Patient Beware

[Jeff Matthews]

Anyone ever see the 60-Minutes program where it was revealed that the medical charges billed to insurance providers were only a small fraction of what you would be billed if you were uninsured - i.e. gouging the uninsured? Well, anyway, here's a real case....

Cracked rib. Go to emergency room. 30 minute visit total. 20 minutes used to get X-rays. The last 10 minutes were apparently for the doctor to review the x-rays and have his nurse practitioner tell me there's nothing they can do except write a prescription for pain medicine and tell me to take it easy. That was fine; I figured that before going in. Incidentally, I never met the doctor. I am quite sure he invested 5 minutes or less of his time.

Doctor's bill: $653.00.

Needless to say, I knew that was horse-hockey.

Bill has CPT Code (which is like "part number") of 99284. The description is "Emergency Evaluation and Management Services." That is the only item on the bill.

I Google around and find what this same doctor charges for CPT Code 99284 when billing a Medicare patient.

He charges only $111.97. https://catalog.ama-assn.org/Catalog/cpt/cpt_search_result.jsp?_requestid=558802

Someone tell me that is not ****ed-up.

Anyway, they will accept $111.97, or if they want to go the distance, I will have his happy-a$$ in court to explain.

Some of you might want to keep the link on your "Favorites" in your browser for reference "in case of an emergency." [] It was very helpful to me, because now, I can prove that this really is the devil.

[Jeff Matthews]

Yes, I was aware of the issues you brought up. It still makes no difference in my opinion. If he can't make "losses" up across the board - i.e. IN HIS BILLS TO INSURERS AND MEDICARE AS WELL - it is unconscionable to pass it on to me. We all need to pay in similar proportions. These deep discounts - very, very, very deep discounts (if you want to call them that) - should not be given if the effect is to selectively pass the "loss" on to a certain group of people.

And... I am quite sure it will work out for me. I could afford to pay the bill. That's not the issue in the least. I have a pretty high set of morals on how to treat others, and even though I might devote more time jacking with this issue than it is worth (since I could easily work and make money as opposed to dealing with this), I choose to do what my conscience tells me - and that is.... don't let those ****ers **** me. It is the principle of the matter. That's not to imply that I am stopping work to go on a mission. It just means that I have the time to fit this in to my schedule, which I will.

I will stand on principle as to my particular issue. As to resolving it in a manner that would be workable for everyone, I have already pointed this out to Patient Advocates Foundation in D.C. and suggested a law needs to be enacted making it unlawful to charge any unisnured patient more than 120% of the amount charged to Medicare for the same type or class of procedure." Something like that.... I might even look up my legislators.

[Jeff Matthews]

I knew you were, Mark. My response was just to point out the other side of the argument against the "passing off losses" argument and the "discount" argument in case anyone else wanted to see the counter-points. I know you are aware of the counter-points. I believe I have a fair grasp of your political philosophy. Your past posts on such topics are quite interesting to me.

[BEC]

Jeff,

Yes, Medicare gets a nice discount. Here is an example from a minor out-patient surgery I had last year.

Bob

[jacksonbart]

When you say $653.00, did that cover the x-rays and all the other misc items they attach? If so sounds cheap. If it was just the charge from the Doctor, then I agree. I am currently in my 2nd year in medical school, not to practice but take care of me myself. Its more cost effective to avoid the insurance companies, lawyers and jury awards and to do it yourself and to pay for medical school then to pay the accumulated life time of heathcare bills, which really amount to reimbursing insurance companies, lawyers and jury awards delivered to defendants.

[Jeff Matthews]

Dang, Bob! You want to testify in my court case? []

Cross-exam of doc like this:

Doctor, let's see if I understand. Let's use these people sitting in this row as an example. Okay, there's ten people here. The seven on the left are covered by either insurance or medicare, and the three on the right are self-pay. Are you with me?

Doc: Yes.

