Podiatrist has different prices based on insurance

[Brian Tymchak]

Went to a new podiatrist recently as my old orthotics have bit the dust. They offered 2 prices, one a lower "self-pay" and another higher if using health insurance. I've not seen that before. The orthotics self-pay price was about 25% lower than the insurance price. With my past experience with insurance coverage (or lack thereof) of orthotics, I opted for the self pay. They use this price model for all their services. I need a little PT for chronic plantar fasciitis. I had them bill the insurance for the first session to see what the difference will ultimately be.

Anyone else seeing this kind of pricing model? I wonder if this going to become a trend.

[Jeff Roltgen]

It's everywhere, and has been this way for a very long time. I've got friends who refuse to buy health insurance, and simply call accounting when bills arrive, declare they're not insured and proceed to negotiate the actual cost they will be paying the hospital, which is always a 40-60% reduction of what they'd charge the insurance company.

As a former insurance agent of a few decades ago, I can assure you, this is rampant in that industry. A local billboard advertises that your deductible will be waived for paintless hail dent repair. No, they simply fake a bill to the insurance company and bury the deductible in the invoice. It's called theft, but hey, we all hate the insurance companies, so when we get the chance, a person generally has no sense of remorse in being a party to the ripoff.

Then your next insurance bill comes, and then you scream, ripoff!
It's a vicious cycle.

jeff

[Patty Hann]

Went to a new podiatrist recently as my old orthotics have bit the dust. They offered 2 prices, one a lower "self-pay" and another higher if using health insurance. I've not seen that before. The orthotics self-pay price was about 25% lower than the insurance price. With my past experience with insurance coverage (or lack thereof) of orthotics, I opted for the self pay. They use this price model for all their services. I need a little PT for chronic plantar fasciitis. I had them bill the insurance for the first session to see what the difference will ultimately be.

Anyone else seeing this kind of pricing model? I wonder if this going to become a trend.

It depends on the doctor (or group).
I have had that exact "orthotics" situation that you describe.
When doing PT (for one thing or another *sigh*) I casually asked about pricing, even tho' insurance was paying for it.
Billing would be different (slightly lower) for those paying cash.

[Edwin Santos]

The next step in this phenomenon is those physicians or groups who simply don't take insurance. Some will reject all insurance except for traditional Medicare. This is because Medicare pays promptly and the billing process is fairly straightforward, meaning fewer hoops to jump through, not to mention fewer denied claims.
For most physicians, getting to the point of being able to do this is like the Holy Grail because it simplifies life so dramatically.
Even better are those doctors that are able to run a "concierge" practice. Under this model, patients pay something like a membership fee and in return the doctor will be more available because he/she presumably has fewer patients. My mother uses one, and indeed, she can call her doc on his cell phone, and when she was very ill he made a house visit.

There's an analytical measure called effective rate. Let's say the insurance company has agreed to pay a doctor $100/visit (hypothetical round number). But then they proceed to deny claims for prior auth, billing code, or some other finicky reason 20% of the time. At that point, the doc realizes he/she is effectively being paid $80 not $100. Then on top of that, let's say the insurance company is not paying in 30 days, but stretches payment out to 90, 120, maybe 150 days. They have models that show how much money they make by stretching the payment cycle.
Worst of all, let's say the insurance is increasing deductibles and co-pays on the insured, so now the doctor's office is in the business of collecting from the patient after the insurance has denied the bill for deductible reasons. So insurance means you will effectively be paid less, it will take much longer, and require more staff.
No surprise why cash paying would be attractive enough to offer a discount.

[Stan Calow]

and since all of this is well known to all the actors, one could infer collusion in the whole for-profit US medical system.

[Patty Hann]

It's everywhere, and has been this way for a very long time. I've got friends who refuse to buy health insurance, and simply call accounting when bills arrive, declare they're not insured and proceed to negotiate the actual cost they will be paying the hospital, which is always a 40-60% reduction of what they'd charge the insurance company.

jeff

How do your friends get service BEFORE paying anything?
In my experience if someone doesn't have insurance, (no card to hand over) they are basically shown the door right then and there.
I know people that negotiate costs PRIOR to ,say, entering the hospital (for elective surgery).
But without showing an insurance card are paying up front I don't see how they even get past the Glass window, unless it was an ER visit.

[roger wiegand]

Though the billing to the insurance is higher, in all likelihood the reimbursement is much lower. It's extremely likely that your doc makes more money on the discounted cash price. People without insurance pay the highest prices in our wonderful system.

