Ricochet Member Recommended FeedRecommended by R> Members

Health Care Discussion – Why Does No One Discuss This?

 

What is this? What is this all about? What other business is run this way?

I say again: What kind of business is this?

Isn’t this a symptom of something that is severely distorted? Isn’t that first number a cry for help when viewed in context with the adjustment? That first number is a fake number.

Here’s what’s going on — the government has stepped into this field in a big way and it has caused an intelligent and clever response from the business people in the medical industry. This creative invoicing method is done in concert with the insurance industry people. Government people know that the top “price” is a scam number and they don’t talk about it. None of us talk about. I want to know why this issue isn’t discussed and why it isn’t used as a method of measuring (at least indicating) the level of damage that government regulations do to a critical industry — and the medical industry is important to each one of us.

As I tell my Swedish brother-in-law doctor: “The medical industry is too important to let the government control it.” This causes him to visibly blanch because it turns his world view upside down.

(Thanks to @davecarter and @docjay for the excellent Radio Deplorable podcast at https://ricochet.com/podcast/evening-doc-jay/. I was going to put this in a comment there but decided to write a post instead. I hope you all can give Dave’s episodes a listen.)

Published in Healthcare
This post was promoted to the Main Feed by a Ricochet Editor at the recommendation of Ricochet members. Like this post? Want to comment? Join Ricochet’s growing community of conservatives and be part of the conversation. Get your first month free.

Members have made 157 comments.

  1. 1
  2. 2
  3. 3
  4. 4
  5. 5
  6. 6
  1. Profile photo of Ann Inactive
    Ann

    Thanks for bringing this up. I know what you mean.

    In the last ten years the local hospital and “clinic” and all the doctors in town have merged into one organization. The hospital does the billing and it looks very similar to your bill. A very high price first then what the “insurance” paid, your co-pay and then the ADJUSTMENT. This can be$2 or hundreds etc. It is all baloney.

    Just like the insurance monthly statement that claims what the medicine you got at the pharmacy supposedly cost (that they covered) and what you paid. I think that is window dressing to make you get to your limits sooner. Who knows and we are powerless against it.

    • #1
    • March 18, 2017 at 7:17 pm
    • Like5 likes
  2. Profile photo of Zafar Member

    Is the “adjustment” the difference [theoretical] between what they claim they charge a la carte (if you will) and the rate that the insurance company has negotiated as the representative (in this case) of a large number of clients? Iow, basically by collective bargaining?

    • #2
    • March 18, 2017 at 7:26 pm
    • Like1 like
  3. Profile photo of Larry Koler Member
    Larry Koler Post author

    Zafar (View Comment):
    Is the “adjustment” the difference [theoretical] between what they claim they charge a la carte (if you will) and the rate that the insurance company has negotiated as the representative (in this case) of a large number of clients? Iow, basically by collective bargaining?

    First, what kind of business deal is it that allows a special rate of this size (in %)? It’s totally unbelievable that insurance companies have that kind of clout.

    Second, I hear all kinds of things about a la carte prices. Some people have tried to pay cash and get a much reduced price and been turned down — they are told they will have to pay the full price (which is absurd, if true). This type of person is of the opinion that this is a scam by the insurance companies to get control of the industry and keep the people who want out of the “collective bargaining” scheme.

    • #3
    • March 18, 2017 at 7:33 pm
    • Like4 likes
  4. Profile photo of Chuckles Thatcher

    Zafar (View Comment):
    Is the “adjustment” the difference [theoretical] between what they claim they charge a la carte (if you will) and the rate that the insurance company has negotiated as the representative (in this case) of a large number of clients? Iow, basically by collective bargaining?

    That’s what the fine print says, but since most everyone is on insurance or on Medicaid, and since folks that aren’t often get an adjusted rate as well, I think Larry’s question is legitimate. And his proposal of the difference between that cost and the actual cost is a measure of dysfunction.

    • #4
    • March 18, 2017 at 7:36 pm
    • Like10 likes
  5. Profile photo of Zafar Member

    Larry Koler (View Comment):

    Zafar (View Comment):
    Is the “adjustment” the difference [theoretical] between what they claim they charge a la carte (if you will) and the rate that the insurance company has negotiated as the representative (in this case) of a large number of clients? Iow, basically by collective bargaining?

