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Thursday, January 23, 2014

High SOMC Doctor Bills and Higher Insurance Premiums




OK, I'm venting again. Sorry that I am being bitchy, but I just cannot understand the high cost of being healthy, especially the dollars required by medical professions -- charges I incur after obtaining sufficient health insurance and paying the high premiums for the coverage. Let me explain.

I am a retired teacher, so my one choice for medical coverage is Medical Mutual. I have the SuperMed plan and pay a pricey monthly premium for coverage through the State Teachers Retirement System setup. I guess I am lucky to be eligible for this insurance, but lately costs seem to be spiraling out of control.

I recently made my first doctor visit to my family M.D. in a couple of years. He had tragically passed away, and I just hadn't yet seen his replacement since I felt no need. But, I was struck by an illness in November 2013, and I needed to visit the new practice that had been established for his patients.

Of course, my first visit cost extra to set up new records, which also astounds me since my old records still exist in the office, but I was just a tad upset over the $250 charge, and I discovered it had something to do with SOMC updates. I have experienced rather "signup" fees before in other physicians' offices.

During my second visit I discovered I am a type 2 diabetic, which requires some adjustments and continued checkups. After a second office call a couple of weeks later, I got my next bill from Medical Mutual  for $200 (sans another $770 charge for one session of blood work), and since then, I have been to two other appointments with bills of $200 and $150. 

On each visit, I made a $25 copay (I have since discovered I have no copay for normal office visits. After phoning Medical Mutual about the charges, I was told the money went towards my yearly deductible, which is so high I know I will never meet.

Medical billing is ridiculously complicated (even doctors hate it). I am learning to hate it more and more on my fixed income. I understand two things:

(1) Fees are based on the "complexity" of the issue or the duration of the visit. So, if have a sore throat, don`t hop up and say "what about this bump on my skin" unless it really is of concern and you want to pay for another issue.

(2) There is the fee for a "new" patient, and the fee for an "established" patient. The fee for a new patient is higher. Yes, it is higher for the same exam. Why? Because it really is not the same exam... the doctor knows nothing about you and must consider possible things that would be ruled out had you been seeing them. So, it makes since, once you see one doctor, you should try to continue seeing him/her for the lower "established" patient fee.


But don't the rates seem unbelievably high? I decided to do a little research into the cost of a visit to a doctor's office in the United States.

In 2009, the national average doctor’s office visit was approximately $60. 

(A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association)


Here is an updated chart of doctors' office data from Fallon Community Health Plan:

Doctor’s office visits
Low cost
Average cost
High cost
Existing patient visit
$60
$158
$249
New patient visit
$60
$171
$249
These costs do not include any tests or procedures at the time of or following the office visit.

   (Fallon. http://www.fchp.org/ 2014)

People on the Net are saying the average doctor visit in New York City is around $100. Some of these folks say you should join a doctor`s "Membership Plan" for $500-$600 per year which allows you to see them all you need for one flat rate. Many doctors in NYC have started these. The fee will include your "Annual Physical" which is typically $200-$300 by itself. Some of these doctors have even negotiated discounted lab fees for some of the blood tests performed.



We Pay Good Money For Health Insurance

In the NYC area, the average doctor visit is around $100. Medical billing is ridiculously complicated (even doctors hate it). But 2 things to remember. 1) Fees are based on the "complexity" of the issue or the duration of the visit. So, if have a sore throat, don`t hop up and say "what about this bump on my skin" unless it really is of concern and you want to pay for another issue. 2) There is the fee for a "new" patient, and the fee for an "established" patient. The fee for a new patient is higher. yes, for the same exam. Because it really is not the same exam....the doctor knows nothing about you and must consider possible things that would be ruled out had you been seeing them. So, once you see one doctor, try to continue seeing him/her for the lower "established" patient fee. Best deal: Join a doctor`s "Membership Plan" for $500-$600 per year (not month, year) and see them all you need to for that one flat rate. Many doctors in NYC have started these. The fee will include your "Annual Physical" which is typically $200-$300 by itself. Some of these doctors have even negotiated discounted lab fees some of the blood tests performed.