[Jeff Roltgen]

How do your friends get service BEFORE paying anything?

Just the way our local hospital does business, which I believe still is classified as a non-profit. And they are hurting, similar to the Denver system, who went in the red to the tune of many millions last year, based on caring for the huge volume of patients admitted who have no means to pay. My DIL , an employee in the local hospital's pharmacy, narrowly missed a layoff last week, due to this very problem, as they are trying to cut overhead to stay afloat with all the unpaid invoices, so naturally, they start whittling down the workforce.

Seems that, once people realize they can walk away (or again, negotiate a smaller invoice), why would they ever embrace the huge monthly expense of insurance, when they're convinced it's just a big rip-off? I hear it stated as such quite regularly by people of all walks of life.

So, those of us responsible enough to take care of ourselves and hemorrhage the crazy insurance premiums simply get hammered all the harder, as someone's got to pay enough to cover the shortfall, somewhere in the midst of it all. Doesn't seem to matter how much the Guv tries to leverage us all into paying. Just isn't worth it for most people who's salaries do not include healthcare. Lots of non-working poor in the local larger city create an immense amount of burden on the system. Our state has the embarrassing distinction of taking in $1.50 in federal aid for every $1 paid in. Not sure the local healthcare system could run as anything but a nonprofit.
Again, it's a vicious cycle.

[Patty Hann]

Though the billing to the insurance is higher, in all likelihood the reimbursement is much lower. It's extremely likely that your doc makes more money on the discounted cash price. People without insurance pay the highest prices in our wonderful system.

'Zactly....my doctor explained it to me (in detail).
Basically he inflates the price provided to the insurance company (including Medicare), because by the time he gets paid the amount is about equal to what the service "really" costs (and what he charges cash patients.)

[Jim Becker]

In addition to the wait time to get paid and the requirement to accept what the insurance pays, the cost of processing claims comes into play. It's often a full time employee or three that just processes insurance claims for a busy practice.

A doctor that was my primary years ago left the practice and started his own in a "premium service" system that doesn't accept insurance at all. You pay an annual fee to get a whole bunch of things for "free" and a doctor with a lower case load (he limits the number of subscribers) who has time to work with you and file for insurance reimbursement yourself.

Additionally, many practices sell out to corporations to get away from the whole insurance thing...the providers are "employees" of the bigger corporation and don't do anything relative to insurance coverage at all.

'Tis a very complex system that we've evolved to in the US and it should be no surprise that both providers and consumers are trying hard to find a way to make things work for themselves since the system is what it is.

[Ron Citerone]

Just the way our local hospital does business, which I believe still is classified as a non-profit. And they are hurting, similar to the Denver system, who went in the red to the tune of many millions last year, based on caring for the huge volume of patients admitted who have no means to pay. My DIL , an employee in the local hospital's pharmacy, narrowly missed a layoff last week, due to this very problem, as they are trying to cut overhead to stay afloat with all the unpaid invoices, so naturally, they start whittling down the workforce.

Seems that, once people realize they can walk away (or again, negotiate a smaller invoice), why would they ever embrace the huge monthly expense of insurance, when they're convinced it's just a big rip-off? I hear it stated as such quite regularly by people of all walks of life.

So, those of us responsible enough to take care of ourselves and hemorrhage the crazy insurance premiums simply get hammered all the harder, as someone's got to pay enough to cover the shortfall, somewhere in the midst of it all. Doesn't seem to matter how much the Guv tries to leverage us all into paying. Just isn't worth it for most people who's salaries do not include healthcare. Lots of non-working poor in the local larger city create an immense amount of burden on the system. Our state has the embarrassing distinction of taking in $1.50 in federal aid for every $1 paid in. Not sure the local healthcare system could run as anything but a nonprofit.
Again, it's a vicious cycle.

I am the ultimate suburban child, convince me that the country folk in rural areas don't cost me money. Blame it all on the evil cities if you want show me that rural areas don't cost me money..............show mw the data.

[Alan Lightstone]

In addition to the wait time to get paid and the requirement to accept what the insurance pays, the cost of processing claims comes into play. It's often a full time employee or three that just processes insurance claims for a busy practice.

A doctor that was my primary years ago left the practice and started his own in a "premium service" system that doesn't accept insurance at all. You pay an annual fee to get a whole bunch of things for "free" and a doctor with a lower case load (he limits the number of subscribers) who has time to work with you and file for insurance reimbursement yourself.

