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 http://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.)

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  1. Bob Thompson Member
    Bob Thompson
    @BobThompson

    MLH (View Comment):

    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?

    I know this.  But, three things. Does one always clearly know what procedures were administered? There is no personal incentive for me to check it. What about all the incompetents in the Medicare group?

     

    • #31
  2. MLH Inactive
    MLH
    @MLH

    Bob Thompson (View Comment):

    MLH (View Comment):

    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?

    I know this. But, three things. Does one always clearly know what procedures were administered? There is no personal incentive for me to check it. What about all the incompetents in the Medicare group?

    1. It will say “office visit, established patient,” “influenza vaccination.”
    2. yup. but you should at least check the dates. I found an optometry visit billed for my dad when he hadn’t lived in the area of that OD for over a year. I called the office: someone had enter the wrong patient ID or something.
    3. huh? fellow patients, CMS/HHS employees, or providers (and their billing services)?
    • #32
  3. RabbitHoleRedux Inactive
    RabbitHoleRedux
    @RabbitHoleRedux

    Bulls-eye! Unless they reform the itemized billing for medical procedures and let competitive markets drive the costs then every reform to the health care “system” in the aggregate will be meaningless. We cannot continue to allow  costs for everything from a cotton swab to surgical implement to cauterize be internally valued. Period.

    Markets work. Let them work.

    • #33
  4. MLH Inactive
    MLH
    @MLH

    RabbitHole: that is an itemized bill in the OP.  No really. OK: maybe if Larry asked for an itemized bill it would read: “Inpatient stay 0X/xx/2017 to 0X/0y/2017. . . ”

    On the other hand do you want your massage therapist to give you an invoice with: “3 Tbsp lavendar oil; 1/4 cup laundry detergent; fee for rights to the music played; % of rent, utilities; hands on time; greeting and discussion time” itemized out for you ?

    • #34
  5. Miffed White Male Member
    Miffed White Male
    @MiffedWhiteMale

    MLH (View Comment):
    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.

    About 20 years ago at my previous residence I started receiving a monthly medicare statement for someone, with my address on it.  I didn’t recognize the name (and I knew the name of the previous residents and it wasn’t them either) and tossed the first few.  After several months I finally opened one up, and called the medicare office number to report possible fraud, or at the very least a billing mistake.

    Their response was to tell me that I could get in trouble for opening Medicare mail addressed to someone else and I shouldn’t do that again.

    • #35
  6. Bob Thompson Member
    Bob Thompson
    @BobThompson

    MLH (View Comment):

    • yup. but you should at least check the dates. I found an optometry visit billed for my dad when he hadn’t lived in the area of that OD for over a year. I called the office: someone had enter the wrong patient ID or something.
    • huh? fellow patients, CMS/HHS employees, or providers (and their billing services)?

    Patients. There are more than a few patients who suffer from dementia in its various forms and those on excessive medications suffer hallucinations and other manifestations. Not everyone checks their billings like you did your Dad and you did it because you saw the address was not his current address. And then, I’m capable but not very interested in being the auditor for this monster. What @miffedwhitemale described when calling to report an issue is not uncommon. The whole process, however handled, should be more local.

    • #36
  7. MLH Inactive
    MLH
    @MLH

    Bob Thompson (View Comment):
    There are more than a few patients who suffer from dementia in its various forms and those on excessive medications suffer hallucinations and other manifestations. Not everyone checks their billings like you did your Dad and you did it because you saw the address was not his current address.

    Then the system shall be gamed.  Do you check the bills from you mechanic? Your internet/phone provider? Grocery receipt? Restaurants? Why be cavalier about your medical bills?

    And then, I’m capable but not very interested in being the auditor for this monster.

    But will gladly accept the care under the broken system. Sort of NIMBY, no? Just saying, Bob, not pointing fingers.

     

    • #37
  8. Bob Thompson Member
    Bob Thompson
    @BobThompson

    MLH (View Comment):
    Then the system shall be gamed. Do you check the bills from you mechanic? Your internet/phone provider? Grocery receipt? Restaurants? Why be cavalier about your medical bills?

    And then, I’m capable but not very interested in being the auditor for this monster.

    But will gladly accept the care under the broken system. Sort of NIMBY, no? Just saying, Bob, not pointing fingers.

