This medical charge seem outlandish

[Rich Engelhardt]

I had a sleep study done May 21st.
It was a split night study (half without a CPAP machine and half with) done at a sleep center.

Yesterday, I got a bill in the mail for it.
It says it's not a bill, but, it looks like a bill.
I guess this is what they will give to the insurance company.

The total on it is - are you ready? -

$7678.00

This is just the bill from the sleep center and does not contain the doctor's charges - which I haven't seen yet.

In looking around, I see that Healthcare Bluebook lists a split might study as - $1153.00 being the fair price for both the physician's fee and the overnight study.

I'm wondering here - who's kidding who and/or who's overbilling for what or who's in left field somewhere with their cost estimate?

I can see a hundred or so difference - but - $6500.00 difference?

[David Weaver]

It should be criminal. It's as matter of (dentist does the same thing) seeing if you can get it and being ridiculous, but it illustrates a simple point. You need to have insurance of some type just to get the negotiated rates, and preferably some kind that doesn't have balance billing (where the provider may try to recover some or all of the difference between 7678 and 1153.

The most disgusting thing to me about all of this is that it's considered SOP and each provider doesn't think that there's an ethical issue with doing business that way.

When I first started going to the dental practice I go to, they were billing garbage charges to the insurance company, like $50 for various "hygiene advice" items. I told them the next time I was in that I wasn't going to listen to any discussions about flossing or any of the standard stuff the hygienist likes to talk about because I didn't think it was worthwhile for someone to tell me to use 3 feet of floss and how often and then spring a $50 charge on a bill. The response of the billing lady was "we always drop that charge if it's not covered, we add it because the insurer doesn't pay enough for the cleanings. It doesn't necessarily mean you got any advice, we add it on all of the bills regardless". (the insurer never paid it on mine - fortunately. If they had, I would've called them and told them it was a false charge).

Well, OK. That would seem to me to be at the very least extremely unethical.

When the HC reform bill was written, I was hoping for some cost control items that wouldn't allow attempts at collecting several multiples of reasonable and customary charges, or balance billing for insureds, etc, but none of that stuff was included (maybe there was something about in network balance billing, I don't know, but it still seems to be allowed at least sometimes). I don't care if the bluebook charge is changed to $1300 to cover the cost of the few lucky lottery winners where the dr. office can turn you over to collections and try to get all of the charges, it's wrong and there's no excuse for it.

[Matt Meiser]

Yeah, but your insurance will pay 573.41 and they'll write off the difference.

[Phil Thien]

When the HC reform bill was written, I was hoping for some cost control items that wouldn't allow attempts at collecting several multiples of reasonable and customary charges, or balance billing for insureds, etc, but none of that stuff was included (maybe there was something about in network balance billing, I don't know, but it still seems to be allowed at least sometimes).

That is the long and short of it right there.

My wife and I (and I'm sure everyone else here) get reports from insurance companies indicating the amount they were billed, and the contracted reimbursement rate.

Whatever game the hospitals/doctors/insurance companies want to play is fine by me. But if I go to a provider and tell them I'm paying cash, I feel they should be required to bill me something close to the average contract rate they are reimbursed by insurance companies. And no padding it with advice charges, etc.

[Greg Peterson]

Two or three years ago, the LA Times did report on insurance costs for a specific medical procedure. Several hospitals provided costs that were all over the place.

In many instances, the cash price for the procedures (Pelvic CT Scan) was less than the patients insurance co-pay.

Insurance companies negotiate with the hospitals what they will pay for each procedure/item/service.... The larger the group of customers the insurance company can bring to the medical provider, the more leverage they have in negotiating costs. Being able to opt out of the plan and pay the cash price on a procedure by procedure basis would be disruptive.

I'm sure someone can provide a reasonable sounding explanation for the existence of health insurance companies, but they seemingly do little more than add another layer of cost and control between the patient and their doctor(s).