    First, what kind of business deal is it that allows a special rate of this size (in %)? It’s totally unbelievable that insurance companies have that kind of clout.

    Is it really hard to believe that buying in immense bulk can get you a significant discount?

    Why?

    What the adjusted price tells me, however, is that the hospital (or whatever) can provide that service and make an adequate profit off of it for $3,044.10 – because otherwise they wouldn’t do it.

    The $5K on top of that is additional.

    Some people have tried to pay cash and get a much reduced price and been turned down — they are told they will have to pay the full price (which is absurd, if true).

    Why is it absurd?

    Why should Hospitals charge $5K less than they can?

    This is the free market.

    This type of person is of the opinion that this is a scam by the insurance companies to get control of the industry and keep the people who aren’t in the “collective bargaining” scheme.

    Insurance companies can’t force hospitals to charge uninsured patients the a la carte price.

    Hospitals do that of their own volition.

    • #5
    • March 18, 2017 at 7:44 pm
    • LikeLike
  6. Profile photo of Stina Member

    There seriously needs to be pricing transparency. I should be able to call the hospital and get a baseline cost for an uncomplicated delivery of a baby + some added procedures (fetal monitor, epidural, stitches, 3 day hospital stay, blood sugar tests, bilirubin…) and judge approx how much to save in advance.

    But complications happen and legal mumbo jumbo and…

    This is ridiculous…

    • #6
    • March 18, 2017 at 7:52 pm
    • Like11 likes
  7. Profile photo of Zafar Member

    Chuckles (View Comment):

    That’s what the fine print says, but since most everyone is on insurance or on Medicaid, and since folks that aren’t often get an adjusted rate as well, I think Larry’s question is legitimate. And his proposal of the difference between that cost and the actual cost is a measure of dysfunction.

    What do you mean by actual cost?

    What it cost me to produce something that I sell?

    Or what it costs you to buy it from me?

    Two different figures – and the second depends on who you are, how much you’re buying, how much I need your (repeat) business, how much/soon you need my product and how much time you have to bargain with me.

    Unless you want to regulate pricing and limit how much profit a hospital can legitimately turn from a procedure – in which case it’s a sound question, and one I am somewhat in sympathy with (hey @larrykoler!).

    • #7
    • March 18, 2017 at 8:04 pm
    • LikeLike
  8. Profile photo of Admiral janeway Inactive

    I do not understand that line on my insurance either. I think that maybe it is to impress us with how much they spent. That was there way before the ACA, by the way.

    I worked at a PT clinic 1996-1998. A few times I got to fold up the bills for mailing. The prices were beyond stunning. The director told me that they had to overbill because they never, ever got what they asked for.

    The patients, never knowing how much or what would be covered until long after the visit, lived in mystery.

    If I pulled this kind of shenanigans in my practice I would not have one.

    The “free market” model works for cars and movies and shoes, does not work for healthcare. The Greatest Country in the World can do better than this.

    • #8
    • March 18, 2017 at 8:07 pm
    • Like11 likes
  9. Profile photo of MLH Member
    MLH

    Larry Koler (View Comment):

    Zafar (View Comment):
    . . .

    First, what kind of business deal is it that allows a special rate of this size (in %)? It’s totally unbelievable that insurance companies have that kind of clout.

    Second, I hear all kinds of things about a la carte prices. Some people have tried to pay cash and get a much reduced price and been turned down — they are told they will have to pay the full price (which is absurd, if true). . . .

    Providers have made a deal with insurers to take a % of a billed amount. The billed amount is considered usual and reasonable (or some such). If is provider uses a third party payer (accepts insurance), it is, I have been told, illegal to offer a “cash” discount. So, “professional courtesy,” “overhead reduction” might suffice. yes, it is all very absurd. but without accepting insurance most providers would have no patients b/c most patients want someone else (employer, insurance, gov’t) to pay for their care.

    When I was in the Navy, the ERs in military medicine, like in the civilian world, were used as urgent care centers. The Air Force did a small study and found that charging even a nominal ($5) fee reduced use of the ER. But, they couldn’t, by law I suppose, charge such a fee.

