it will cost more, if a nurse anesthetist (CRNA) does your anesthesia rather than an MD it will cost less, etc. Another reason they may not want to give you an estimate is because they have no idea. This is in my experience the case most of the time. A given clinic/hospital is going to have many many contracts with many payors. There's a ton of nuance in these contracts and they are sometimes extremely complicated. I've read hundreds of these contracts and written software to try to scale price estimate tools for patients. It's really hard, happy to dive into it more if there's interest. I often see comments on hackernews along the lines of "it's just a fee schedule, how hard is it to put it in a database and select amount from feeschedule where procedure = 99215". The big wrinkle here is the contracts. The contracts are often times super complicated, dependent on many many different fee schedules and pricing methodologies. The fee schedules/pricing methodologies may be from the payor, they may be from 3rd party vendors, they may be proprietary, they may be based on medicare, etc. Then there's a whole slew of adjustments/modifiers that can trigger depending on tons of different events and combinations of procedures codes that may appear on a claim. Another reason they may not want to give you an estimate is because it's not straightforward to verify your insurance. There are clearinghouses that aggregate benefits data from major payors, but the data is kind of shoddy. It may return your insurance is active when it really is inactive. It may have bad data on what is covered vs not covered, what your deductible, coinsurance, etc are so given all this data is kind of unreliable then giving an estimate becomes pretty unreliable. Anyway, these were a few reasons off the top of my head. Again, I want to emphasize I'm 100% with you on how annoying it is that we can't get estimates. I spent 3 years literally trying to solve this problem, and we actually made really good progress if it gives you any hope that things will maybe (fingers crossed) get better overtime. I just wanted to give some context / spark some conversation around these contracts and why they are challenging from a technical perspective to automate price estimates.

IG_Semmelweiss 4y ago
I had a contribution drafted, but lost it all. In summary: >>>>>>>>>>>>>>>>> One reason they may not want to give you an estimate is because depending on what happens during your visit/procedure, the codes that get billed could change quite a bit. Because of this their initial estimate could be wildly different. This is a common excuse given by industry. Its also BS. I want to put it out there so people know. Would you accept if an airline tried to charge you extra if because of weather they served you extra food? Or took you to a different airport ? No. https://surgerycenterok.com/ https://surgerycenterok.com/ has a price on every procedure. It never changes. How? Because they know that price changes are related to a problem doctor. You can reliably predict a problem doctor due to (a) surprise coding and (b) complications. Good doctors (and pilots) know their cases and plan accordingly. >>>>>> Another reason they may not want to give you an estimate is because they have no idea. This is true. They don't know because no one has bothered to translate a scheduled case into specific CPTs and/or looked up rates rates with insurer. So someone dropped the ball. >>>>>>>>>I often see comments on hackernews along the lines of "it's just a fee schedule, how hard is it to put it in a database. Actually, you are misinformed here. The vast majority of contracts for independent providers are simple affairs that are % of medicare rates. The only excuse they have for not putting those % rates in the open is that they have no incentive to do so. But its lazy. They could say to patients "our contract with X payor is % of medicare" and then even the patient could figure it out. They don't even do that. And patients suffer as a result. ASC and Hospitals have no excuse. Even with complex contracts, they have massive staff that can do the work. >>>>>>>>..Another reason they may not want to give you an estimate is because it's not straightforward to verify your insurance.It may have bad data on what is covered vs not covered, what your deductible, coinsurance, etc are so given all this data is kind of unreliable then giving an estimate becomes pretty unreliable. In my experience, some of the data fields are reliably accurate. For the rest, we are actually working on a solution. But let's not make perfect the enemy of the good. Its not hard to caveat a response like: "Assuming all your procedures are covered by your plan, based on your remaining deductible of X and coinsurance of Y, your patient responsibility for this procedure is Z" Its not rocket science. I do it all the time myself.
- JohnBjorge 4y ago