[Brian Elfert]

I was once billed something like $7,000 for an overnight hospital stay. Insurance only paid around $2,250 for it. The $7,000 didn't include the MRI, radiologist, or doctor fees.

[Matt Krusen]

Aside from woodworking, my life is spent in the biotech/biomedical fields. While the price of biomedical research and development is incredibly high, the amounts that hospitals attempt to charge these days is straight up robbery. I had a hip surgery done at Mayo clinic a few years ago due to soccer injuries. The total bill was just over $97,000. I got an itemized list and it was laughable. It was almost $900 just for two screws that they had to put in! Yeah they're silver-coated titanium for strength and infection prevention but come on... I work with that kind of stuff every day and its not THAT expensive!

[Phil Thien]

I'm sure someone can provide a reasonable sounding explanation for the existence of health insurance companies, but they seemingly do little more than add another layer of cost and control between the patient and their doctor(s).

Insurance companies have to take some of the blame for runaway medical costs.

But they similarly deserve much of the credit for the quality of healthcare available today.

Without health insurance, we probably wouldn't find hospitals full of expensive devices like MRI's, nor would drug companies spend billions (cumulatively) searching for new remedies.

[David Weaver]

Two or three years ago, the LA Times did report on insurance costs for a specific medical procedure. Several hospitals provided costs that were all over the place.

In many instances, the cash price for the procedures (Pelvic CT Scan) was less than the patients insurance co-pay.

Insurance companies negotiate with the hospitals what they will pay for each procedure/item/service.... The larger the group of customers the insurance company can bring to the medical provider, the more leverage they have in negotiating costs. Being able to opt out of the plan and pay the cash price on a procedure by procedure basis would be disruptive.

I'm sure someone can provide a reasonable sounding explanation for the existence of health insurance companies, but they seemingly do little more than add another layer of cost and control between the patient and their doctor(s).

Providers sometimes charge negotiated cash costs ahead of time for non-insured individuals at low rates (if you ask first) because they figure those are individuals that don't have much in terms of means.

If they charged only those cash amounts for everyone, they'd go out of business. The community hospital profit margin around where I live is sometimes negative and up to 4% in some cases. This year, it's trending around 1%.

My wife ran into the same thing, because someone asked her if she'd pay for a routine service with cash or insurance, and she didn't follow the question right and figured it might be an option. What the person asking meant was whether or not we were insured. Cash cost was $50. Insured cost was $140. We have a high deductible plan. That means that I paid $140 because I was insured, out of my deductible for the year - it cost me real money. I would've MUCH rather paid $50 out of pocket, even outside of the HSA, and needless to say, the provider would much rather collect $140.

If the discussion had not been up front, who knows what the charge would've been....$500? That's all part of the problem. The LA times story was a bit misleading, suggesting that there's money pouring out of insurers making providers rich. AS far as I've seen, the only people getting paid that well in medical care are the folks who sell stuff to hospitals on commission and certain classes of docs. At this point, the current administration is going to take a hard line with the classes of docs who make a lot (and by a lot, I mean more than half a million a year, for example - they have been a target for reform since the beginning). IIRC based on disclosures that were quoted in the newspaper here, our largest health system here had something like 20 docs with compensation over a million, and 30 people total over a million. In a "not for profit" enterprise.

It's a tough situation to figure out all the way around. Someone will eventually be negatively affected at the patient level if it is "fixed", but who knows how many people are already being negatively affected.

[Steve Peterson]

The sad part is that an uninsured person has very little room to negotiate. They may be stuck with the entire $7678 bill. Add a few more exaggerated medical bills and the person is likely to declare bankruptcy, and we all get stuck with higher rates.

Steve

[David Weaver]

Yeah, the negotiation has to occur beforehand. Always. I don't think half of the people who are uninsured know that, but it should be printed on posters and stuck everywhere - you can easily negotiate beforehand, but often not after.

