Tips for questioning costs in today’s health care system

by Joanna Fief

About two years ago in the wee hours of the morning, I found myself in a local emergency room with severe stomach pain, incessant vomiting and dehydration.  It wasn’t pretty, and I was desperate for something – anything – to ease my pain and stop my vomiting.

Gratefully, within minutes of receiving an IV with medications for pain and nausea, my symptoms subsided.  After a couple of blood tests that all came back normal, I was discharged.  The ER doctor said I probably just had a virus.  I wish …

Over the next six months, I lost 20 pounds, and had repeated bouts of stomach pain and vomiting.  After another ER visit, countless doctor visits, an ultrasound, an x-ray, a CT scan, an endoscopy and a gastric emptying study, I was diagnosed with gastroparesis.  Gastroparesis is a disorder where food moves slowly – or sometimes not at all – through the stomach and digestive tract.

Thankfully, today my condition is well-managed, and I feel pretty good.  However, it took me until last month to finish paying my medical bills – and that’s with good insurance.  Although I definitely don’t mind paying for the care that I received, I do wish medical pricing was more straightforward and transparent.

My mother is a nurse and I work for a health insurance company. Until I got sick, I considered myself pretty savvy about the health care system.  Over the course of my medical journey, though, I realized even with “insider’s knowledge” it can be extremely difficult to navigate the system, know the right questions to ask, and make informed decisions about cost and quality of care.

Not until after I got my first emergency room bill did I find out that while the hospital was in-network, the doctor was out-of-network.  Only when I was lying on the gurney getting ready to be sedated for my endoscopy did it occur to me to ask the doctor how many of these procedures she had done (thankfully, more than 5,000).  And, not until a few months ago, did I even consider that I might have shopped around for the best price on a CT scan.  I always felt like I was one step behind.

The new health reform law promises to change the health care experience, but we shouldn’t underestimate the power each of us holds to drive that change.  If I had it to do over again, I would ask more questions about the cost and reason for each procedure – while there was still an opportunity to influence the outcome.  The questions might make others uncomfortable, or as I found, the answers might not be readily available, but it’s the best way to be your own advocate.

Learn from my experience.  When your doctor suggests going to the ER for a non-emergency x-ray just because it’s faster, you might think twice before going along with it.  Below are five simple questions you can ask to create options and protect your pocketbook.

  1. How much does that cost? It’s a simple question with a complicated answer. Costs can vary depending on your insurance (or lack thereof).  Be sure to ask up-front how much it will cost for you.  I had to talk with a couple of people at my doctor’s office and insurance company to get an answer.  Be persistent!  It’s your money!
  2. Is that really necessary? Do you really need two MRIs in the same month? Although, at first it might feel uncomfortable, it’s okay to ask this.  It can help protect you from unnecessary physical risk (think excess radiation exposure) and financial hardship.
  3. Is there a cheaper option? The newest and most expensive technology is not always the best option.  Many times there is an equally safe and cost-effective alternative that can save you hundreds – even thousands – of dollars.
  4. Is there a generic for that? One of the simplest things you can do to save on medical expenses is to ask your doctor or pharmacist if there’s a generic alternative for any prescription drug you are taking.  The generic may look different, but the FDA requires it to meet the same strict standards of safety and effectiveness as the branded version.
  5. Has anybody out there had this before? Ask your family and friends what their own experience has been with a particular condition or treatment.  Their insights can also help you ask good questions of your provider and care team.

Joanna Fief works at Regence BlueCross BlueShield in Portland, Oregon. The company’s blog about health care costs is What’s the Real Cost.

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  • Vox Rusticus

    In the ED setting, a patient’s opportunities to start asking questions about the costs of the evaluation become vanishingly small. In fact, the perceived latitude to begin parsing the value for cost in that setting would beg the question of the acuity and thus the need to be in an ED in the first place. Now that isn’t meant to be a license to the practitioner to throw consideration of costs to the wind, either, but the priority in the ED is to prefer speed in diagnosis, or at least in exclusion of critical diagnoses over economy, and to stabilize the patient.

    Suggesting that the prospective ED patient come to the hispital armed with a bagful of questions makes a thinking person wonder at the decision to go to the ED vice a normal office appointment.