Okay, now, for procedure 99284, you will charge for your services $111.97 for the seven people on the left. Correct?

Doc: Yes.

For this same procedure 99284, you will charge the three people on the right $653.00. Correct?

Doc: Yes.

And, you say the reason is because your experience is that a great many self-pay individuls do not pay, and in effect, you have to recover your costs of business or else you can't stay in business. Is that a fair summary of your position?

Doc: Yes.

And of course, you do not up-charge the seven people on the right for that problem?

Doc: No. Since they are insured in one form or another, I know they all will pay, so I don't need to.

I see. So, let's talk about the 9th person (right in the middle of the three self-payers), what if you knew this person would pay? Then, would you agree to charge her the same as you do the first seven?

Doc: No. Because I need to pass the uncollectible amount from others to her because I can't pass on uncollectible amounts to insured patients.

I see. Now, if you raised your prices you charge to medicare and the insurers....

Doc: I can't do that. They won't let me. They set the price. I can't negotiate it.

But you could just say "no thanks" and not do any work for them, couldn't you?

Doc: Yes, I suppose. But then, I'd be out of business.

I see, so even at the rates you charge medicare and other insurers, there's still enough profit in those prices to make a profit and stay in business?

Doc: I suppose so.

Incidentally, I see you stated that medicare and the insurers set prices that disallow your ability to pass on uncollectible losses across the board to them.

Doc: Yes.

And you said that you can't negotiate that with them?

Doc: Right.

How does that make you feel that you can't negotiate with them to charge what it really costs you to operate your practice?

Doc: Errr....

(Busted).

[Jeff Matthews]

When you say $653.00, did that cover the x-rays and all the other misc items they attach? If so sounds cheap. If it was just the charge from the Doctor, then I agree. I am currently in my 2nd year in medical school, not to practice but take care of me myself. Its more cost effective to avoid the insurance companies, lawyers and jury awards and to do it yourself and to pay for medical school then to pay the accumulated life time of heathcare bills, which really amount to reimbursing insurance companies, lawyers and jury awards delivered to defendants.

It was just the doc's examination. No x-rays. No hospital (I already paid for that). Nothing else.

[seti]

invoked the wayback machine

[HatTrick66]

Until we all care how much things cost, it will never change. For too long now nobody has cared because the general public perceives it as somebody else is paying for it-insurance company, my employer, etc. It is not somebody else, it is us whether in the form of premium or actual expenses.

We shop harder for paper towels than we do health care. Now the other side is we can go to the store and see what competing brands of paper towels cost. Try asking anyone in a doctors office or even better a hospital how much services cost and see the reaction you get. What other industry are you expected to spend thousands and tens of thousands of dollars without knowing up front how much it is going to cost? It doesn't matter to people as long as they believe it is someone else's money.

[seti]

Until we all care how much things cost, it will never change. For too long now nobody has cared because the general public perceives it as somebody else is paying for it-insurance company, my employer, etc. It is not somebody else, it is us whether in the form of premium or actual expenses.

We shop harder for paper towels than we do health care. Now the other side is we can go to the store and see what competing brands of paper towels cost. Try asking anyone in a doctors office or even better a hospital how much services cost and see the reaction you get. What other industry are you expected to spend thousands and tens of thousands of dollars without knowing up front how much it is going to cost? It doesn't matter to people as long as they believe it is someone else's money.

Very interesting point. The medical billing industry is like the twilight zone. I worked with a medical billing department and it was just a nightmare. Bureaucracy at its scariest.

[Klipschguy]

This thread has a number of disturbing aspects, but I am going to hold my peace because this is a Klipsch forum.

[Jeff Matthews]

This thread has a number of disturbing aspects, but I am going to hold my peace because this is a Klipsch forum.