[Andrew Pitonyak]

I had a scope shoved up my backside and I had to sign that I would pay if the insurance refused. So, I asked the obvious question. If the insurance pays, how much are we talking. Answer.... "we have no idea". They were not even willing to make a ball park estimate. Did not know if it was closer to $10K or $1K. Nope, no idea. Just sign the paperwork and stop being a bother. I was incredulous.

[Greg Peterson]

Yeah, the negotiation has to occur beforehand. Always. I don't think half of the people who are uninsured know that, but it should be printed on posters and stuck everywhere - you can easily negotiate beforehand, but often not after.

For many procedures, this is true. But health crisis tend to occur without warning and the patient is left seeking immediate care. Negotiating follow up care may be an option, but for serious conditions requiring long, invasive treatment protocols (cancer - chemotherapy) there may be no realistic cash amount the patient can arrive at.

If you don't have insurance, you don't want to get seriously injured, and you certainly do not want a life threatening or quality of life compromising disease.

If you think you can't afford insurance, you really can't afford to not have it. Sadly.

[Chuck Saunders]

I did hear a comment on the radio a while back about hospital rack rates. They said that the only person who would pay the total amount billed by the hospital would be a wealthy man from a foreign country whose wife was not with him. I spent last year deep in the medical word as my wife came to the end of the cancer road. Total medical bills for the year were right at $600,000. Blue Cross Blue Shield payed around $250,000, We payed about $2000. Blue cross pointed out that they saved us $350,000.

[David Weaver]

If you think you can't afford insurance, you really can't afford to not have it. Sadly.

That's the real issue - it would be nice if there was an allowable insurance that had a very high deductible for people in that situation, but that also got you negotiated rates and no balance billing. That was another real daily life practical thing that the reform disallowed and that's too bad. That kind of thing would be a real trigger to cost control, which is still lacking.

Finding out what you can and can't negotiate after the service has been performed is, as you say, not the time to do it. And financial ruin and medicaid is often the only real option. Like many things in life (wills, retirement planning, succession planning in small businesses, etc), I guess it's human nature to ignore things until they are a problem.

[Jason Roehl]

I guess I'm left wondering why dental cleanings would be on an insurance plan. If you know that you're going to get 2 cleanings a year for the rest of your life, that's a (more or less) fixed cost. If your insurance handles it, they will simply pass that cost on to you, PLUS their overhead and profit to administer the payment for those cleanings. Same with annual doctor check-ups.

Insurance is meant to protect against catastrophic, unaffordable loss. That's why car insurance is much cheaper if you raise your deductible and pay out of pocket for small damages. If you choose to insure against regular, affordable costs, the insurance companies will gladly take your money.

But, I am disgusted by the lack of ability of medical professionals to set costs. About 18 years ago, I slipped on some wet grass, and my elbow must have found a piece of glass when I went down. When I got home and washed out the cut, it looked like a split hot dog--off to the ER for some stitches (it was July 4, no less). I didn't have insurance, so I signed that I would pay and didn't ask about the cost. I got a bill for $200. Not bad, but when I saw that the local anesthetic was half of that, I was annoyed--I could have easily skipped that and saved myself $100 (I have a pretty high pain tolerance and threshold).

Maybe I need to just target hospital administrators to paint their houses. We won't discuss any aspect of the cost ahead of time, and I'll paint whatever I think needs to be painted, and in whatever color I deem best. I'll be rich!

[Brian Elfert]

I guess I'm left wondering why dental cleanings would be on an insurance plan. If you know that you're going to get 2 cleanings a year for the rest of your life, that's a (more or less) fixed cost. If your insurance handles it, they will simply pass that cost on to you, PLUS their overhead and profit to administer the payment for those cleanings. Same with annual doctor check-ups.


Insurance covers preventive care because otherwise many of us would just skip the preventive care and only visit the doctor/dentist when we need expensive care that could have been caught before it became expensive. A lot of folks look at insurance as a deduction from their pay check if employer supplied, or a monthly bill if they pay. They won't save the money to pay for preventive care once or twice a year. The other thing is teeth cleanings and such often cost more when you and I pay than when the insurance pays for it.