    • #9
    • March 18, 2017 at 8:20 pm
    • Like3 likes
  10. Profile photo of MLH Member
    MLH

    It doesn’t matter what a provider charges an insured patient. They are only going to be reimbursed what the insurer pays plus any co-pay’t.

    • #10
    • March 18, 2017 at 8:22 pm
    • Like1 like
  11. Profile photo of MLH Member
    MLH

    Larry Koler:What is this? What is this all about? What other business is run this way?

    What that is is the percentage discount the hospital agreed to take for the privilege of having Blue Shield of WA patients. it looks like the hospital agreed to accept a whopping 35% of the billed amount (suckers: in PT in AZ, our BCBS “discount” is about 20%).

    • #11
    • March 18, 2017 at 8:31 pm
    • Like3 likes
  12. Profile photo of Zafar Member

    MLH (View Comment):

    Larry Koler:What is this? What is this all about? What other business is run this way?

    What that is is the percentage discount the hospital agreed to take for the privilege of having Blue Shield of WA patients. it looks like the hospital agreed to accept a whopping 35% of the billed amount (suckers: in PT in AZ, our BCBS “discount” is about 20%).

    Could one assume that 35% of the Washington price is going to be pretty close to 20% of the Arizona price?

    • #12
    • March 18, 2017 at 8:48 pm
    • Like1 like
  13. Profile photo of Larry Koler Member
    Larry Koler Post author

    Zafar (View Comment):
    Zafar

    Larry Koler (View Comment):

    Zafar (View Comment):
    Is the “adjustment” the difference [theoretical] between what they claim they charge a la carte (if you will) and the rate that the insurance company has negotiated as the representative (in this case) of a large number of clients? Iow, basically by collective bargaining?

    First, what kind of business deal is it that allows a special rate of this size (in %)? It’s totally unbelievable that insurance companies have that kind of clout.

    Is it really hard to believe that buying in immense bulk can get you a significant discount?

    I ask again: where else have you seen such an invoice for any other service or product? This is not a complicated question I’m asking. This is absolutely absurd and we all know it.

    • #13
    • March 18, 2017 at 10:17 pm
    • Like2 likes
  14. Profile photo of Larry Koler Member
    Larry Koler Post author

    MLH (View Comment):

    Larry Koler:What is this? What is this all about? What other business is run this way?

    What that is is the percentage discount the hospital agreed to take for the privilege of having Blue Shield of WA patients. it looks like the hospital agreed to accept a whopping 35% of the billed amount (suckers: in PT in AZ, our BCBS “discount” is about 20%).

    Let’s compare apples and oranges: this is a 65% discount. You confuse me but I think you mean that in Arizona it would only be a 20% discount or about $1,708 instead of $5,495.

    • #14
    • March 18, 2017 at 10:20 pm
    • LikeLike
  15. Profile photo of Larry Koler Member
    Larry Koler Post author

    And why is it called an adjustment? Why not use the word discount if that’s what it is?

    • #15
    • March 18, 2017 at 10:20 pm
    • LikeLike
  16. Profile photo of Larry Koler Member
    Larry Koler Post author

    Zafar (View Comment):
    The $5K on top of that is additional.

    I love this as an explanation.

    • #16
    • March 18, 2017 at 10:22 pm
    • LikeLike
  17. Profile photo of Larry Koler Member
    Larry Koler Post author

    Admiral janeway (View Comment):
    I worked at a PT clinic 1996-1998. A few times I got to fold up the bills for mailing. The prices were beyond stunning. The director told me that they had to overbill because they never, ever got what they asked for.

    This is the explanation I’ve always heard. My mother worked for a urologist in private practice 25 years ago and she always complained about the fake prices. Also, the doctor refused to take on medicare patients after about 1/3 of his patient load. My mom said that she spent 2/3 of her bookkeeping time on that 1/3 of patients.

    • #17
    • March 18, 2017 at 10:26 pm
    • Like6 likes
  18. Profile photo of Larry Koler Member
    Larry Koler Post author

    MLH (View Comment):
    It doesn’t matter what a provider charges an insured patient. They are only going to be reimbursed what the insurer pays plus any co-pay’t.