Read more: What is a routine doctor visit - How much does it cost to get a doctors appointment with insurance :: GoFTP Answers at http://www.goftp.com/qna/What_is_a_routine_doctor_visit-qna86685.html
It burns me that doctors won't accept the insurance company's allowance for service. I'm not against welfare, but if you are on it, you definitely have health care without insurance high premiums and uncovered costs. The personal cost after coverage is very frustrating to those who pour money into their own health insurance coverage and can barely afford other needed goods and services.

Premiums keep skyrocketing. The average annual premiums for single and family health insurance under employer-sponsored coverage was $5,615 and $15,745, respectively, in 2012.

(Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2012)

Here are some key findings about "average" Americans and their doctor and health insurance concerns:

* 41 percent of the adults (2 of 5 adults, or an estimated 75 million people) reported that they had a hard time paying their bills, even with health insurance, and had been contacted by a collection agency or had to change their way of life in an effort to pay their medical bills.

 (Study by Commonwealth Fund. 2012)

* Approximately 50 percent of personal bankruptcies are due to medical expenses. 

(Source: Health Affairs)

* 28 percent of middle income families (annual family income between $30,000 and $75,000) stated that they were currently having a serious problem paying for healthcare or health insurance.

(Kaiser Family Foundation poll)

* Health care expenditures in the United States are the highest of any developed country, at 15.3% of GDP. The country with the next highest spending is Switzerland, at 11.6% of GDP. 

(Organization for Economic Co-operation and Development)

*
The United States does not spend health care money efficiently. An estimated one-third of 2006 health care expenditures, about $700 billion or nearly 5% of GDP, did not improve health outcomes.

(Source: Congressional Budget Office)

* Prescription prices for drugs still under patent protections (as opposed to generic medications) are about 35% to 55% higher in the United States than they are in other countries.

(Congressional Budget Office)



Fair Price?

The Healthcare Bluebook is an online guide to help you determine fair prices in your area for healthcare services. Reports about the Bluebook have been in established media sources such as Forbes, The Wall Street Journal, CNN Money, and NPR. Here is what the site says:

"What we do is simple – we help consumers save on healthcare expenses while helping Fair Price providers attract cost-conscious consumers. 

"Unfortunately, it is difficult for consumers to determine fair pricing for healthcare. Prices are not generally published and the list prices (or billed charges) are higher than providers typically charge most of their patients with insurance. The Healthcare Bluebook is a free resource that shows a Fair Price for healthcare products and services to consumers.

"Our consumer-friendly tool helps consumers quickly and easily understand what they should pay for the healthcare services they need. Secret pricing practices have contributed to high price differences among providers and have left the consumers and employers paying more for services than they should. Once consumers know what healthcare services should cost, they can find providers that offer the best value."

 (The Healthcare Bluebook.www.HealthcareBluebook.com or

As health insurance plans shift more cost to consumers, consumers need to be able to choose healthcare services at Fair Prices. Average deductibles are increasing, and coinsurance rates, which are the percentage of the bill that the consumer must pay, range from 20 to 40%. Many consumers would prefer to use the doctor of their choice but also want their doctor to refer them to cost effective facilities and testing centers.

According the the Bluebook, even if consumers with insurance go "in-network," they may be charged 3 times to 5 times more than they should pay depending on which provider they use. The Bluebook has consumer-friendly tools that help consumers quickly and easily understand what they should pay for the healthcare services they need. Secret pricing practices have contributed to high price differences among providers and have left the consumers and employers paying more for services than they should.

Once consumers know what healthcare services should cost, they can find providers that offer the best value. The Bluebook workw with healthcare providers who believe that transparent pricing is the future of healthcare and whose pricing strategy is designed to be fair and reasonable. We promote their practices on our site and connect them to consumers who are seeking a Fair Price.

The Bluebook price is based on the typical fee that providers in your area accept as payment from insurance companies. (You supply the zip code.) This is the price you should have to pay, even if your provider charges more. You can use this price to negotiate with your provider or shop for an in-network provider that charges a Fair Price. 

Here is an example for fair pricing (zip code 45662) from the Healthcare Bluebook site:  

Office Visit, Established Patient, Level 3


Total Fair Price: $134

Fair Price Fee Details


Physician Services
Fee: $134
Fee Details: Physician fee. Moderate problem requiring counseling and treatment, may require coordination of care with other providers- approximately 15 minutes with the doctor.


