New York Times article on medical billing and insurance:
Getting Lost in the Labyrinth of Medical Bills
By Tara Siegel Bernard
Ask Jean Poole, a medical billing advocate, about her work helping people navigate the bewildering world of medical bills and insurance claims, and the stories pour out. Theres the client who was billed almost $11,000 for an 11-minute hand surgery. The cancer patient who was charged $9,550.40 for a round of chemotherapy he never received.
And then, theres the tale of the woman who came to Ms. Poole with a large rolling suitcase stuffed with bills for her 68-year-old husband, who had gone to the emergency room after he fell getting out of bed. The hospitals doctors discovered a series of problems kidney failure, blood and urinary tract infections, and a blood clot. Ultimately, he ended up staying in the hospital for two months and being transferred to a nursing home for rehabilitation.
Though the couple had two insurance policies one through Medicare and a secondary policy at Blue Cross Blue Shield they still received more than $25,000 in medical bills and another $65,000 from the nursing home. And some of them threatened collections if they werent paid within days.
Most people have a false sense of security if they have two insurances like this, said Ms. Poole, who is based in Virginia. Many of the bills were confusing and she was very concerned there were errors and overcharges. ...
Hospital care tends to be the most confounding, and experts say the charges you see on your bill are usually completely unrelated to the cost of providing the services (at hospitals, these list prices are called the charge master file). The charges have no rhyme or reason at all, Gerard Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins Bloomberg School of Public Health. Why is 30 minutes in the operating room $2,000 and not $1,500? There is absolutely no basis for setting that charge. It is not based upon the cost, and its not based upon the market forces, other than the whim of the C.F.O. of the hospital.
And those charges dont really have any connection to what a hospital or medical provider will accept for payment, either. If you line up five patients in their beds and they all have gall bladders removed and they get the same exact medication and services, if they have insurance or if they dont have insurance, the hospital will get five different reimbursements, and none of it is based on cost, said Holly Wallack, a medical billing advocate in Miami Beach. The insurers negotiate a different rate, and if you are uninsured, underinsured or out of network, you are asked to pay full fare.
With the exception of Medicare and Medicaid, experts say, the amount paid for services or the price your insurers pay is based on the market power of the insurance company on the one side and the hospitals and providers on the other, and the reimbursement agreements they ultimately reach. So large insurers that command a lot of market power may be able to negotiate lower rates than smaller companies with less influence. Or, insurers can place hospitals or providers on a preferred list, which may help bolster their business, in exchange for a lower reimbursement rate. On the other hand, well-regarded hospitals may command higher prices from insurers.
So lets say you have coverage through a high-deductible plan, where youre responsible for, say, the first $5,000 or $10,000. Its possible that you may have to pay more out of pocket for your medical services than your friend, also in a high-deductible plan, but one with an insurer that has greater negotiating power. The ones that are affiliated with the larger insurers do best, Mr. Anderson said, adding that the uninsured have virtually no bargaining power, which is why they are expected to pay much more.
With so little pricing information available, expecting people to shop around for quality care at the lowest cost something thats not always possible in emergency situations is also asking a lot of consumers. I have always found a bit cruel the much-mouthed suggestion that patients should have more skin in the game and shop around for cost-effective health care in the health care market, said Uwe E. Reinhardt, a health policy expert and professor at Princeton University, when patients have so little information easily available on prices and quality to those things.
President Obamas Affordable Care Act, the health care overhaul law passed in 2010, tries to make some improvements (though the Supreme Court is expected to rule whether all or some of the law is constitutional this month). But while the laws changes help you shop around for insurance policies specifically through its new HealthCare.gov Web site, a one-stop shop that lists all of your insurance options in one place its still unclear how effective the law will be for anyone comparing medical services. ...
As for the 68-year-old patient, Ms. Pooles detective work ultimately reduced his out-of-pocket costs by more than $22,000, which left him responsible for about $3,915. Since the couple didnt have long-term care insurance, he was also responsible for the nursing homes charges of $65,000, which Ms. Poole said Medicare covered for only a short period of time. (Ms. Poole, a former emergency room nurse, who later received an M.B.A., generally charges about 25 percent of the savings found.)
She uncovered the savings in various places there were charges for brand medications when the patient ordered generic, services that were double-billed, as well as charges for a private room that the patient did not request; he was only there because no other rooms were available. In another instance, a surgeon belatedly submitted his $4,400 bill to the insurance company, so the claim was denied. That wasnt the patients fault, but he was billed anyway. She lobbied the billing department to drop the charges, and they did.
Then, when the $132,000 hospital bill came, the patient was told he owed $9,200 and it had to be paid in 10 days. As it turns out, only one of the insurers had paid its share, which was hard to decipher from the bill. Ultimately, the patient only owed $164.99. There were three explanation of benefits from Blue Cross Blue Shield, each with an different amount due, she said, ranging from about $164 to $81,900. Hows that for confusion?
All told, Ms. Poole spent about 96 hours dissecting each bill, line by line, comparing it with the providers medical records and keeping track of it all in a complex spreadsheet.
Its a broken system, she said.
http://www.nytimes.com/2012/06/23/y...he-labyrinth-of-medical-costs-your-money.html
We have a system that requires us to spend 4 whole days of our lives (6 waking days) perusing medical bills (due in 10 days) to make sure we are not being overcharged by as much as $9000 (or, alternatively stated, overcharged by 5,575%).
The system is criminal, and anybody who does not support the immediate enactment of single payer health care is a traitor, as far as I'm concerned.