[Brad Adams]

This is what is wrong with insurance companies and hospitals in general. The hospitals gouge the insurance companies for enormous amounts. I'd like to see itemized bills for exactly where every penny is going. In my plumbing business if I gave someone a bill like the hospitals billed them out, I wouldn't be in business very long.

[Kev Williams]

Winter before last we had an ice storm, I went flying off the back porch, landed on my side on the cement steps--
Went to the clinic. Told them what happened, they took a couple of x-rays, told me a I cracked a rib, and sent me home...
Bill was over $300... I was there maybe 15 minutes...

Couple of weeks ago, Buddy, our Pomeranian, started limping. After a week of limping, I checked his leg and paw, and he seemed to not like being touched between his 2 middle claws, so we thought he may have had a fox-tail stuck up in there (been there done that)-- took him to the vet, who shaved his foot and found nothing wrong, so he did some further examination and determined Bud had a sore shoulder, probably pulled a muscle or tendon. He gave him a shot, Bud's been great ever since...
Bill was $59. They didn't do x-rays, but I think they only charge $15 a pop anyway...

Our 'human' medical system is definitely a greedy charge-what-you-can-get-away-with industry. All I know is, next time I fall down the stairs I'm going to see a vet...

[Phil Thien]

This is what is wrong with insurance companies and hospitals in general. The hospitals gouge the insurance companies for enormous amounts. I'd like to see itemized bills for exactly where every penny is going. In my plumbing business if I gave someone a bill like the hospitals billed them out, I wouldn't be in business very long.

An interesting (to me) question: How did we get where we are? How in the world did a system evolve in which bills are so high and reimbursements so comparatively low? How did things get so twisted?

[Dave Sheldrake]

$300 is less than that X-Ray machine cost Kev ;)

cheers

Dave

[Phil Thien]

Our 'human' medical system is definitely a greedy charge-what-you-can-get-away-with industry. All I know is, next time I fall down the stairs I'm going to see a vet...

LOL, that kind of goes to my question (above).

Nobody completing a medical school application answers the question "why do you want to be a doctor" with "to make lots of money." And yet here we are.

Don't get me wrong, I think we have the best healthcare in the world. But for what we're paying for it...

[eugene thomas]

My wife had operation few years ago the hospital would not tell use the coast before hand but pointed out if we didn't pay they are good at getting their money Where worried we would go hospital shopping kind of seemed like. Had few worry some nights before got the statement and was happy to only Owe $1200.

[Jerome Stanek]

$300 is less than that X-Ray machine cost Kev ;)

cheers

Dave

So you say that you charge what your laser costs for every job you do

[Rich Engelhardt]

All I know is, next time I fall down the stairs I'm going to see a vet...LOL! Vet probably has 1000 times better bedside manner to boot!

[Pat Barry]

LOL! Vet probably has 1000 times better bedside manner to boot!
Plus, you will get a nice treat!

[Scott Shepherd]

You might not like how they take your temperature at the vet......

I had 4 hours in the ER for a kidney stone (posted in another thread). So far the bill is around $14,000. No treatment, just a cat scan (bill for $400), dr. ($1000), and $12,500 for the 4 hours laying there waiting to be released. No insurance either, so it's a real treat to have this happen and deal with it all.

[Greg Peterson]

That's the real issue - it would be nice if there was an allowable insurance that had a very high deductible for people in that situation, but that also got you negotiated rates and no balance billing. That was another real daily life practical thing that the reform disallowed and that's too bad. That kind of thing would be a real trigger to cost control, which is still lacking.

I don't know if high deductible policies were outright banned by the PPACA. I do know that many, if not most of the high deductible policies failed to deliver the benefits most clients assumed were covered, essentially rendering the polices worthless. The items that were excluded from coverage, common in most of these polices, led one to wonder under what narrowly defined medical crisis these polices were designed to provide relief. The exclusions were right there in the fine print, and while many among us here would likely read all the fine print, more than enough people never did, thus enabling the insurance companies to market a high margin product that left clients stranded at their most financially vulnerable time.