    It’s a bad system and it will be gamed. I do check those other bills you mentioned because there is incremental out-of-pocket costs that motivate me to do that. When I have a negative experience with a vendor or service provider where there is a competitive market, I can make a change. With the Medicare system and the bureaucracy no such option. It actually facilitates an approach where once a person has paid the necessary upfront costs there is no longer anything regarding costs to be thought about. If every service I used had an incremental cost from my pocket you can be sure I would be checking. All I have to do is make sure my provider accepts Medicare as payment.

    • #38
  9. Z in MT Member
    Z in MT
    @ZinMT

    Zafar (View Comment):
    Insurance companies can’t force hospitals to charge uninsured patients the a la carte price.

    Hospitals do that of their own volition.

    No. The Obamacare did that for them.

    Obamacare doesn’t allow providers to give cash customers a discount.

    • #39
  10. MLH Inactive
    MLH
    @MLH

    Z in MT (View Comment):

    Zafar (View Comment):
    Insurance companies can’t force hospitals to charge uninsured patients the a la carte price.

    Hospitals do that of their own volition.

    No. The Obamacare did that for them.

    Obamacare doesn’t allow providers to give cash customers a discount.

    It was before that, I think.

    • #40
  11. Z in MT Member
    Z in MT
    @ZinMT

    MLH (View Comment):

    Z in MT (View Comment):

    Zafar (View Comment):
    Insurance companies can’t force hospitals to charge uninsured patients the a la carte price.

    Hospitals do that of their own volition.

    No. The Obamacare did that for them.

    Obamacare doesn’t allow providers to give cash customers a discount.

    It was before that, I think.

    MLH,

    There were some issues before Obamacare related to Medicare in that the government could come back and change a providers reimbursement rate based on the new “customary rate”. What Obamacare did is apply this similar thinking to providers that did not accept Medicare, but did accept private insurance. Now the only way to give a discount for cash is to not take any insurance.

    • #41
  12. Z in MT Member
    Z in MT
    @ZinMT

    What is clear about this bill is that the provider can provide those services at break-even or better for about $2,694.14. The top line price is for suckers.

    • #42
  13. MLH Inactive
    MLH
    @MLH

    Z in MT (View Comment):
    What is clear about this bill is that the provider can provide those services at break-even or better for about $2,694.14. The top line price is for suckers.

    Suckers: people w/o insurance?

    Did you read my comments?

    • #43
  14. Z in MT Member
    Z in MT
    @ZinMT

    @Zafar,

    I think not being in America it is hard to believe how royally messed up the US healthcare industry actually is. I had used basically no healthcare for the past 10 years then this year I had some gastric issues and finally entered into the healthcare market. Honestly, I don’t think one could design a system so arcane and tortuous for everyone in it: providers, insurance companies, and patients all know it is a shell game.

    At least before Obamacare paying patients basically knew that some of the costs were higher so that providers could offset some of the costs of charity care and bad debts to deadbeats. We were told that Obamacare would fix this, where instead what it did is it provided subsidies to lower income folks so that they could finally get on health insurance – which they did – then greatly increased their utilization of healthcare driving up the expenditures in the system. The deadbeats who didn’t pay anything before Obamacare still don’t pay anything, but the people who were insured previously are now paying significantly more.

    Don’t get me wrong, Obamacare helped many lower income and per-retirement older people get healthcare they probably  wouldn’t have, but it has done it in about as inefficiently as possible.

    • #44
  15. Z in MT Member
    Z in MT
    @ZinMT

    MLH (View Comment):

    Z in MT (View Comment):
    What is clear about this bill is that the provider can provide those services at break-even or better for about $2,694.14. The top line price is for suckers.

    Suckers: people w/o insurance?

    Did you read my comments?

    Yep. & Yes. I wasn’t disagreeing with you I was expressing what I think hospital paper pushers must think of those who are forced to pay the top line number.

    • #45
  16. Larry Koler Inactive
    Larry Koler
    @LarryKoler

    MLH: you seem to be blaming the insurance companies more than the 600 lb. gorilla of the government’s intervention here. Are you avoiding this subject? Who is more to blame here — the government or the insurance companies? I say they are only responding in lawyerly fashion to what is basically a nationalism of the health care industry.

    • #46
  17. Phil Turmel Inactive
    Phil Turmel
    @PhilTurmel

    Admiral janeway (View Comment):
    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.

    Wait, now we’re talking about healthcare?  I thought we were talking about screwy insurance practices.

    Oh, that’s right, it’s not really health insurance, is it?

