Occupy Doctor’s Office & Health Insurance Agencies

They say the occupy movement is unfocused — it’s about all these various things we’re upset about — but a lot of the movement is about the lack of transparency in between bureaucracy and us common folk.

When I got home yesterday, I went through my mail and discovered a “explanation of benefits” mail from a recent “surgery” I had on two pilar cysts on my head. The doctor’s office never knows about costs — they don’t really care about how much you end up getting charged, as long as you pay it. Even with medical insurance from work, the two cysts removed cost me $550. Last time I had two cysts removed it was $300, so I was a little surprised that the cost went up $250. But I haven’t found a way to identify how much any medical interaction will cost in advance of the treatment… it always has to be a big surprise after the fact.

Another example… I went to a regular yearly gynecological exam a while back, which is covered by my insurance. Or is it? The gynecologist decided to do an ultrasound to check out my polycystic ovaries which — big surprise — still had cysts on them. That procedure wasn’t covered by the free annual checkup description, as it was considered diagnostic, and ended up costing me a few hundred bucks.

Meanwhile, I’ve decided to use my dental insurance and get my teeth cleaned up — my insurance covers two cleanings a year — the dental hygienist spent two sessions in one month to finish my cleaning (it’s been a while since I’ve had insurance) and wants me to come back in four months for another cleaning. The dentist filled a few of my back molars — which I haven’t received a bill for yet, but I assume will be a few hundred bucks.

What I’d like is transparency in medical billing. While your medical choices shouldn’t only be determined based on the cost, why can’t you find out the price of services in advance of the procedures? The admin at the doctor’s office always looks at you like your off your rocker when you inquire about such things. Either they don’t know or they don’t want to tell you.

While I’m relatively healthy, I also have some health issues I should look into… but it’s so hard to know which to get checked out and which to ignore. If I had a better understanding of how much every piece costs (a menu of the cost to get one cyst removed versus two, or to get blood work to find out if i’m vitamin deficient) would be ideal.

Instead, I’m stuck with surprise bills a few weeks after. Do you know of a medical operation that has transparency in costs? I’d like a menu of procedures with the prices attached to them, and a column that shows the price if you have certain insurances. Why can’t they just have this?

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4 comments

  1. Hi Joy,

    I agree with Little Miss Moneybag 🙂

    The doctor’s insurance can’t possibly know or keep track of what insurance will cover for all of their patients, but educating yourself about the things involved dental insurance is important. The dental plan can easily take you through the hard time by covering for basic dental treatment which would get very tough for us.

    When insurance providers speak about basic dental benefits to patients, they mean basic services like cleaning, checkups ups and fillings. Knowing the types of procedures & services offered can benefit you to know how you need to calculate your money so that you can take care of your teeth.

    Thanks for sharing !!
    Alfred

  2. I was going to suggest exactly what Money Beagle did. The doctor's insurance can't possibly know or keep track of what insurance will cover for all of their patients, but you can become an educated consumer.

    For planned services, your insurance company can send you an estimated cost, if you ask ahead of time (I just asked for one, and I'm going to post about what I learn when I get it). They do this all the time for scheduled surgeries.

    If your doctor's office won't give you a rate sheet, and you're able to go elsewhere with your insurance, I'd do it. You are a paying customer for medical and dental care, and you should be able to exercise the same consumer rights you have for any other product or service. I have found that asking the admin doesn’t help – that’s not their job, necessarily, they’re often just receptionists – but calling and asking for the billing department can give you someone with a wealth of information. Of course, your offices may vary, but if they won’t give you the information, consider going elsewhere. There ARE doctors out there who provide this information up front.

    Another thing that can help is to go through the booklet that your insurance company sent you and learn exactly what they cover. That booklet explains that an ultrasound is not part of standard preventive care and will cost you X%. Then when the doctor starts to do it, you can say, "Wait, what does this cost?" so you have a rough idea of your share ahead of time. I just went through my booklet and called the insurance company for things I didn't understand, and I got an amazing explanation of everything.

    Some things you should ALWAYS know from your insurance company: which visits are free and what is covered, what your co-pay is for various types of visits and how those visits are defined (ie, urgent care, emergency care, preventive care, office visit), what your annual cap is, what your max out of pocket is, and the percent you owe for co-insurance. All of this information is in that booklet.

  3. Money Beagle says:

    The doctors office can't really give you that because of the negotiations that they do with the insurance companies. An identical procedure will yield them three different amounts from three different patients who have different plans. They could probably give you the 'non-insured' rate but this is probably not going to be helpful.

    When my son needed surgery, I found that the best approach to getting cost estimates was this: Contact the doctors office and get the procedure codes, then call the insurance company and ask for the negotiated rates on those codes. Even that can end up different because there can be other codes that go in based on equipment used or such, but it at least gives you a start.

    This obviously means, though, that you would need some time in advance to do this research.

  4. Sarah says:

    I worked as a scheduling coordinator of a dental office for a year and a half, so here's the situation with insurance:

    Benefits are incredibly hard to determine. If you have a full practice of patients, you likely have to deal with countless insurance companies, each with countless different policies within each plan. They're all different. If you're giving someone an estimate for a filling for example, it can sound a little like this, "Assuming you don't max out with this procedure [maximums are generally only 1k-2k, which is eaten up incredibly quickly, and if the person has had to have any external work done recently with any other specialists that hasn't hit his insurance yet, as insurance claims generally take a month to process, then you can see how this happens not infrequently], and assuming they decide it's a covered benefit, and assuming they'll cover the first surface of the composite filling at 50% of their "approved" fee, and then the remaining 2 surfaces only at 50% of the approved fee for amalgam filling, as is the general rule, and assuming the filling won't be more extensive than the doctor thinks it will be at this exact moment in time… then your portion will probably be, roughly, $350." And that's after 20 minutes of holding with the insurance company, additional research online, and time crunching numbers for EACH patient. One tool you do have at your disposal that will make life slightly easier is the pre-estimate. Ask them to send for a pre-estimate. It does take a month to hear back, but upon receipt of that, insurance has already gone through its sometimes arbitrary decision-making process, and has taken some of the largest variables off the table. Then you've got an estimate in-hand, on paper. When you ask for an estimate as you're leaving and they give you a number on the spot, it's definitely a guess based on what many plans have covered in the past, and in reality can't be wildly different than what your particular plan covers.

    If you're having a lot of dental work done at once (fillings, a crown, a root canal all in one year, for example, which happens a lot), and a max-out is imminent, then it gets 10x more complicated and you will probably owe your entire salary out-of-pocket.

    Anyway, just know that it's just as frustrating for the people giving you the quotes, so much so, in fact, that there's a movement toward no-insurance practices where everything is out-of-pocket and no insurance is processed at all. Only doctors with rich patients, but still, it's there.

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