The real problem with health insurance

[disneysteve]

I am a family practice physician. One of my employees is having surgery later this month and we're trying to figure out how much it will cost her out of pocket. We have our insurance cards, the book that comes with it explaining our benefits and her account pulled up at the insurance company's website. With all of that information, 4 of us (2 physicians, 1 medical assistant, 1 office manager) can not figure out how much she has already paid in, what remains on her deductible or what she might possibly be responsible for as a result of this surgery.

It is insane that it is so complex and convoluted that 4 reasonably intelligent people WHO WORK IN THE FIELD can not make sense of the information provided. How any regular patient manages I have no idea. If we can't understand it, how can anybody else?

[kork13]

Very simple, DS my friend:

Patient goes under the knife --> Hospital bills Insurance --> Clerical employee enters invoice into computer --> ***MAGIC HAPPENS HERE*** --> Patient gets bill for "her share"

[bjl584]

That's an issue for any sort of entity that is large and has many different businesses, and government agencies involved in the process. There is bound to be a lot of inefficiency, confusion, and waste.

[disneysteve]

Originally Posted by bjl584

That's an issue for any sort of entity that is large and has many different businesses, and government agencies involved in the process. There is bound to be a lot of inefficiency, confusion, and waste.

True. I just worry about how this affects people. How many patients put off getting needed medical care because they simply can't figure out what it will end up costing them? And calling the company doesn't generally help because if you call 3 times and ask the same question, there is a good chance that you'll get 3 different answers. Even the people who work for the company don't always know how things work.

[bjl584]

Originally Posted by disneysteve

True. I just worry about how this affects people. How many patients put off getting needed medical care because they simply can't figure out what it will end up costing them? And calling the company doesn't generally help because if you call 3 times and ask the same question, there is a good chance that you'll get 3 different answers. Even the people who work for the company don't always know how things work.

Yes, it's a shame that it's peoples' health and finances that are on the line when it comes to decisions involving healthcare.

A lot of the regulars on this board budget and plan for everything. But it is quite frustrating when even the best planner gets blindsided with an unexpected bill.

This would make a good debate topic for the upcoming Presidential race. Someone that could figure out how to streamline and simplify this process may be on to something.

[disneysteve]

Originally Posted by bjl584

A lot of the regulars on this board budget and plan for everything.

Very tough to budget and plan when you can't figure out what it will cost.

When I see the President in December maybe I'll ask him about this.

(Yes, I will be seeing the President, but no, I probably won't have the opportunity to ask questions. There will be 5,000 other people seeing him with me.)

[cschin4]

I think confusion is planned on the part of the insurance company. That way, people calling in trying to figure it out just give up and pay the bill, especially the elderly. There should be some reality but there isn't. There should be some basic ability to pinpont or estimate costs. And, as it is now, you go for care wondering if it will be covered or not and nobody seems to know until after the fact.

[disneysteve]

Originally Posted by cschin4

as it is now, you go for care wondering if it will be covered or not and nobody seems to know until after the fact.

This is so true. When my office calls an insurance company to get prior authorization for something, the approval letter they fax us specifically states that authorization is not a guarantee of payment. Really! Then what the heck is it? Why do we need to waste our time getting "authorization" first if doing so doesn't assure payment?

[cypher1]

Originally Posted by disneysteve

This is so true. When my office calls an insurance company to get prior authorization for something, the approval letter they fax us specifically states that authorization is not a guarantee of payment. Really! Then what the heck is it? Why do we need to waste our time getting "authorization" first if doing so doesn't assure payment?

Really? Interesting to know. A few years ago when I needed some dental work done, there was definitely a miscommunication on both sides for coverage with my insurance and the office that did the work. Long story short, I ended up paying 5x more than I expected for that work. Had I known that, I would've pushed back the work. My new dentist advised to always get a fax from insurance carrier with the quote for authorization. It just makes me more paranoid about getting a surprise bill after work is done and questioning my coverage.

[disneysteve]

Originally Posted by cypher1

Really? Interesting to know. A few years ago when I needed some dental work done, there was definitely a miscommunication on both sides for coverage with my insurance and the office that did the work. Long story short, I ended up paying 5x more than I expected for that work. Had I known that, I would've pushed back the work. My new dentist advised to always get a fax from insurance carrier with the quote for authorization. It just makes me more paranoid about getting a surprise bill after work is done and questioning my coverage.

I think they just do it to cover their butts. I can't think of any case of payment actually being denied after authorization was obtained.