    With any other form of insurance, when a covered event happens, an adjuster looks at the event before any solution is executed, gets quotes, and generally offers the average of the quotes, less the deductible.  The insured can then do what they please with the money, including not replacing the loss.  (Though government will typically require paying to clean up / haul away the detritus if not rebuilding / repairing.)  In the case of life insurance, of course, the heirs decide how to use the money.

    Car insurers try to get you to use their preferred repair places by guaranteeing the fixed fee, but they can’t make you use them.  You are free to fix your car yourself, if you like.  Or pocket the money and drive an ugly car around.  (Been there, done both of those.)  Car insurers would love to have a captive supply chain like the medical insurers.

    Health insurance was drifting inexorably towards a high deductible/low premium model prior to Obamacare.  Because the absurdities resulting from ER mandates and ridiculous regulations were driving employers away from “traditional” policies.  The 1986 mandate that ERs treat all comers regardless of ability to pay has forced many ERs out of business (especially in small towns, where progressives don’t notice), to be replaced by “Urgent Care” facilities that technically are not ERs (and can turn you away).  Obamacare’s mandate to cover all comers regardless of pre-existing conditions will do the same to healthcare in general.  Concierge practices will become the only way to get a full spectrum of services without interference, and only the upper middle class and the wealthy will be able to pay for it.

    I predict that if the pre-existing condition mandate is not repealed, within about ten years the Canadians will have responded by relaxing their rules to allow Americans to cross the border to pay for services there.  And Canadians won’t come to America for health care any more.

    • #47
  18. Bob Thompson Member
    Bob Thompson
    @BobThompson

    MLH (View Comment):
    But will gladly accept the care under the broken system. Sort of NIMBY, no? Just saying, Bob, not pointing fingers.

    Well, I think there may also be strings attached. I’m not sure how carrying my group health insurance into my retirement past my medicare qualifying age would have been treated if I had opted not to use Medicare.  Lots of rules and penalties associated with these programs to make individuals do what the programs want, much like Obamacare.

    • #48
  19. Chuckles Coolidge
    Chuckles
    @Chuckles

    Zafar (View Comment):

    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!).

    Ah.  Good question.  What I meant was perfectly obvious to me, but unless you are a mind reader we could easily have a different understanding.   The more I think about how to respond the more difficult it becomes.  I’ll get back to you…

     

    • #49
  20. mollysmom Inactive
    mollysmom
    @mollys mom

    Ann (View Comment):
    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.

    That merging is happening in my town of 17,000 too.  Both my orthopedist and GP, both busy, successful practices, are joining our hospital group so they can concentrate on practice and leave the billing to the hospital.

    • #50
  21. Kozak Member
    Kozak
    @Kozak

    Zafar (View Comment):

    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.

    There hasn’t been a “free market” in US healthcare since Medicare was signed.

    • #51
  22. Vance Richards Inactive
    Vance Richards
    @VanceRichards

    What is this? Well, it’s labeled “BS” . . . oh wait, that means Blue Shield . . . never mind.

    • #52
  23. Larry Koler Inactive
    Larry Koler
    @LarryKoler

    Chuckles (View Comment):
    And his proposal of the difference between that cost and the actual cost is a measure of dysfunction.

    This is really what I want to talk about. We have a big problem and it is apparent to all of us who read these statements but no one is talking about it.

    Why doesn’t Trump talk about this? Why don’t the Republicans talk about this?

    I think that the explanations that would come out in defense of this or even explaining it would clarify the whole debate.

    • #53
  24. MLH Inactive
    MLH
    @MLH

    Larry Koler (View Comment):
    MLH: you seem to be blaming the insurance companies more than the 600 lb. gorilla of the government’s intervention here. Are you avoiding this subject? Who is more to blame here — the government or the insurance companies? I say they are only responding in lawyerly fashion to what is basically a nationalism of the health care industry.

    How is it that the gov’t makes providers agree to take less than they bill? Dentists don’t do this. I’m blaming providers.

    I understand that gov’t has deemed what a medical insurance plan has to cover (and offer for “free”). Then they decrease reimbursement (rather than jack up premiums or deductibles or co-pays — until recently, anyway).

    • #54
  25. MLH Inactive
    MLH
    @MLH

    Larry Koler (View Comment):

    Chuckles (View Comment):
    And his proposal of the difference between that cost and the actual cost is a measure of dysfunction.

    This is really what I want to talk about. We have a big problem and it is apparent to all of us who read these statements but no one is talking about it.

    . . .

    I think that the explanations that would come out in defense of this or even explaining it would clarify the whole debate.

