Healthcare pricing insanity

Parent Cafe
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<p>Sheesh. Would you buy a pair of running shorts if they couldn’t tell you the price until after you had bought them?</p>

<p>I want to get the [the</a> Lipoprotein NMR Particle Test](<a href=“http://www.theparticletest.com/interpreting-the-results.html#counseling-and-explaining]the”>http://www.theparticletest.com/interpreting-the-results.html#counseling-and-explaining) instead of (or in addition to) the regular cholesterol panel at my annual physical. In addition to the information (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides) from the standard lipid panel, it also gives the NUMBER of LDL particles and the size of the LDL particles. The latest research shows that the NUMBER of LDL particles may be the best correlation with coronary artery disease risk. In any case, I’ve read enough about this test that I’m interested in seeing my results – and, frankly, the standard lipid panel numbers aren’t that interesting to me at this point.</p>

<p>So, I know the the lab my doc uses can order this test. In fact, I can buy it online, without my doc being involved at all for $127:</p>

<p><a href=“https://www.directlabs.com/Resources/Cardiovascular/NMRLipoProfile/tabid/181/language/en-US/Default.aspx[/url]”>https://www.directlabs.com/Resources/Cardiovascular/NMRLipoProfile/tabid/181/language/en-US/Default.aspx&lt;/a&gt;&lt;/p&gt;

<p>I pay for it online, take the order form to the same lab my doc sends me to to draw the blood and they send me the results. I don’t even have to give the results to my doc or insurance company if I don’t want to.</p>

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<p>So, all I want to know is: what is the price if I buy this health care product from my doctor/insurance company? I’m happy to pay the $127 internet price, but it makes more sense to do it as part of the same bloodwork routine as my annual physical. I don’t want to buy it from my doctor/insurance and find out their price is higher than I could have gotten on my own. Seems simple enough to ask the price before I buy it. It’s what you’d do when you buy a pair of running shorts, right? You might buy them from Zappos. You might buy them from TJMAXX. You might buy them on Amazon. Or Ebay. But, you would at least know the price before you buy them, right?</p>

<p>1) Will Anthem just pay for it as a substitute for the standard lipid panel?</p>

<p>2) If they won’t cover it, will they just charge me the difference in price for the test upgrade over the basic test they do cover?</p>

<p>3) If they won’t pay for any of it, then what is my price after the Anthem discount from the lab?</p>

<p>Pretty simple, right? I just want to know the price of the running shorts if buy them from Store A compared to Store B.</p>

<p>Turns out, that you cannot get that information. I got the retail price of the test from Labcorp (after 30 minutes bouncing around on the phone with their national office): $166. But, they can’t tell me Anthem’s discount price.</p>

<p>So, I get on the phone to Anthem. They can’t tell me if it will be covered. And, if it’s not covered, they can’t tell me what their negotiated discount price from LabCorp is. There is NO mechanism for getting a price quote until AFTER a procedure is done and bill is generated by the computer! </p>

<p>All I know is that, if Anthem doesn’t cover it as part of my annual wellness, then the price might be the $44.08 official Medicare reimbursement price for this test – if that’s the price Anthem has negotiated as their volume discount from LabCorp. It might be some other discounted price that Anthem gets, but whatever it is will remain a super-top secret until I get the bill. It almost certainly won’t be LabCorp’s $166 retail price and it seems likely that it won’t be MORE expensive than the $127 internet price. So, I’ll get my doc to order this test instead of the standard lipid profile and then I’ll find out my price.</p>

<p>Is it any wonder that healthcare costs are so screwed up? An entire industry that functions without a price list. Nobody in the entire chain can tell you what something as simple as a blood test is going to cost. Not the doctor. Not the lab doing the test. Not the major insurance company. The only supplier who can give me a price is an internet company that will sell me the exact same test at the exact same lab without any involvement from my doctor or my insurance company at all. And, nobody (other than the internet online supplier) can even look up the test without the AMA/Medicare CPT code.</p>

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<p>You never know on that retail price - someone might add in an administrative fee somewhere.</p>

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<p>That’s the point, in some ways - if we had true insurance (ie insurance pays for expensive procedures only), you would know the cost. But not in the current system.</p>

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<p>I’ve always argued this exact point only I always say I know how much the hamburger costs at McD’s vs Burger King–it’s right there on the drive-thru sign. Why should lab tests or common procedures be any different?
I worked doing insurance audits for a couple years for a hospital. I’ll just say that pricing for the insurance cost usually has no relation to the actual product/service and is very much tied in with Medicare/medicaid allowances. Insurance (in other words–you) basically subsidizes government programs. Since insurance costs vary among facilities (as does gov. reimbursement),according to region, age of population, etc. the company can’t give you a set price. The cost is a constantly moving target.
I’ve always maintained the best case scenario is NO insurance for anyone–the prices for everything would drop precipitously. and you would know what the price would be upfront. You may even be able to afford health care on your own instead of living in fear. And I still think the medical field could make a buck even then with less paper work.</p>

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<p>If you think Medicare is driving up the costs, or that there is any rhyme or reason to these charges, read this:
<a href=“http://www.time.com/time/magazine/article/0,9171,2136864,00.html[/url]”>http://www.time.com/time/magazine/article/0,9171,2136864,00.html&lt;/a&gt;&lt;/p&gt;

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<p>10 characters…</p>

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<p>Anthem is an absolute bear to deal with. I question every reimbursement and negotiated rate. I was successful in having only one agent get back to me with the specific charges, negotiated rate and coverage on my aunt’s plan, only after I hinted at possible medicare fraud. I then received an “official letter of explanation and an apology”. It should be easier than this.</p>

