There is a “Let’s Talk About Fees” campaign in Australia that encourages patients to talk to their doctors about the costs of procedures.
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For practical purposes fees are set by third party payors. The exceptions are plastic surgeons, botox doctors, alternative practitioners, concierge physicians, and others of that ilk. They can afford the extra time to discuss fees. No sympathy from me.
For the rest of us who practice real medicine and largely participate with third parties including Medicare, Medicaid, and local Blue-Cross companies, fees, including co-pays are set by those third parties.
When asked by a patient to explain fees, I give a pre-printed sheet explaining the above along with a list of telephone numbers of the insurance companies.
Would you purchase a life or auto insurance policy and then have no clue of what it covers or what the pay-out is?
Exactly, it is like purchasing an auto insurance policy, then expecting the mechanic to explain to you why/how you need to pay a deductible. A.) Understand the policy before you purchase it, or B.) If you don’t, call your darn insurance company!
I’ve made this point before and got the typical “but those contracts are so long and complicated and hard to understand, no reasonable person could be expected to figure it out” boo-hooing. Sorry, but that isn’t your doctor’s problem.
Exactly, it is like purchasing an auto insurance policy, then expecting the mechanic to explain to you why/how you need to pay a deductible. A.) Understand the policy before you purchase it, or B.) If you don’t, call your darn insurance company!
Personally, I never ask doctors for cost (except for cosmetic procedures when I pay cash). In other cases, I try to get an answer from the insurance or, if unable to do so, I may call the billing department or, if it is a private doctor, talk to the person in the reception who does the billing.
Having said that, I think your comments about patients’ not willing to read contracts don’t consider the fact that the majority of patients get the insurance through their job and don’t see these contracts.
From personal experience: you call the insurance company and ask “what is the cost of X”, they tell you “we cannot say because the billing done by the local branch”. “could you give me the number for the local branch?”,”no, they will not be able to say because it depends on the code”. “OK, could you give me a very rough estimate, I am simply trying to figure out what my 20% will be so that I can put enough money in the health account (but not too much)”. “We cannot say in until we see the bill”.
And before you say that we shouldn’t get insurance from the employer – at least in case of large companies, the insurance works because the majority of people in the group are young and healthy. Do you seriously believe the insurance companies will want to sell individual policies to people who need it most?
I did not fail to consider that most insurance plans are delivered as a benefit through employment. You may be confusing the contract that your employer makes for a group policy with the contract (sometimes called a “rider”) that all patients must receive (by law) when they enroll. Now I realize that the majority of people probably discard these materials or thrown them into a bottom drawer somewhere, but still. Most people probably don’t even remember having it (just like they claim to have no access to their formularies either).
Why you would think I’d advise not getting through insurance through an employer, I don’t get (that has nothing to do with anything)…
And let’s make sure we distinguish between two different types of billing conversations here: asking up front about a doctor’s fees is not only acceptable, but welcome.
Laying into them or their staff about why their insurance didn’t cover this, why they have a deductible for that, why they’re responsible for the charge on a non-authorized test, can’t get the lower co-pay on a certain drug, etc. is the problem. This is really none of your doctor’s concern, and is an issue between a patient and their insurance.
There is a small minority of patients who do not have the mental capacity to understand the abstract notions of a contract and who pays for what. Those are the people who seem to be the most irritated when they demand an MRI for their head pain and their insurance company denies it. My current approach is to order them whatever they like, make it clear in my note that it isn’t necessary, and then politely tell them when it is declined that their insurance company felt they didn’t need it.
This does two things. It insulates me from their misplaced wrath and it redirects their anger at their insurance company. All the while, the tincture of time is curing their headache. Voila.
My former family doctor actually did something recently that I’ve never had done by any other physician. I went to the doctor’s office with rapid heart rate and high blood pressure. He had me wear the holter monitor for 24 hours. As it turns out, my insurance doesn’t cover that. I had no idea. So when the office received the rejected claim from the insurance company, the office adjusted their price by a significant amount since I was suddenly paying out of pocket. I was pleasantly surprised as one of the things I’ve always stood by is that it’s frustrating that insurance companies can pay such and such % of the fee, but an uninsured person cannot simply say, “Well….I think I’m only going to pay 20%” and leave it at that. To have my doctor’s office reduce the fee once it was rejected by insurance was really a nice compromise!