  • rezmed09

    “How much does that cost?”
    I doubt you will get an accurate answer. The CT costs one amount, the contrast another, the radiologist fee yet another. The EKG costs another as does the interpretation. The Telemetry monitor another, the ER doc, the IV fluids, each IV medication, and on and on. We are but pygmies in this vast wilderness of health care bills. The only giants of simplicity are those on Medicaid.

    “How many of these procedures have you done?”…
    Are you willing to pay more or less for the experience level of the endoscopist? or the Anesthetist? or the Nurse putting in the IV? If provider experience level is valuable to the patients, should it not also be valuable to the providers – at every level?

    How about some other important questions:
    “Did you get sleep last night?”
    “How many lawsuits have you had?”
    “Do you have a substance abuse problem?”

    We used to have travel agents. Maybe we need health care agents? Someone with no vested interest in the profit and legal sides. Docs are too immersed in the hustle and flow to be consistently reliable in this regard. But asking questions is time; and time is, and should be, money.

  • Killroy71

    Time is money — OUR money, and our health. So much of medical treatment is discretionary, testing this or that “just in case,” the MRI instead of the x-ray. We should ask, do I really need that? My doctor has backed off on things and said, well I just always order that, when there’s nothing in my medical history to indicate I need it.

    Costs are out of control. Sometimes it’s unreasonable pts who demand treatment and doctors give in. Sometimes it’s doctors on auto-pilot (who nonetheless protest cookbook medicine). We all have to stop and think about what we’re doing and why. The answer cannot be, “just because we can” or “it’s covered.”

  • http://warmsocks.wordpress.com/ WarmSocks

    We’ve had the same experience with a hospital accepting insurance, but the ER doctors there not accepting insurance. Now we know that if there’s a choice, take an extra five minutes to get to the other hospital in town – the docs there do take insurance so the cost to us is significantly less.

    This is a good reminder. Although it is true that once an emergency strikes, it’s kinda late to be asking questions, we can anticipate that someday we might have an emergency and figure out in advance (now!) where we’d want to go when/if that time comes. There are things we can ask beforehand to help control the costs.

  • Marc Gorayeb, MD

    Physicians should be prepared to tell patients how much their fee will be for the services they render. I must confess that I don’t have this information at my fingertips because I have never been asked.
    As to services and procedures provided by a hospital, the only way that a list of charges will ever be posted is through pressure from patients (or government) applied to the hospital administrators. Neither physician nor nursing staff alone will ever be able to move that mountain.

  • stargirl65

    “Do you really need two MRIs in the same month? … It can help protect you from unnecessary physical risk (think excess radiation exposure) …”

    MRIs do not use any radiation. They use magnetics. CT scans use a lot of radiation. Ultrasounds use sound waves and have no radiation as we think of it.

  • hawk

    maybe instead of saying the local ER docs dont take insurance, it might be better to ask why they dont take YOUR insurance. perhaps you should be calling your insurance company and asking why they dont provide a fair payment so that you can go into your local ER.

  • Maria

    this is only peripherally related, but something that has been bothering me for awhile…I had an outpatient surgery at a nonpar facility-I’ve had surgery there before & they will submit an outrageous fee but will accept what the insurance pays for the facility costs. They were paid about $1000 for a prior surgery 4 yrs ago & a different facility was paid $1200 facility fee for the same orthopedic surgery 6 mos before the one in question. Keep in mind this does not include the surgeon’s or anesthesiologist’s fee-merely the facility fee. Well, they submitted a fee of $35,000.00 AND my insurance paid it in FULL! You may wonder why I care as I had no out of pocket on it, but my company is self-insured and we just went through an ugly contract negotiation centered around their desire to raise our health care premium cost-shares due to rising costs, (which, btw, was not so subtly hinted to be the fault of employees w/ chronic conditions such as R.A., that I have) I know this was processed incorrectly, (I also work for an insurance company) and brought it to the attention of the HR dept, who in turn contacted the insurance company who administers our plan but they contend it was processed correctly & that was that. I’m not sure if I should pursue this further or not but if this is a routine situation, is it any wonder our costs are skyrocketing? I welcome comments and advice…