In 2000, health insurance company profits were $2.5 billion. In 2009, their reported profits were $12.5 billion. At the same time, they were dropping people from coverage or pricing them out of the market.

[Scott Shepherd]

In 2000, health insurance company profits were $2.5 billion. In 2009, their reported profits were $12.5 billion. At the same time, they were dropping people from coverage or pricing them out of the market.

Wait until you see their profits in 2015 and beyond, when everyone's deductible is $6,000 or so. Where you used to only have to pay $500, or maybe $1,000 out of pocket, wait until you have to drop $6K out of your pocket before anything gets picked up.

There are millions of people like me, that lost my healthcare when the ACA passed, and believe me, we're out here, despite what you read or see in the media.

[David Weaver]

Most of our local high deductible plans, that had really high deductibles didn't have the exclusions you're talking about (this is known as a "rich" plan area, though, where most of the plans are higher priced and thus cover more, so we don't have some of the really stripped down stuff that's in the west).

There is a catastrophic plan option, I think, under ACA that is available to people under a certain age (30?) and there may be more conditions on it than that.

I've read some articles (but admittedly didn't pay that close of attention to provide a definitive statement about it) saying that a market for plans that violate ACA requirements is emerging, where an individual will pay the fine for not having ACA compliant coverage and still get a plan that is the level of coverage they want.

How that will play out, I don't know. Those folks are essentially trying to have the same coverage they had before and are just paying a penalty tax for not following the rules. That wasn't allowed for in the ACA bill because the money-side of it requires healthy individuals to buy more generous coverage to subsidize the less healthy individuals. If they didn't mandate that, then the adverse selection issues (sick people elect good coverage, non-sick would elect stripped down coverage) would've driven up the cost of the coverage too much unless there were other funds to offset.

I have a relative who became medicare eligible and bought his spouse a major medical only type policy with a high deductible. She had a heart attack the only year she needed to be covered by it, and IIRC, he said he paid the deductible, and the coverage paid everything else (~100k), so it's not universal here or where he lives that those policies are sleight of hand type policies.

[David Weaver]

I don't know if high deductible policies were outright banned by the PPACA. I do know that many, if not most of the high deductible policies failed to deliver the benefits most clients assumed were covered, essentially rendering the polices worthless. The items that were excluded from coverage, common in most of these polices, led one to wonder under what narrowly defined medical crisis these polices were designed to provide relief. The exclusions were right there in the fine print, and while many among us here would likely read all the fine print, more than enough people never did, thus enabling the insurance companies to market a high margin product that left clients stranded at their most financially vulnerable time.

In 2000, health insurance company profits were $2.5 billion. In 2009, their reported profits were $12.5 billion. At the same time, they were dropping people from coverage or pricing them out of the market.

I wonder what the business volume was to get $12.5 billion of profit. If the volume was $200B or $400B or something, that doesn't really amount to much. The suggest was made at the time that elimination of profits was going to save us money as policyholders, but thus far, the only individuals I've seen who have gotten the benefit of anything are individual policyholders in the upper age range (where the bill mandated a limitation on age rating - that limitation flings the cost over onto younger policyholders instead, so it's not really a savings of anything, it's just a mandated lower premium for older policyholders).

The issues that really are a problem in terms of costs - especially in unpredictability of cost, above and beyond things like bed sores for medicare covered individuals, were not really addressed, and that was a disappointment.

[Scott Shepherd]

I hope something changes David, because I'm in the small target group of "individual" policy holders. We're paying the price in a big way. If the vast majority of people knew what has happened to people like me, they would be outraged. Sadly, what's happened to me, and people like me, is going to happen in 2015 to everyone else. Those with company run policies will be looking at the same issues we did, and when it happens to the 95% of the people it hadn't happened to, I expect a revolution.

