I have MS and the drugs are very expensive. Insurance covers them and it is a big business that each pharma company wants. They woo you. They offer to pay your copay. Your copay could be $25/month or $500/month and they will offer to pay that for you if you choose them.
I’m not sure how it may work for other people who take expensive drugs that may have less competition. But I have a friend who is on something and she can’t afford the copays, which are 20% of the total cost. I advised her to call the pharma company and tell them she would have to go off the drug entirely if they didn’t help her out with the copay. If she does that, they will lose all their profit. I hope it works!!
The vagaries of health insurance and medical costs are amazing. I am currently retired with a BCBS Medicare Advantage plan with Rx coverage. No problems in Boston but my wife and I visit Montreal at times to visit my son’s in-laws. Last summer I checked our insurance coverage should we need to visit an ER there. I knew that there would be no in-network providers of course. Rather there are preferred providers who will “accept” the insurance meaning no payment up front and deal with the claims later. Not sure if you are familiar with bilingual Montreal but there are French hospitals and English hospitals. The only preferred providers on my BCBS plan were three French hospitals! The six English hospitals were not preferred. While we have a decent knowledge of French (long story) in an emergency situation I would prefer to receive care in English.
The amount of the discount doesn’t matter. The price matters. If the retail price is even more ridiculously high, the discount gets even bigger, but the price (which is what we care about) remains the same.
Many years ago, my physician recommended that I have an unusual blood test done (I can’t even remember now what it was for; ruling out a specific possible but unusual malady, I assume). This was during one of my family’s bad-insurance-coverage periods. I asked the physician how much the test would cost and he guessed “a few hundred dollars.” The test cost nearly $1,000. I politely complained to the physician, and he apologized; he said he wouldn’t have ordered it if he had known how much it cost but that often, he doesn’t know.
After learning by experience that doctors have no idea how much anything costs, I asked the hospital billing department what codes would be billed for a certain test, then asked my insurance company what the negotiated rate for those codes was. The total I got was about half of of the actual EOB result. (We have a high deductible plan, so the negotiated rate is usually the amount I pay. In this particular case, the test would not have changed the treatment, so I was willing to pay something to rule a given diagnosis in or out, but wasn’t willing to pay very much.)
Anyone who claims that HSAs plus high deductibles will result in lower costs because patients will be incentivized to use lower-cost providers knows nothing about how health care is billed in the US.
I’m supposed to use in network providers for my BCBS PPO plan. I get that. It would just be much better if we didn’t have to struggle so mightily to find out whether each provider is in or out of network!
It’s really unfair if we have no idea about what will be charged–gross and net for medical services. It is so difficult to be an informed consumer when even estimates from med center billing depts can be wildly off.
If we on this message board are struggling to understand the medical discounting and pricing, I’m sure the “average American” is even more bewildered, as the medical material for patients is now supposed to be aimed at 3rd-5th grade reading and literacy level.
They don’t. They either don’t get the bloodwork they need, or they get it and then don’t pay the bill, with the resulting credit problems. Most personal bankruptcies are due to medical bills which can’t be paid.
HImom, we’re fighting one of those “no idea what the charge will be” issues. DH needed some Norco for knee pain. The medical group’s policy is no Norco without a drug test first, so DH gave the sample, which was sent to a lab. Now Anthem says the test was not medically necessary, and the lab wants $900.
If you sat down and tried to come up with the craziest, most patient-hostile insurance system possible, you couldn’t come close to what we have in this country. It’s a disgrace.
I found it very difficult to learn the cost of a procedure BEFORE deciding to undergo it. A few years back I had a $2500 deductible (seems so low now!) so I figured I would be paying entire cost out of pocket for some diagnostic procedure. The provider kept referring me back to my insurance company, and my insurance company kept telling me to ask the provider. It was very frustrating. I eventually found out what my cost would be, and decided to pass (thinking I would pay almost $1000 and very likely learn nothing new).
MRI’s in particular vary greatly in price from provider to provider. It’s always a good idea to “shop” around before getting such a procedure. My H had an MRI and called around, got pricing ranging from $1K to $4K.
Here is a useful tool for consumers to estimate costs of procedures in a specific zip code. Of course to find out the actual cost a provider charges, you have to call.
One of the problems with health care is there is no transparency, for example MRI clinics don’t post their rates online, and if you get pneumonia no hospital has a website saying “pneumonia- 1500 bucks”. Even on elective procedures, for example a knee replacement, there just isn’t the ability to ‘shop around’ (and would you go to the lowest price provider and take a chance you might not be able to walk?). It is also telling that where there is price transparency, it is services where insurance is not really involved. You see it for laser eye surgery, you see it for things like breast implants or lifts and other cosmetic surgery. When it involves insurance it is all about the network you are in, and even if you go out of network the provider will not tell you the price.
As far as the difference in price, what you are seeing isn’t really a discount. Doctors and other providers negotiate with the health insurer on the price of procedures (so yes, price transparency is possible), and that varies. Why do they do this? Because they figure they will make it up with volume, having a guaranteed flow from the insurance networks (and keep in mind you are talking only a handful of insurance providers in any area).
Does anyone pay that full price? Yep, if you happen to go outside the network, guess what, you get billed for what your provider won’t pay for, so if an MRI is priced at “1500”, and you go out of network and they decide to pay 200, you will likely get a bill for the 1300 difference. Yeah, you can try and negotiate it down, but the reality is these places would rather you either paid, or they will send it to a collection agency which will ruin your credit rating, so the leverage is on their side.
Under normal conditions, I don’t find this task too difficult. However, there was one time when I went to an emergency room at a hospital labeled “in network”. But later got a bill because the doctor was “out of network”! What?! I assumed if the hospital was in network, that I was covered. But this implied I’m suppose to ask each doctor if they are in network before I see them in an emergency situation. Fortunately, after I called my insurance provider they readily agreed to pay the costs (whew! they didn’t actually expect me to pay that…but why did they charge me in the first place?) and I only paid my in network rate. But I found this very enlightening!
In addition to lacking the insurance-based distortions of the market, those medical services are much more optional as well. A normal (in economics terms) functioning market can more easily happen there compared to the situation of “you must do something soon about ___ or face death or disability”.
I think this is another game the insurance companies play – they routinely deny claim they are obligated to pay, giving a “reason” that looks good on paper but really doesn’t apply. A knowledgeable patient will contact the insurance company to question or contest the determination – but my guess is that the majority of the patients don’t.
I go through this every single year with lab costs for my routine annual physical. In my case, I am getting “discounted” bills that show a fairly low amount owed by the patient (between $35-$95 on bills in the $600-$800 range before the “discount”) – so it’s easy enough to just pay and move on. But at this point I know that as soon as I call to ask why the insurance didn’t pay, someone will say “oops”, claim a computer error, and issue a revised EOB.
I have noticed an improvement since ACA – before that I would take a lot longer to process claims and a lot more back-and-forth on the claims “appeals” process. Now the insurance company fixes things with the first phone call.
I think insurer denies when it can and waits to see if patient or provider will follow up. If not, they’re happy to keep the $$$$; if the provider resubmits and provides more info, they will reconsider the claim and MAYBE pay more. It’s a game for insurer, with it holding most of the aces.