Don't hold back. Fire away. There are diplomatic ways to debate and exchange ideas. I'd be interested to hear the counter-argument. I already know one question that could be raised, which is "why am I not insured?". Personal choice. I feel young enough and have the ability to pay for most things a person my age suffers. As far as sudden trauma, I will be admitted and treated. Again I can pay what it's worth. For anything outrageous, the terms of my coverage are in Chapter 7. If dems don't go with national coverage soon, I am getting to the age where I will purchase coverage before too long.

[Jeff Matthews]

Not much good for the policy of allowing people out of a world of bad luck or bad choices. I am not a bk attorney, but I think that the idea is that if you have the means (i.e. any discretionary income), then you must pay at least something toward the debt for a limited period of time. I don't know that they stick you on a 13 and make you stay in a 13 plan forever. Actually, I am quite sure they don't. Creditors receive a portion of the amounts owed. It is not real bothersome to me that they tightened the reigns, so long as the reigns aren't so tight as to work an extremely long-term hardship on a person.

[Jeff Matthews]

Yeah, I only know annecdotally that some people have been blocked under the new law and problems are being reported, but ya know, I am not expert and I haven't dug very deep into it. I do know that it was lobbyed for by banks, so onviously they paid to tilt the table in their direction.

That much is fact. It goes to show the correctness of your prior observation wherein you referred to "God given rights" where the use of that phrase was made in order to try to slap at people for insisting that national health coverage can be provided.

[oldbuckster]

When a Loved One is in the Hospital for an Emergency I bet you don't ask, or for that matter care, how much the bill is , Do you ?

[JJkizak]

What insurance company is going to pay $110,000.00 for a cockleor implant, an $85,000.00 heart bypass, (not a transplant) $29,000.00 gall bladder removal, $200,000.00 cancer treatments and operations, and I have only touched on the common simple operations for older people.

Answer: None

JJK

[ZAKO]

JJ Your wrong the insurence co. paid for mine 100%

[darylomer12]

Doctor, let's see if I understand. Let's use these people sitting in this row as an example. Okay, there's ten people here. The seven on the left are covered by either insurance or medicare, and the three on the right are self-pay. Are you with me?

Doc: Yes.

Okay, now, for procedure 99284, you will charge for your services $111.97 for the seven people on the left. Correct?

Doc: Yes.

For this same procedure 99284, you will charge the three people on the right $653.00. Correct?

Doc: Yes.

And, you say the reason is because your experience is that a great many self-pay individuls do not pay, and in effect, you have to recover your costs of business or else you can't stay in business. Is that a fair summary of your position?

Doc: Yes.

And of course, you do not up-charge the seven people on the right for that problem?

Doc: No. Since they are insured in one form or another, I know they all will pay, so I don't need to.

I see. So, let's talk about the 9th person (right in the middle of the three self-payers), what if you knew this person would pay? Then, would you agree to charge her the same as you do the first seven?

Doc: No. Because I need to pass the uncollectible amount from others to her because I can't pass on uncollectible amounts to insured patients.

I see. Now, if you raised your prices you charge to medicare and the insurers....

Doc: I can't do that. They won't let me. They set the price. I can't negotiate it.

But you could just say "no thanks" and not do any work for them, couldn't you?

Doc: Yes, I suppose. But then, I'd be out of business.

I see, so even at the rates you charge medicare and other insurers, there's still enough profit in those prices to make a profit and stay in business?

Doc: I suppose so.

Incidentally, I see you stated that medicare and the insurers set prices that disallow your ability to pass on uncollectible losses across the board to them.

Doc: Yes.

And you said that you can't negotiate that with them?

Doc: Right.

How does that make you feel that you can't negotiate with them to charge what it really costs you to operate your practice?

Doc: Errr....

(Busted).

Jeff-- I couldn't agree more with you, but seriously though, that was the funniest thing I have read! I was having a pretty crappy day until I read that. You are too funny.[] Hope things work out for you.

[DizRotus]

The so called "retail prices" charged to the uninsured are essentially meaningless.