    So, have you ever seen any other industry with invoices like this? What does logic tell us here?

    • #18
    • March 18, 2017 at 10:28 pm
    • Like1 like
  19. Profile photo of Zafar Member

    Admiral janeway (View Comment):
    The “free market” model works for cars and movies and shoes, does not work for healthcare.

    It tells you this.

    Ideologically that’s a hard pill to swallow.

    • #19
    • March 19, 2017 at 1:37 am
    • Like1 like
  20. Profile photo of Eb Snider Member

    I find the billing in the medical industry confusing and frustrating. It’s not just trying to figure out the charging, but also the long delays in the bills. I went to the hospital and get three different bills for the one visit. I have also routinely received an accounting for a bill that states it’s not a bill, but that I’ll receive the bill later on when it has finally been determined and possibly adjusted – say what? Then four months later (or whatever the huge lag in time is) I finally received the bill. It seems nutty.

    • #20
    • March 19, 2017 at 4:37 am
    • Like5 likes
  21. Profile photo of MLH Member
    MLH

    Eb Snider (View Comment):
    I find the billing in the medical industry confusing and frustrating. It’s not just trying to figure out the charging, but also the long delays in the bills. I went to the hospital and get three different bills for the one visit. I have also routinely received an accounting for a bill that states it’s not a bill, but that I’ll receive the bill later on an it has finally been determined and possibly adjusted – say what? Then four months later (or whatever the huge lag in time is) I finally received the bill. It seems nutty.

    I worked for a hospital and got a past due notice for a bill I hadn’t yet received.

    • #21
    • March 19, 2017 at 6:08 am
    • Like8 likes
  22. Profile photo of MLH Member
    MLH

    Larry Koler (View Comment):

    MLH (View Comment):

    Larry Koler:What is this? What is this all about? What other business is run this way?

    What that is is the percentage discount the hospital agreed to take for the privilege of having Blue Shield of WA patients. it looks like the hospital agreed to accept a whopping 35% of the billed amount (suckers: in PT in AZ, our BCBS “discount” is about 20%).

    Let’s compare apples and oranges: this is a 65% discount. You confuse me but I think you mean that in Arizona it would only be a 20% discount or about $1,708 instead of $5,495.

    I think it also depends on who provided what. PTs still do pretty well with Medicare (we won’t accept an insurance that reimburses less than 80% of what MC does) but physicians, not so much. … an aside to that: at our practice the PT spends 45 -60 min with a patient.

    • #22
    • March 19, 2017 at 6:12 am
    • LikeLike
  23. Profile photo of MLH Member
    MLH

    Larry Koler (View Comment):
    And why is it called an adjustment? Why not use the word discount if that’s what it is?

    Because it is not a discount. It is the payer adjusting the billed amount to the percentage of the “usual and customary” amount that the provider said they would accept as payment.

    If one bills $100 but has agreed to take 80%, one will be paid $80 (or 60 from the 3rd party + the $20 co-pay). So, why not just bill $80? Because you’ll only get $64 (or $44 +20).

    • #23
    • March 19, 2017 at 6:17 am
    • LikeLike
  24. Profile photo of Bob Thompson Member

    With billing approaches like this, how would any given patient on Medicare, for example, be able to recognize fraud in the billing for services rendered and report that to the government? In my case, for example, I have supplemental coverage that covers all copayments so that I have no out-of-pocket costs for any treatment where the practitioner accepts the Medicare approved amount. How can I possibly know that I got what is billed and what is my incentive to even care?

    • #24
    • March 19, 2017 at 6:19 am
    • Like2 likes
  25. Profile photo of MLH Member
    MLH

    Larry Koler (View Comment):

    MLH (View Comment):
    It doesn’t matter what a provider charges an insured patient. They are only going to be reimbursed what the insurer pays plus any co-pay’t.

    So, have you ever seen any other industry with invoices like this? What does logic tell us here?

    Nope. That providers of medical care have sold their souls.

    Makes you wonder why massage therapists, personal trainers, acupuncturists, etc., want to have their services covered by insurance, doesn’t it?