[David Weaver]

We cost some of these types of things at work, and knew at the outset that the ACA was generally going to cost people more. I don't know how long ago that was now, two years, I guess?

I can't tell people that it's going to cost them more in the long run because nobody believes it until they get the bill. We've been sort of waiting to see what would happen and where it will go from here, because it affects our costing of liabilities - to estimate the overall current and future costs. There have been some short term bumps here, where people get into line with the loss ratio requirements, but I am no expert on any of that stuff (in terms of at which level it's applied - company/policy type, etc) - I get the inputs from other folks and do the modeling of it into the future. At any rate, the crux is for some folks there was a short reprieve and others there was an immediate cost increase.

We knew early on that the minimal coverage type healthy individuals were going to get hammered.

[Scott Shepherd]

We knew early on that the minimal coverage type healthy individuals were going to get hammered.

That's why I say "Wait until what happens to us, happens to everyone else". Right now we're ignored and brushed off like we don't exist or we're just complaining about the ACA. Just wait. I have heard from a number of friends and family that have told me their companies will stop paying for their families insurance in 2015. They'll only cover the employee. That means people that make $50,000 a year will get hit with about a $700 a month increase in their costs to keep healthcare.

That's coming, that's real, and that's going to shock everyone else out there like we (individual policy holders) have already been shocked.

How anyone thinks someone making $50K a year with a family can afford to spend $9000 a year out of their pocket that they didn't spend before (not to mention the new $6,000 deductible they'll have to deal with for their families) is going to make it is beyond me.

It's coming soon. It would be here now if they would stop delaying it until after elections to protect the people from finding out about it.

[Joel Goodman]

I am baffled why a hospital bill is $10,000 then gets a "Blue Cross" discount of $8,000 so that the bill is really $2,000. Try negotiating for 80% off on a car! In reality people without insurance rarely pay the whole bill because they don't have the money -- just hounded forever and have their credit ruined. The worst part is that it keeps the major insurance companies stranglehold on the market -- if you tried to start an insurance company you couldn't get the 80% off that you would need to compete. Case in point - my union self insures but we pay a fee to a major carrier to get their discount -- they provide nothing other than the discount. What would be wrong with a "one price for everyone" law at the hospital as an added part of the Affordable Care Act? If a hospital can make out giving Blue Cross a discount, give it to everyone. When you go to the hospital you are usually in extremis and not in a place to negotiate. It's a very different type of transaction than pretty much anything else we buy and should have different rules to reflect that. BTW can you imagine giving one of your customers a bill as opaque as the standard hospital bill -- I can't!

[Scott Shepherd]

I am baffled why a hospital bill is $10,000 then gets a "Blue Cross" discount of $8,000 so that the bill is really $2,000. Try negotiating for 80% off on a car! In reality people without insurance rarely pay the whole bill because they don't have the money -- just hounded forever and have their credit ruined. The worst part is that it keeps the major insurance companies stranglehold on the market -- if you tried to start an insurance company you couldn't get the 80% off that you would need to compete. Case in point - my union self insures but we pay a fee to a major carrier to get their discount -- they provide nothing other than the discount. What would be wrong with a "one price for everyone" law at the hospital as an added part of the Affordable Care Act? If a hospital can make out giving Blue Cross a discount, give it to everyone. When you go to the hospital you are usually in extremis and not in a place to negotiate. It's a very different type of transaction than pretty much anything else we buy and should have different rules to reflect that. BTW can you imagine giving one of your customers a bill as opaque as the standard hospital bill -- I can't!

So far, everyone I have contacted has offered a pretty decent discount if you pay for it. They tend to offer 50% off the bill without even asking. I haven't worked through the hospital bill part yet, but on the other people that's been the case.

[Joel Goodman]

Glad they are offering you a "discount" -- I just wonder if it's as much as they give the major insurers in their network. My point is that it would be a better policy to actually post the real price -- and have it the same for all. Dealing with hospitals made me feel that I was negotiating in an outdoor market in a third world country for a carpet.