Another random insurance problem I ran into happened when I was away at school in a rural area and had gone to the ER twice for the same thing. The first time, my insurance paid the bill. The second time, the claim was rejected and the insurance stated that I went to an out-of-network hospital and even though I was seen in the emergency room, the reason for the visit was not emergent. Well – that about flipped me out right then and there. How do they know it’s not emergent? Did they assess me or provide treatment? No. Did they speak with the physician and staff who did? No.
So in the many months it took my mother and I to resolve this situation, we made countless calls to the ins. co. We told one representative that we felt every person should be required to take a class in insurance policy since there is no way a single individual can understand every bit about their policy. Then, since my claim was being denied on the basis that the visit was not deemed emergent, I asked the representative if the company could provide me a list of diagnoses deemed to be non-emergent when visiting out-of-network emergency departments. You know. Just for future reference. No – the insurance company could not provide me with this information. (Right – like I expected they would hand over this list…) In the end, they paid the claim on the basis that they had already paid the claim on the prior visit for the same reason.
Another kicker was that a different insurance rep told me to make sure I went to an in-network hospital in the future. I told him that I lived in the middle of nowhere and there is only one hospital to go to. His response was, “Only one hospital? What kind of place is that?” He’d obviously never taken classes in geography in order to know that outside of the metropolitan areas, access to care can be kinda slim. In an emergency, I can’t afford to travel 3 hours to get to the nearest in-network hospital.
Can’t win sometimes…
Now I realize that the majority of people probably discard these materials or thrown them into a bottom drawer somewhere, but still. Most people probably don’t even remember having it (just like they claim to have no access to their formularies either).
When I had an HMO, I indeed received a book describing the services. I am not in the habit of throwing away contracts or any important paper, btw.
After I switched to a PPO (my company self-insures and only uses insurance company to manage the plan), I haven’t received any communication in the mail. There is a website and it does contain generic information, but no specific billing details. I find it interesting how they are required to send us the information, yet while they don’t. Maybe because my employer is self-insured it doesn’t have to do it.
As far as covered/not-covered goes, doesn’t it depend if you are the member of the network? If it is out-of-network, I fully expect to pay for not covered services – in fact I may even pay in cash and then get a refund as I do with my periodontist. But don’t you make some contract with the network when you agree to take it? Just asking.
Obviously I mean the tests you recommend, if a patient insists on something – it should absolutely be his problem. Much as when I go to the dermatologist – I either pay upfront for things I know are not covered or have it billed. With the dermatologist it is usually obvious which is which.
I’m not sure what you’re really asking when you say don’t I make some sort of contract with the insurance when I agree to take it. Of course I make a contract, but that has little to do with whether your services will be covered. They still need to be deemed medically necessary by your insurance, and additional restrictions on individual policies vary greatly (some don’t cover prevantative care, hence, physicals and pap exams are the patient’s expense; many new plans have a six-mont “prior exisiting” clause, where any treatment you get for a condition that existed before you started coverage with them is also denied, etc). Ultimately, just because I am an “in-network provider” is absolutely no guarantee that all the services I provide are covered, and it definitely has nothing at all to do with whether tests (MRIs, etc.) that I order are covered.
“Maybe because my employer is self-insured it doesn’t have to do it.
“
Contact your state insurance department to find out about your right to get a copy of your health insurance contract. You may have to contact the state where your employer is headquartered, as well. I used to work for a large corporation that was self-ensured, and they did mail the 40 page contracts out to employees. I don’t think it matters whether the company is self-insured or not. I do know that the contract came directly from the company, and not through the insurer.
The contracts I’ve had are somewhat clear, but can be confusing on some points. For instance, for me to get physical therapy that is ordered by a specialist, I have to get the script from the specialist. But I have to get a referral for the therapy from my family doctor, and go to the physical therapy provider that she is contracted with. This is even though I have a referral already from the family doctor to see the specialist, and the therapy is for the condition that she sent me to the specialist for. This is how patients get confused, having to get paperwork from both a family doctor and a specialist for the same service.
What I have figured out is that whenever I’m in doubt as to what to do paperwork-wise, I’ll get the referral and the script from my family doctor; there’s no way the insurer can then say I didn’t get the right paperwork processed.
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