As for my employee, she called her surgeon today to see if they could give her a ballpark estimate of the price of the procedure. They said to call the insurance company as they would know the fee schedule they use to pay those claims. So she called the insurance. The insurance company told her they can't give her that information. They won't know how much they'll pay until they receive the bills from the surgeon.

It is amazing. The doctor doing the surgery can't tell the patient how much it will cost and the insurer can't tell the patient what they cover. Apparently, nobody really has any clue what the heck they are doing.

If you call my office and ask how much something is, we can tell you. We can give you the price of an office visit. We can give you the price for any vaccine you may need. We can give you the price for any lab testing that we perform or for a EKG. There is nothing we do that we don't know the fee we charge. I can't imagine how these other places operate without knowing how much they're going to charge or how much the insurance company is going to pay them.

[GREENBACK]

This should get really exciting when Obama care fully kicks in

[disneysteve]

Originally Posted by disneysteve

The doctor doing the surgery can't tell the patient how much it will cost and the insurer can't tell the patient what they cover.

Can you imagine if any other business worked this way? What if you took your car to the shop and were told they won't be able to tell you the cost of the repairs until after the work is done? What if you hired a contractor to work on your house and he said he can't tell you how much the bill will be until he completes the work? What if the grocery store had no prices on their merchandise and you couldn't find out the cost until after the items were rung up at the register, at which point you must pay for them - no returns allowed. What if the airline said you won't be given the price of your flight until you arrive at your destination?

[DayByDay]

In my younger days, I worked for a couple of health insurance companies as a claims processor. I was ordered to increase the number of claims processed per day at the expense of accuracy.

They expected/were okay with a certain percentage of incorrectly processed claims. The claims more likely to be incorrectly processed were the more complicated, expensive hospital bills where errors could be quite costly to the patient.

[dfeucht]

Originally Posted by disneysteve

It is amazing. The doctor doing the surgery can't tell the patient how much it will cost and the insurer can't tell the patient what they cover.

This.

I am an actuary who works in the health insurance business - I work as a consultant and have had many insurance companies as clients.

Almost no one can answer the simple question - how much will this cost? If you have surgery at the hospital - you get one bill from the hospital, one from the physician in many cases neither can tell you what they charge. They can blame the insurance companies all they want, but in the end they don't know - because thy have charges that are 20-50% above what they will actually get paid depending on who pays for it. For instance if you are in a car accident and get care, the money first comes from your auto insurance. If auto insurance is paying they are definitely going to pay much more than a health insurer because they can't negotiate enough volume to get a better deal.

If you call the health isurer, the contracts they have are so competitive one they won't share them and two they ultimately don't know how the physician or hospital will code the procedure - although in the end you will see how much they paid because it is on the bill you ultimately receive anyways.

I will say - for my own personal insurance it is pretty clear on the website how much I have paid in either deductible or coinsurance and I at least know what my share of the next procedure will be (in my case right now 20%) - I just don't know 20% of what.

I know insurance companies are the easiest target in the health care debate, but physicians and hospitals have equal blame in the complexities of this system in my opinion (no offense Steve). The incentives are misaligned - we pay for each service as opposed to having quality outcomes.

I always say insurance companies will cover whatever anyone wants them to cover, the issue is premium costs would accelerate even faster. They haven't helped themselves by denying claims that they ultimately know they should have to cover so they have put the target on their own back. Still I think a parternship of private insurers and physicians and hospitals can come up with the best solution for providing affordable care to society.

[creditcardfree]

Hmmm...I wonder if it is all in the question? If you ask the surgeon's office for how much they might BILL the insurance company for a procedure such as this you might actually get an answer from the billing department. If they could then provide that information to the insurance company prior to the proceedure, the insurance company MIGHT be able to give an estimate on the cost share of the procedure. Maybe.

[rj.phila]

Originally Posted by disneysteve

True. I just worry about how this affects people. How many patients put off getting needed medical care because they simply can't figure out what it will end up costing them? And calling the company doesn't generally help because if you call 3 times and ask the same question, there is a good chance that you'll get 3 different answers. Even the people who work for the company don't always know how things work.

i am in the 33% tax bracket and only carry a catastrophic ins plan cause of this. its amazing how inefficient our health care system is here, and how we rank LAST in the developed world in terms of care(inf mortality rates), and HIGHEST in cost per capita. its totally insane.

how does it affect people? well, we dont visit doctors very often

[MonkeyMama]

I think it's almost better on some level to be uninsured in that then you know what you are paying for.

