<p>To the poster above who asked about doctors having a financial interest in the lab, unless it is an in office lab, that doctor runs the risk of violating the Stark laws, and state anti fraud and kickback laws. While a doctor might be able to own stock of a publicly traded laboratory (maybe - this is not legal advice), if he or she owned a lab that was not an in office lab, (and by the way in office labs are currently under scrutiny for many things from CMS (Centers for Medicare), there is probably a problem. Clinical lab services are DHS (designated health services), and are on the list of things that are not generally permissible for referral to entities which the doc has a financial interest. </p>
<p>Medicine has become one of the most highly regulated industries, and things that are permissible in other industries are not permissible. Things that were legal are no longer legal in medicine. The Stark laws have been around for a long time, so don’t assume the treating doctor has an interest in the lab. </p>
<p>Coding–how a service is billed makes a huge difference in reimbursement. I was getting twice weekly allergy shots for some years, via different docs. Was amazed at the differences in the charges and reimbursements between the different docs!</p>
<p>We have been with the same BCBS most of my life. It covers about 75-80% of our state and H’s plan is a federal employee one with especially good coverage. Nonetheless, it is helpful to be patient and persistent when you are billed more than you expect, and have surprise out of network charges. It can be very helpful. </p>
<p>For those of you who have negotiated a big bill down, how did you do it? I followed the suggestions I find online, including pointing out that they were charging me 4 times the average cost in our area. The best they would do was a 5% discount for paying in full. </p>
<p>I’m interested in this issue. I recently had a discussion with a friend who had used an out-of-network doctor for a surgery for his son, which wound up getting charged at about 30,000 and the insurance company only paid a small amount. </p>
<p>And I had a personal experience with a family member who had a hospital procedure (orthopedic) that kept him for about 36 hours total. The hospital alone billed 27K, and the insurance company paid about 12, if I recall. I don’t think I’m going to be hounded for the balance, because it appears to have been forgiven…but for the life of me I don’t understand what is going on with these types of billings. Why bill many multiple X what a reasonable fee is? I don’t think its logical to expect well off patients to pay for what others can’t or won’t…(even though that’s what universities do, and it works there).</p>
<p>In any case, my simple question would be: what is the reason for the anesthesiologists billing 150K? They know it won’t be paid, so why do it? Does it help with private fundraising so hospitals can say that they only get paid a small fraction of what they bill? I’m at a loss to understand this. </p>
<p>I very much appreciated YoHoYoHo’s frank explanation. DH and I had routine screening colonoscopies a couple of weeks apart, at the same facility with the same doctor, however our portion of the cost varied by several hundred dollars because of anesthetist, etc., who were in-network in one case and out-of-network in the other. The gastroenterologist himself is in-network to us, of course, or we wouldn’t be seeing him, but it drives me crazy how the patient has no control over all these other people whom we don’t get to choose. Actually what drives me right around the bend is the claim that the US healthcare system is “the best in the world” and one of its benefits is competition - the patient gets to be an informed consumer. This is a scurrilous lie. As an immigrant from a country with a single payer system I am just incredulous and outraged every time I have an encounter with the US system. It’s completely impossible to predict the out of pocket cost of any encounter beyond a routine office visit. DH saw his cardiologist recently and had some lab tests. We’re now looking at a bill for $680 because the cardiologist switched his lab service to one that’s out-of-network to us. (And before you think we have some rare kind of insurance, it’s Anthem Blue Cross - one of the biggest insurers in the country).</p>
<ol>
<li><p>Medicare and Medicaid pays crap for anesthesia services. Thus, anesthesiologists depend on private payers to make up the differences. </p></li>
<li><p>Some private payers will pay well (3-4× Medicare). Trust me, this doesn’t mean we are getting rich. I pay my plumber per hour more than twice what Medicare pays me.</p></li>
<li><p>For those payers who won’t play ball, the department goes out of network.</p></li>
<li><p>When you charge $150K for an epidural, as an example, it does several things: It helps meet out of network deductibles right away (for most insurance companies). Insurance companies typically pay a percentage of the remaining out of network fee. Now, they aren’t going to pay 50% of this fee, but they are afraid of their patients getting a bill for the remaining amount. As a result, they typically reimburse at a much higher rate than they’ve offered during negotiations. My experiences have been twice what they’ve offered.</p></li>