As has been pointed out previously, the amount the insurer is willing to pay is ALWAYS substantially less. Nevertheless, I have observed providers willingly, if not eagerly, accept the same amount from the uninsured, rather than receive nothing.

[jwc]

Anyone ever see the 60-Minutes program where it was revealed that the medical charges billed to insurance providers were only a small fraction of what you would be billed if you were uninsured - i.e. gouging the uninsured? Well, anyway, here's a real case....

Cracked rib. Go to emergency room. 30 minute visit total. 20 minutes used to get X-rays. The last 10 minutes were apparently for the doctor to review the x-rays and have his nurse practitioner tell me there's nothing they can do except write a prescription for pain medicine and tell me to take it easy. That was fine; I figured that before going in. Incidentally, I never met the doctor. I am quite sure he invested 5 minutes or less of his time.

Doctor's bill: $653.00.

Needless to say, I knew that was horse-hockey.

Bill has CPT Code (which is like "part number") of 99284. The description is "Emergency Evaluation and Management Services." That is the only item on the bill.

I Google around and find what this same doctor charges for CPT Code 99284 when billing a Medicare patient.

He charges only $111.97. https://catalog.ama-assn.org/Catalog/cpt/cpt_search_result.jsp?_requestid=558802

Someone tell me that is not ****ed-up.

Anyway, they will accept $111.97, or if they want to go the distance, I will have his happy-a$$ in court to explain.

Some of you might want to keep the link on your "Favorites" in your browser for reference "in case of an emergency." It was very helpful to me, because now, I can prove that this really is the devil.

Jeff. My response to this is not a rebuttal that your principles are incorrect. Your logic makes all the sense in the world. Logic has no bearing of what is "right or wrong" in medicine. Typical business principles do not apply to medicine. I didn't make these rules. I don't necessarily like them.

For instance. I performed 5 operations thursday and 3 today. 4 of the ones on Thursday were identical.

One of the patients Thurday has medicaid. For services I rendered, I will get about $600. Same CPT code on another patient with medicare, I'll get about $1000. Those that were insured will be about $1800-2000. In these cases, all the CPT codes are the same.

......so in the scenario where all the codes are the same.....why do I get paid more for one over the other? The code is the same. In fact the hardest case of the 4 was the medicare one that took me twice as long. Just to let you know......the previous week, I did the same procedure on a patient with no insurance.

NOW....The "charge" for all the pateints was the same. What is expected to be reimbursed is different depending on your insurance carrier. I don't control this.

Hmm....so where do these reimbursement anounts come from???? Well...medicare rates and medicaid rates are non negotiable. Private insurance rates are negotiable...but I have little power to tell a private insurer to pay me "so much" for a surgery. So I'm kinda stuck with what they will give me.

Hmm....why is jc putting all this stuff in writing. Well....there are some facts here that I can't change and are a reality. Have you ever thought that those contracts I sign with insurers may have something in there about giving "discounts" to non insured? Such that I could be sued for charging you a "medicare rate"? In fact.....I might not be able to charge you "what is expected as the reimbursed by the insurance".

Also....do you realize that medicare has special CPT codes that are only used for medicare and not for anything else?

The amount of time spent on you in the ER will not help your argument. Nor will how much time was spent on you by a medical personel. But what will help is to find out what is "required" to charge the CPT code that you were charged. Such as......."bullets"....or how many "points" have to be made to meet the criteria of that code. If you broke your rib........did someone actually "push" on your rib...or "listen" to you lungs? It doesn't have to be an MD anymore to do this. Rules not made by physicians now allow for "mid level providers" to fill in for exams and to obtain a history. The public would look upon this as physicians being lazy wanting someone else to do the work. BUT....this is where MD's training is getting diluted. It will continue to happen. Cost will drive this.

Anyway......this is not a disagreement......but typical business principles will not apply to medicine. I didn't make these rules.

Good luck. Seriously.

jc