    It’s not the COST. It’s what is billed so that the provider gets paid enough to cover overhead, salaries, etc. If I want to make $50 for a patient visit and have signed a contract with an insurer that I’ll accept 50% of the billed amount for their enrollees, I bill $100.

    • #55
  26. Kozak Member
    Kozak
    @Kozak

    MLH (View Comment):

    Larry Koler (View Comment):
    MLH: you seem to be blaming the insurance companies more than the 600 lb. gorilla of the government’s intervention here. Are you avoiding this subject? Who is more to blame here — the government or the insurance companies? I say they are only responding in lawyerly fashion to what is basically a nationalism of the health care industry.

    How is it that the gov’t makes providers agree to take less than they bill? Dentists don’t do this. I’m blaming providers.

    I understand that gov’t has deemed what a medical insurance plan has to cover (and offer for “free”). Then they decrease reimbursement (rather than jack up premiums or deductibles or co-pays — until recently, anyway).

    The providers are frequently coerced by the Hospitals. I was with a private ER group, we refused to sign a contract with the local BC-BS because their reimbursement rate was awful.  So then when the patients came to the ER they screamed at the hospital which had a BC-BS contract, and advertised they accepted it.  The hospital then came back to us and essentially said, “sign with them or else”.  We resisted for awhile, but eventually buckled.  This dustup eventually cost us our contract, and most us ended up losing our jobs.  Because of the “non compete” ( could not work for another hospital within 50 miles for 2 years) contract we had had with the hospital, many were forced to move.

    • #56
  27. MLH Inactive
    MLH
    @MLH

    @kozak: BCBS and Medicare are our biggest insurers. We don’t contract with the state Medicaid (AHCCS) because they reimburse pennies and require extra paperwork. I don’t think even the local hospital’s PT department takes it.

     

    • #57
  28. Ontheleftcoast Inactive
    Ontheleftcoast
    @Ontheleftcoast

    One of the local hospitals used to have a “Resource Recovery Unit.”

    It worked something like this: Jane Doe goes into the hospital, which bills Blue Cross for her care.

    Blue Cross pays some charges, rejects others.

    Sometimes overpayment happened.

    Usually rebilling for unpaid charges happened.

    But under Resource Recovery, the hospital says: We got paid too much for Bob Roe’s care. We’ll take the excess and apply it to Jane’s unpaid charges.

    I think they were also applying Blue overpayments to, say, Aetna underpayments. I think in theory it was all settled up every few months.

    My friends in private practice all said “If we did this we’d be in prison.”

    • #58
  29. Chris Campion Coolidge
    Chris Campion
    @ChrisCampion

    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.

    The hospital where I worked had a department that worked only on Medicaid claims – a small army of people paid just to deal with it.

    Single-payer: Bringing you cheaper and free health care for all.  Unless, of course, you ask someone who’s been either a) a patient, or b) a provider under the Medicaid umbrella.  They might tell you something different than what idiots in pantsuits in Washington DC tell you.

    • #59
  30. Larry Koler Inactive
    Larry Koler
    @LarryKoler

    Kozak (View Comment):

    MLH (View Comment):

    Larry Koler (View Comment):
    MLH: you seem to be blaming the insurance companies more than the 600 lb. gorilla of the government’s intervention here. Are you avoiding this subject? Who is more to blame here — the government or the insurance companies? I say they are only responding in lawyerly fashion to what is basically a nationalism of the health care industry.

    How is it that the gov’t makes providers agree to take less than they bill? Dentists don’t do this. I’m blaming providers.

    I understand that gov’t has deemed what a medical insurance plan has to cover (and offer for “free”). Then they decrease reimbursement (rather than jack up premiums or deductibles or co-pays — until recently, anyway).

    The providers are frequently coerced by the Hospitals. I was with a private ER group, we refused to sign a contract with the local BC-BS because their reimbursement rate was awful. So then when the patients came to the ER they screamed at the hospital which had a BC-BS contract, and advertised they accepted it. The hospital then came back to us and essentially said, “sign with them or else”. We resisted for awhile, but eventually buckled. This dustup eventually cost us our contract, and most us ended up losing our jobs. Because of the “non compete” ( could not work for another hospital within 50 miles for 2 years) contract we had had with the hospital, many were forced to move.

    Same question then: where else is this invoicing scheme used? And why is it only this area that is so messed up?

    My answer is that the original and main reason is the government’s intrusion into this field.

    • #60
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