<li><p>After a few months of this, they return to the bargaining table with something reasonable.</p></li>
</ol>
<p>I had a situation where an insurance companies offered me $150-$250 for a procedure code. They wouldn’t budge. I purchased $18,000 in equipment, drugs and supplies. I needed at least $500 to recover my investment within 18 months. So, I went out of network, charged $5000 and the insurance companies paid me $750. THIS IS CRAZY!!! But that is the game.</p>
<p>“it drives me crazy how the patient has no control over all these other people whom we don’t get to choose.”</p>
<p>Yes, I’m not enjoying the wait for the bills from my recent hospitalization. So many doctors popped into my room for five minutes over the course of three days, I have no idea who they all are. Am I really supposed to grill them from my bed about what they are there for, what insurance they accept, what they charge, whether there is another surgeon I can talk to, etc? As it was, I kept refusing their ibuprofen and sleeping pills and breaking the rules to take ones I brought. I didn’t want their darn $14 Advil.</p>
<p>It’s a catch-22, because I believed I didn’t need the second night in the hospital, but if you leave against medical advice, then NOTHING is covered (often true even of a Cadillac plan). So you’re stuck accepting what may be expensive over-treatment.</p>
<p>I was supposed to have a follow-up visit 3 days after discharge, but could not find an in-network specialist to see me in that time frame (right before a holiday weekend, no less). So I booked an appointment with an out-of-network doctor and asked the staff what it would cost. They wouldn’t tell me. Even though it was a simple check to ensure healing, they said it just depended on how the doctor coded it. I refused to enter the examining room under those circumstances; they want me to accept an unknown obligation where I might be on the hook for $10,000? The doctor came out and found me arguing with her staff and said, “Well, I can’t imagine it would be more than $300.” Thank you! That’s all I needed to know!</p>
<p>Thanks for the explanation. Not sure I grasp it completely, but as you’re casting it there, its a negotiating tactic with the 3rd party payer meant to send a message.</p>
<p>Lots of people covered by employer medical insurance plans have only one or two choices of insurance companies (although they may have more than one plan option for one insurance company). Probably the employer chose the cheapest insurance company for the given amount of coverage.</p>
<p>I was a benefits director for 30 years, in charge of selecting what insurance company(ies) my company would use. We were always self-insured, so the insurance company didn’t charge us premiums – just administrative fees for our using their network and for their processing the claims. The most important factor in selecting the administrator was the amount of discounts in their network – in other words, the actual cost of care. But administrative accuracy, hours of the customer service line, how big the network is, ancillary services (like, oversight of potentially abused services like chiropractic care, speech therapy, etc.) and reporting capabilities (e.g., how many employees are on anti-depressants?) were also extremely important.</p>
<p>For a smaller company that uses insurance, not just administrative services, I agree that the amount of the premium is going to be most important. </p>
<p>It ends up being the employer’s business because the employer is paying for it. (And if the employer realizes that many of its employees are depressed or have unusually high rates of other medical problems, it may just start asking itself whether that is related to working conditions.)</p>
<p>Interesting. How did the “discount” get measured? As we’ve seen from above posts, if its measured from certain billing parameters, it would appear to be a huge discount, but in fact wouldn’t be any discount at all.</p>
<p>Also, can you ballpark what the annual cost of the administration was per employee? That would be interesting to have some idea about. </p>
<p>Ucb, I can’t even get claim information on my own husband without his express written consent, not even if I’m the one paying his premiums. Does HIPAA not apply to employers? </p>
<p>Earlier this year the CEO of (IIRC) Yahoo announced to employees that there would be changes to the 401k program because the year before there had been two “million dollar babies” who had cost the company a lot of money. Yahoo self insures too. The names of the parents/employees weren’t announced, and maybe the company wasnt even told. But does any one really think that the other employees couldn’t figure out who they were? </p>
<p>Thanks. He did, only after a media firestorm. But the point stands: employers shouldn’t have medical information about employees, not even in the aggregate. </p>
<p>ETA - This is also a good argument for the option which must not be named. ;-)</p>