If you have health insurance, you should ask the in-network providers listed in your provider directory what the in-network rate is for this service. Different in-network providers often charge different prices. Call several providers to find one that is willing to accept a Fair Price. 

If you do not have health insurance coverage, then you should call providers and ask if they offer discounts for self-pay patients and what their price is for the service.

Check out this copy of a binding agreement from the Bluebook site:

Binding Price Estimate

Agreement


Healthcare Provider / Facility (hereinafter “Provider”): ____________________________

Patient (hereinafter “Patient”): _______________________________________

Service/Product: Office Visit, Established Patient, Level 3

According to the Healthcare Bluebook, the Fair Price for consumers who pay healthcare providers with cash at the time of service or product delivery is ____$134______. Physician fee.

The Provider agrees to provide Office Visit, Established Patient, Level 3 to the Patient for a total price of (please complete and check agreed upon price):

 $134  or
  _________, subject to the terms below:

1. Physician fee.

2. If the actual service or product required to treat the patient is different from that listed above, then Provider will make a reasonable effort to inform Patient what the new service or product is and what the price will be before treatment.

3. Other terms or conditions: __________________________________________ __________________________________________________________________ __________________________________________________________________

Patient agrees to pay Provider in full at the time of service or in the manner that is agreed to in advance and acceptable to Provider.

In consideration of above, the parties indicate their agreement by signing below.

________________________ ________________________
Patient Provider
________________________ ________________________
Date Date


Instructions:

Please take the Healthcare Bluebook binding estimate agreement to your healthcare provider. Share the Bluebook price with your provider and ask them to provide a cost estimate to you. Once you have agreed on an acceptable price, you can complete the above agreement for your records.

Notice to Healthcare Providers:

CareOperative offers the HealthCare Bluebook as a free resource to patients to inform them of fair healthcare prices. While the Bluebook prices are generally below “billed charges”, they are also generally above standard insurance contract rates accepted by most providers. The prices should be fair compensation for cash paying patients. If you would like to learn more about the Healthcare Bluebook or join the CareOperative Provider Network, please visit us at www.CAREOperative.com.

My Bottom Line

Obamacare, healthcare, Medicaid, Medicare, Big Pharma, Big Insurance -- no one understands all the prices, implications, and dealings of the healthcare and the health insurance industries. I believe prices for health calls and procedures should be made readily available, and people should be able to know upfront what the costs will be. Only when the public has this needed transparency can paychecks and capitalism meet some medium of worth and service.

In an age of technology, medical services and insurance premiums demand high prices from consumers for what would seem to be lower actual financial output. I know all about liability and the risks of inferior practice, but, my God, a regimen of simple office calls, normal blood tests, and preventive procedures can bankrupt even those with "decent" health coverage.

I have vowed to avoid every series of major medical expenses that are not absolutely necessary. Yet, recently I had a problem with glands on one side of my face -- extremely painful, swollen over an extended time, and possibly malignant. 

Depending on where you live in the U.S., a CT scan could cost anywhere from $678 to over $3000. I was advised by the doctor to have one done on my neck at SOMC on November 20, and the bill (CAT Scan and Pharmacy) totaled $1,854.60. I am responsible for $1,376.98 of this claim as Medical Mutual allowed $1,520.77 but only paid a benefit of $143.79.

You see, the typical health insurance policy, which I now know I have, does cover the diagnostic CT scan even though CT scan costs are higher because they have been proven to be medically necessary in the treatment of diseases. Go figure. Good money after bad treatment? Thank God mine scan was negative. I am fine, but much poorer.

So far, I am $2,947 into diabetes in just a little over two months of treatment. This does not count my diabetic supplies and necessary prescriptions. And, of course, I'm still paying those wonderful insurance premiums. I think this cost is ridiculous.

I guess the only thing worse than an old fool is a sick old fool. Still, I am losing weight and eating better. (Which, by the way, proves totally "more expensive" to buy food that is "good for me.") I bet my insurance premiums and doctor visits will also reduce if and when I get totally healthy. See what I mean by being a "fool"? Maybe I should have just hired a beautiful, young babe for a personal trainer with the three grand I spent and have something to look forward to each day besides tofu and tuna.



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