    • #25
    • March 19, 2017 at 6:21 am
    • Like1 like
  26. Profile photo of MLH Member
    MLH

    Larry Koler (View Comment):

    Admiral janeway (View Comment):
    I worked at a PT clinic 1996-1998. A few times I got to fold up the bills for mailing. The prices were beyond stunning. The director told me that they had to overbill because they never, ever got what they asked for.

    This is the explanation I’ve always heard. My mother worked for a urologist in private practice 25 years ago and she always complained about the fake prices. Also, the doctor refused to take on medicare patients after about 1/3 of his patient load. My mom said that she spent 2/3 of her bookkeeping time on that 1/3 of patients.

    And if we went free market will put a lot of people out of jobs. And socializing care (further) should, too. But, it won’t.

    • #26
    • March 19, 2017 at 6:23 am
    • Like1 like
  27. Profile photo of MLH Member
    MLH

    Bob Thompson (View Comment):
    With billing approaches like this, how would any given patient on Medicare, for example, be able to recognize fraud in the billing for services rendered and report that to the government? In my case, for example, I have supplemental coverage that covers all copayments so that I have no out-of-pocket costs for any treatment where the practitioner accepts the Medicare approved amount. How can I possibly know that I got what is billed and what is my incentive to even care?

    When their quarterly MEOB (medicare explanation of benefits) shows charges for dates that they didn’t go to the doctor, duplicate charges (eg: provider billing out of two addresses), asking the billing department what the charges/codes mean. Yeah, you never look at it, do you?

    Edit to add: other providers can now report suspected fraud. Used to be only patients.

    • #27
    • March 19, 2017 at 6:26 am
    • LikeLike
  28. Profile photo of Bob Thompson Member

    MLH (View Comment):

    Bob Thompson (View Comment):
    With billing approaches like this, how would any given patient on Medicare, for example, be able to recognize fraud in the billing for services rendered and report that to the government? In my case, for example, I have supplemental coverage that covers all copayments so that I have no out-of-pocket costs for any treatment where the practitioner accepts the Medicare approved amount. How can I possibly know that I got what is billed and what is my incentive to even care?

    When their quarterly MEOB (medicare explanation of benefits) shows charges for dates that they didn’t go to the doctor, duplicate charges (eg: provider billing out of two addresses), asking the billing department what the charges/codes mean. Yeah, you never look at it, do you?

    Edit to add: other providers can now report suspected fraud. Used to be only patients.

    What if the date matches but they charge for what I didn’t get? I’m supposed to be able to know that? And I going to go to the trouble of auditing these bills for no tangible benefit? Almost everything behind all of this is poorly thought out.

    • #28
    • March 19, 2017 at 6:36 am
    • LikeLike
  29. Profile photo of Bob Thompson Member

    Bob Thompson (View Comment):
    Yeah, you never look at it, do you?

    Half-heartedly, sometimes.

    • #29
    • March 19, 2017 at 6:37 am
    • LikeLike
  30. Profile photo of MLH Member
    MLH

    Bob Thompson (View Comment):

    MLH (View Comment):

    Bob Thompson (View Comment):
    With billing approaches like this, how would any given patient on Medicare, for example, be able to recognize fraud in the billing for services rendered and report that to the government? In my case, for example, I have supplemental coverage that covers all copayments so that I have no out-of-pocket costs for any treatment where the practitioner accepts the Medicare approved amount. How can I possibly know that I got what is billed and what is my incentive to even care?

    When their quarterly MEOB (medicare explanation of benefits) shows charges for dates that they didn’t go to the doctor, duplicate charges (eg: provider billing out of two addresses), asking the billing department what the charges/codes mean. Yeah, you never look at it, do you?

    Edit to add: other providers can now report suspected fraud. Used to be only patients.

    What if the date matches but they charge for what I didn’t get? I’m supposed to be able to know that? And I going to go to the trouble of auditing these bills for no tangible benefit? Almost everything behind all of this is poorly thought out.

    read the claims page. there is a description with the code. Did you get that care?

    • #30
    • March 19, 2017 at 6:52 am
    • LikeLike
  1. 1
  2. 2
  3. 3
  4. 4
  5. 5
  6. 6