  • Renee

    This author is correct on all points, but the process is far more frustrating that you’d imagine. I shopped for an outpatient surgery facility for my daughter’s gallbladder removal and every facility I called was either surprised at the question of “how much do you charge” or couldn’t give a straight answer. Instead they tried to explain how a deductible works. One hospital refused to give out the information. The difference in cost from one facility to another was astounding. And to even get the info, you have to have the procedure code. Because facilities have a different agreement with every insurance company, there is no one single price they can give out. I went through the same process with an MRI and went to the lowest cost provider. However the bill they sent was not the same price I was given over the phone – it was hundreds more. So, to be a smart and responsible medical consumer takes extraordinary effort, and you’re working against a system that doesn’t wish to be questioned and doesn’t think you should even worry about cost.

  • gzuckier

    “Physicians should be prepared to tell patients how much their fee will be for the services they render. ”

    Which, of course, varies hugely depending on which insurer you have, if any, and which contract year you were planning to have the services done.

    • http://warmsocks.wordpress.com/ WarmSocks

      It shouldn’t be that way. The physician should have a set fee per billing code. Different insurers might negotiate different discounts, but the base fee should be the same for everyone.

      • Renee

        SHOULD is the operative word here! There is no base fee as far as I can tell. Some providers charge far more for people who don’t have insurance. My doctor charges far less for people who don’t have insurance. In fact, my husband, who has no insurance pays less for a doctor visit than my insurance co-pay to the same doctor! The system is ridiculous.

  • Maria

    It is not the responsibility of the health-care provider to know your insurance. It IS a courtesy if they inform you when they are proposing a treatment that they know from experience many insurance companies don’t cover, or cover only partially, but it is not their responsibility. I suspect this expectation contributes quite a chunk to our healthcare costs. My orthopedist’s office maintains a totally separate dept. to deal with pre-approval and disability claims issues-in addition to their regular billing dept-they shouldn’t need to do that. Although, I will admit, it is nice.

  • Renee

    It may not be the healthcare provider’s responsibility to know your insurance but it sure as heck is their responsibility to know how much they charge for their services! They have cut deals with every insurer they work with, and that information should be readily available to the patient. They don’t have to know what your deductible is, or what percentage of a charge a patient will pay. But they should be required to tell you the amount they will be charging your insurance company, or you directly if you don’t have insurance. You can’t ask people to be responsible consumers of healthcare and not give them the basic information they will need to make an informed responsible decision. Even an auto mechanic gives you an estimate up front!

  • http://ma-bc.com Sally Brinkmann, R.N.

    As a R.N. and Medical Advocate, I frequently work with clients overwhelmed by mounting medical bills. No, these are not just the uninsured, but the underinsured and the insured with climbing deductibles and co-pays.

    We all live in a time where we need to be smart medical consumers. You are correct that when you are in a true emergent situation, it is the wrong time to ask how much an injection will cost you. There are however, a few things you can do to help control your medical costs and be proactive. Below are just a few suggestions:

    1. If possible a procedure, such as a MRI or particular lab work, can be completed outside the hospital, it will usually be less expensive. Free-standing ambulatory centers and M.D. offices are usually less expensive. If you are insured, check with your insurance company for the best price. Remember to stay in-network.

    2. If a Provider agrees to a Discount – Get It in Writing.

    3. Hospitals – If Uninsured or Underinsured – Add “agree to pay fair and reasonable cost and for compliant billing” in the financial responsibility section of the admitting forms. This can help deter hospitals from engaging in unfair billing practices. Be sure to initial this statement and have the individual assisting you with the paperwork (hospital administrative personnel) sign and date the additional statement as well.

    4. Remember “Cash is King” when trying to negotiate with providers. Many providers will negotiate a fair discount with you, if you pay the full discounted amount in cash. This saves them repeated billing, etc.

    5. If you are hospitalized, depending on your condition, either you or a friend/family member could keep a diary/log of medication / tests conducted during your stay. It will help when you receive that medical bill from the hospital and are in a state of shock. I know it sounds over zealous right now, but this has been a helpful tool for others.

    As I indicated the above are just suggestions. You can see more on my Website: ma-bc.com

    Today everyone needs to learn how to be their own best advocate.