Additionally, many practices sell out to corporations to get away from the whole insurance thing...the providers are "employees" of the bigger corporation and don't do anything relative to insurance coverage at all.

'Tis a very complex system that we've evolved to in the US and it should be no surprise that both providers and consumers are trying hard to find a way to make things work for themselves since the system is what it is.

Ah, retirement is wonderful.

As complicated as it is being explained above, it is in many ways far worse. And I could rant and rave about the evils of corporate medicine too.

Lots of evil in our system. Insurance companies, bloated hospital administrations making obscene salaries, big pharma charging US patients many multiples of the cost they charge other country's patients for medications (plus essentially no competition for all the biologic drugs. $90K a year for all the different medications to cure HepB from multiple companies??? How is that now illegal monopoly/collusion), insane HIPAA rules (try getting results from a practice without a fax machine. Yup, 1843 technology. Not able to e-mail you), lab companies charging massively abusive differentials for in and out of network care (try going to their competitor. They are both owned by the same company), and yes, doctors too.

Oh, did I mention how wonderful it is to be retired from my 100+ hour week job taking care of trauma patients and open-heart surgery? I miss helping people/saving lives. But the rest of the nonsense sadly outweighs all of that.

[Jim Becker]

Alan, it's sad to me that wonderful physicians like yourself can put your hearts into providing extraordinary and life-saving care and be so burdened by "the system". Something's got to give...

[Alan Lightstone]

Alan, it's sad to me that wonderful physicians like yourself can put your hearts into providing extraordinary and life-saving care and be so burdened by "the system". Something's got to give...

Sadly it will. And I don't think in patients' favor. Corporate takeovers of medical practices is evil. Plain and simple. Now being the patient, not the doctor is at times so sad. And I have wonderful hand-picked doctors I have gotten over the years, who I know are stellar, and I trust. Plus, no question, you do get a higher level of medical care as a physician for the most part. Like most professions, we protect our own, and I know the best questions to ask. Plus my physicians don't rush me. As I said, it's a higher level of care than many receive. And I worry about when they will retire and I will have to find new ones. Because they all will retire "early".

It really troubles me as a retired MIT graduate / Harvard Medical School resident and clinical fellow that 70% of Harvard graduates go into finance. That's what the best and the brightest in our country do. Just make money, and not benefit society. Just think of the advances we might have if our brightest students went into medicine. Didn't used to be that way. Sigh....

[Jeff Roltgen]

I am the ultimate suburban child, convince me that the country folk in rural areas don't cost me money. Blame it all on the evil cities if you want show me that rural areas don't cost me money..............show mw the data.

Terribly sorry Ron - thought I had done just that, but allow me to clarify:
That larger city I'm referring to is a mere 75,000 in population, so still, by most standards, a small town, and no way am I saying the "evil big cities" are being supported by us mid-westerners, as you appear to have interpreted it. A large concentration of the non-working poor are there, if for no other reason than easier access to a better hospital, assistance, but more likely to simply escape the depression and hopelessness of living on a reservation. You'd have to go to one to believe the destitution, regardless of the millions poured into upholding the Gov't promises to them. There are many diligently trying, but hopelessness is remarkably difficult to overcome, and clearly, money hasn't changed much of anything.

We, in our thinly populated, subsidized ranching countryside, along with the under-employed, are totally living off the Fed out here. Again, $1.00 paid in Federal taxation, $1.50 back in Federal funding, speaks directly to your demand for data. Not proud of it, but facts are what they are. So yes, you are perfectly correct, and as a resident, self employed, pay my way all the way business owner, I share in a fair bit of your frustration, while I'm living in the midst of it. We're not all living off the fed out here, but it is way out of balance, for sure.

Tourism is one of our biggest "industries". Fed by vacationers, like yourself, seeking a break away from the city, with fresh air, blue skies and prairie, and a nice little haven of the Black Hills to escape to. More evidence of you supporting country folk.

Anger does not help, and I'm sorry to have stirred it up in you. Hope this clarifies just how correct you are. But what to do?
We need to remain calm, and understand, regardless of who's feeding off of whom and for what reason, justified or not, how to strike a balance?
Plenty of us out here, exploring more ways to produce, be self-sufficient, and do our part to be contributors to this great nation. It's just not likely a perfect balance can be found, and you just have to trust that the vast majority of country folk (who all too often could be labeled the working poor) are doing their best to make good, and while not proud of it, appreciate the help we receive, when given.

jeff