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<p>Some might have coupons, in-store specials if you ask for them, some coupons may only work in some restaurants owned in a particular chain.</p>

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<p>The lady at Anthem was quite nice and helpful in explaining how the system is setup with no mechanism for checking a price until a bill is actually generated.</p>

<p>She found the $44.08 price by somehow looking up what Anthem had reimbursed for the same test in my zip code recently, I guess. I later found that this is the Medicare reimbursement rate for this test. So, I’m guessing that Anthem may have negotiated the same rate.</p>

<p>I also found the guidelines by which Medicare will cover this test as part of an annual physical. If Anthem uses the same guidelines for their private insurance, then I figure there’s a 50/50 shot they’ll just cover it as part of the physical. Who knows? Not only do we have to pass this bill to find out what’s in it, we have to have that procedure or test to find out what we are going to pay for it!</p>

<p>My situation complicated by the fact that my insurance pays the annual physical and routine wellness testing, then I pay out of pocket for everything else up to my deductible, then insurance pays everything after that. I come out way ahead on this policy, but I have an incentive to know what stuff is going to cost and not just agree to any and everything without regard to cost/benefit.</p>

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<p>Look at U.S. versus the world:</p>

<p>International Federation of Health Plans 2011
Comparative Price Report Medical and Hospital Fees by Country</p>

<p><a href=“http://www.ifhp.com/documents/2011iFHPPriceReportGraphs_version3.pdf[/url]”>http://www.ifhp.com/documents/2011iFHPPriceReportGraphs_version3.pdf&lt;/a&gt;&lt;/p&gt;

<p>Notice too that U.S. prices show a low, high, and average. Pricing even in the same hospital can be all over the lot. It’s a bit like colleges and airplanes. Everyone pays a different price, and some are subsidizing others. </p>

<p>Prices are dependent on ability to pay and the deals your insurer is able to make. </p>

<p>There is little transparency, which would help lower prices.</p>

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<p>It’s very frustrating for the providers as well. I’ll give you an example of something that irks me…</p>

<p>Ankle brace can be purchased on Amazon for ~$25-31. Can be purchased through medical supply for ~$39. Medicare fee schedule says same brace through DME $104.95. But don’t worry… none of the insurances are actually going to cover that brace! So now the patient has to cover that cost. </p>

<p>That’s just one example…</p>

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<p>I’ve had some luck getting the provider’s billing department to tell me what the cash price for a given procedure would be. Unfortunately, they’ve invariably told me a number that was at least 50% too low, even if I’ve asked if there are any additional billing codes or charges normally associated with the procedure. (Not a case where the doctor opens you up and realizes you need some other operation done - it was all fairly routine testing.)</p>

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<p>The second part is true. But as to the first, it’s the uninsured who get charged the very highest prices. And in general, they’re the least able to pay.</p>

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<p>Labcorp is awful as to lack of transparency about pricing. My insurance was “charged” $311 for a nasal swab flu test (collected by the clinic nurse, not lab corp employee who only had to read the test after 5 minutes. Reads like a pregnancy test with obvious positive or negative signs). After a lot of calling, I found that the “self-pay” price was $86. A google search showed that the kits cost $14 each. Medicare will pay $25. Really, no rhyme or reason for pricing. But, since insurance will only pay what the negotiated price and it doesn’t matter what the charge is to the insurance (such negotiations increase the insurance and lab overhead price quite a bit), it seems the self pay patient is getting screwed.</p>

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<p>We were just having a similar conversation last night with friends. The fact that we are not told the price or anything when it comes to doctors, hospitals and pharmaceuticals is a huge problem. I am glad that there is finally some attention given to this problem. Until the consumers get involved and start to drive prices with their choices there will never be any change no matter how many plans the government tries.</p>

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<p>I have worked in the employee benefits field for 30 years. And we’ve been having these exact same discussions the entire time I’ve been in the field.</p>

<p>I sure hope things change. </p>

<p>Did anyone see the Michael Moore movie Sicko?? It really shows the lunacy of our healthcare system.</p>

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<p>Plenty of transparency in prescription eye glasses :D. You can see thru them.</p>

<p>I have yet to figure out how a $800 ‘initial price’ becomes ‘insurance pays $500 you pay $300’ when the estimate comes in and finally becomes ‘insurance pays $100 you pay $300 and the remaining $400 was Monopoly money that only the uninsured pay in theory’ if you choose the right brand of lenses… Beyond laughable.</p>

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<p>I posted about this exact same issue not too long ago. My cardiologist recommended a stress test and a blah blah stress test which are “diagnostic” and therefore would go against my $2500 deductible so I would have to pay the entire amount. It was so hard to find out what I would have to pay!!! All they would give me was the “list price” and I couldn’t get the “negotiated price.” I wrote a letter to the president of Blue Cross/Blue Shield NC and finally got the “negotiated price” (about 50% of the list price) but I had long since cancelled my appointment out of frustration.</p>

<p><a href=“http://talk.collegeconfidential.com/parent-cafe/1396895-simple-healthcare-question-what-will-procedure-cost-me.html[/url]”>http://talk.collegeconfidential.com/parent-cafe/1396895-simple-healthcare-question-what-will-procedure-cost-me.html&lt;/a&gt;&lt;/p&gt;

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<p>Just one more thing that those of us who are fortunate enough to have universal healthcare find baffling about the system (if it can even be called that) in the U.S. Even ignoring the tens of millions who don’t have health insurance, those who do, often run into issues like this one facing I-dad. It’s crazy.</p>

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<p>The insurances are the reason for having these problems!</p>