& NO - I do not recommend being uninsured. BUT, we do not have dental insurance (have not seen any plan worthwhile) and so in that vein we skip this game completely. We may pay more in the long run, but certainly no surprises. (& maybe even this is not true since I know so many people who blindly pay for unnecessary dental work).

Our health insurer (nonprofit, top rated) is also very good. I don't get bills -just about everything is simply covered. We switched to a HDHP a few years back - I only have a thorough understanding of how it all works because we have used the insurance very thoroughly since the switch. But - it is more along the vein of catastrophic insurance, and a little simpler to navigate. If I Was having surgery, I'd know exactly how much it cost before dedutible. After deductible? Haven't a clue. & would be hard to pin down - I have gotten different answers from insurer before, definitely. I know the maximum they can charge me though. Though I do not have a 100% thorough understanding, I have found this plan easier to understand than just about everything else out there (I have private insurance and do shop around). I should say I might pay more for insurance I Can understand. Though I am not 100% sure because I can not understand the other health plans!

Interestingly, with Obamacare, the insurer had to give us 60 days notice of premiums this year, but they failed to tell me what my deductible and out of pocket would be for 2012. Kind of USELESS information? (It is possible they can not change those figures, with the new laws. But I am not sure on that).

Health care reminds me of the tax code. It's about as complicated. I can hardly think of anything that comes near as complicated as these two monsters.

[bjl584]

Originally Posted by MonkeyMama

I think it's almost better on some level to be uninsured in that then you know what you are paying for.

& NO - I do not recommend being uninsured. BUT, we do not have dental insurance (have not seen any plan worthwhile) and so in that vein we skip this game completely. We may pay more in the long run, but certainly no surprises. (& maybe even this is not true since I know so many people who blindly pay for unnecessary dental work).

Our health insurer (nonprofit, top rated) is also very good. I don't get bills -just about everything is simply covered. We switched to a HDHP a few years back - I only have a thorough understanding of how it all works because we have used the insurance very thoroughly since the switch. But - it is more along the vein of catastrophic insurance, and a little simpler to navigate. If I Was having surgery, I'd know exactly how much it cost before dedutible. After deductible? Haven't a clue. & would be hard to pin down - I have gotten different answers from insurer before, definitely. I know the maximum they can charge me though. Though I do not have a 100% thorough understanding, I have found this plan easier to understand than just about everything else out there (I have private insurance and do shop around). I should say I might pay more for insurance I Can understand. Though I am not 100% sure because I can not understand the other health plans!

Interestingly, with Obamacare, the insurer had to give us 60 days notice of premiums this year, but they failed to tell me what my deductible and out of pocket would be for 2012. Kind of USELESS information? (It is possible they can not change those figures, with the new laws. But I am not sure on that).

Health care reminds me of the tax code. It's about as complicated. I can hardly think of anything that comes near as complicated as these two monsters.

There is something to be said for being uninsured AND having the cash available to pay cash for medical procedures. If you are rather wealthy and simply go to the doctor/surgeon and the hospital and offer up cash for a procedure and a hospital stay, it is much simplier than having to puzzle over insurance coverage and copays. But, most of us don't have that ability.

[disneysteve]

Originally Posted by creditcardfree

Hmmm...I wonder if it is all in the question? If you ask the surgeon's office for how much they might BILL the insurance company for a procedure such as this you might actually get an answer from the billing department. If they could then provide that information to the insurance company prior to the proceedure, the insurance company MIGHT be able to give an estimate on the cost share of the procedure. Maybe.

Nope. That's exactly what she tried. She has the procedure billing codes that will be submitted to the insurance company. We needed those to issue the referral for surgery. So there is no question of what will be done.

She called the surgeon's billing department and was told by them to call the insurance company with the codes to find out how much they would pay. The insurance company, given that information, told her they don't know how much they'll pay until after they get the claim.

[creditcardfree]

Originally Posted by disneysteve

Nope. That's exactly what she tried. She has the procedure billing codes that will be submitted to the insurance company. We needed those to issue the referral for surgery. So there is no question of what will be done.

She called the surgeon's billing department and was told by them to call the insurance company with the codes to find out how much they would pay. The insurance company, given that information, told her they don't know how much they'll pay until after they get the claim.

That makes absolutely no sense to me. I wonder if it needs to go up to a supervisor. There is no way they could not know. It seems they could give a number, but emphasize it is an estimate. I think they just don't want to deal with giving figures until it is a true claim, for liability reasons.

This is really a very good example of what is wrong with healthcare. Too many middle men, specifically insurance. If it was just doctor and patient. There would be not be this kind of problem.