insurance

May 14, 2013 by Aaron Leave a Comment

Actually Using The HealthCare Blue Book

This is a follow up to my last post about the health care costs website www.healthcarebluebook.com. If you haven’t checked it out yet, give it a read. Basically, the site is a resource that has “fair” prices for medical procedures that can then be used to help you haggle down your healthcare costs. A practice that can be very valuable for cash pay patients that either do not have insurance, or coverage to adopt as practically all the health care in the US is grossly overpriced. What’s more, most providers are more than willing to offer cash pay discounts and bend on their prices for non-insured patients. I am reminded of the old truth that it “never hurts to ask”, because, who knows, you might just get what you ask for.

Anyway, I recently got a question from a reader about how to actually get the fair prices mentioned referenced on the site. This got me thinking about providing some more detailed instructions on what the site was good for using the site to reduce your health care bills.

First, I scoured the interwebs for responses from other people that have used the service to try and find out exactly how useful the service is. I was largely unable to find anything from actual patients that have used the service in the past, only news stories talking about the site.. odd. (I would love to hear from anybody who has successfully used the site to reduce their bills!)

Here are the basic instructions taken directly from the site (link to more FAQs about their service):

How do I ask for a price?

Many people are apprehensive when it comes to asking providers about prices, but don’t be afraid to ask. Providers expect patients to ask about treatment cost. You will find requesting a price from a provider surprisingly easy – just follow these steps:

Know what specific service you need – Write down the name of the service and, if possible, ask your doctor to provide the billing codes for the services. (These codes are called CPT codes for doctor’s office visits, and DRG codes for hospital treatments.) The more specific you can be the easier it is for a provider to give you a price.

Determine what a fair price is – Before calling a provider to request a price, look up the services on the Healthcare Blue Book website and write down the price. If you can’t find your service, then submit a request to Healthcare Blue Book to see if we can find the fair price.

Call the office staff – Ask to speak with the person on their staff who can discuss pricing.

Make sure to let them know the insurance company you are using or if you are paying for the service yourself – If you are using an insurance provider network, then you will get the insurance company’s discount. If you are paying for the service yourself, make sure to ask for a self-pay discount.

Ask what their price is for the service you need – If your treatment is a surgical procedure, make sure to ask about pricing for all components of care, including the surgeon, hospital and anesthesia fees. Also ask if there are any fees related to the procedure that you have not covered in your conversation.

If my provider’s price is higher than the Healthcare Blue Book fair price how do I get a lower price?

If you are using an insurance provider network, you will need to call other in-network providers to request their pricing. Most network providers have to use the network rates. You may also contact your insurance company and ask them to help you locate a different provider.

If you are paying for your own services, then you can either ask your provider for a discount or call other providers to request their pricing. It is OK to ask the provider if they will accept Healthcare Blue Book price. If the provider is not comfortable with the Blue Book fair price, then ask them what they accept as payment from Blue Cross/Blue Shield patients for the service. (Why should you have to pay more than the other patients they treat when you are paying cash?)

Most providers understand that cash paying customers want the best value, and many will give a discount. However, the first provider you call may not offer a price that you are willing to accept. It is helpful to request prices from at least three providers before making a decision.

As you can see from the description above, negotiating for the best prices may not be an easy task. If you lack health insurance, and need healthcare it is definitely in your best interests to do some haggling. Because, as I said above, most providers are very willing to offer at least a token cash pay discount, and some might be willing to offer significant price cuts. They already give huge discounts to their insured patients, and paying in cash also reduces their overhead when it comes to billing and managing insurance claims. A little time and effort can end up saving you thousands of dollars.

Hope this is of some help. Again, I would really love to hear from someone who has actually used the site’s fair prices in their negotiations, and what their experience was. If anyone has any questions feel free to post them in the comments.

April 10, 2013 by Aaron Leave a Comment

Healthcare Bluebook Gives You Fair Prices for Medical Treatment

One of the problems with healthcare is that costs are typically not very transparent. This makes it very difficult for consumers to shop around for the “cheapest” provider in town. If you are able to obtain prices for the services you need, how are you going to be able to know if they are fair or overpriced? This is a big problem for the millions of people with no health insurance. If you do have insurance, it can be helpful to know if the “non-covered” services are priced fairly or not.

Most providers bill out one amount to insurance companies, while being willing to accept a lower (sometimes much lower) amount upfront from cash pay patients. As a default, all patients are charged this standard billing rate, but providers are often very willing to accept a lower price for their services. The problem has always been, what is a good price? Healthcare Bluebook website is just the place to go for an answer.

Healthcare Bluebook aims to help fix all the confusion by publishing fair prices for a large variety of medical and dental procedures. The prices are different depending on your area and are pulled from industry data from healthcare providers and employers all over the country. According to the site these prices are what you should expect to pay a quality provider for the particular service. These prices are best used as a basis for bargaining your bill down before they are actually carried out. They offer a printable pricing agreement for each service that can aid your efforts to lock in that lower price. It is still possible to bargain after a service is carried out, just more difficult.

The site offers tips on how to use their fair pricing data and instructions on how to bargain down your costs. I found the information very helpful, and have already recommended it to a cousin of mine that is in need for a teeth cleaning, but doesn’t currently have insurance and had no idea where to start looking.

While the site is more useful for those of us without health insurance, it can also be valuable for those of us with insurance. Either way it pays to be an informed consumer, and Healthcare Bluebook certainly helps in that regard. So check out the site if you don’t have insurance and need some medical care, it could save you a bundle on your medical or dental work.

Cheers!

March 4, 2013 by Aaron Leave a Comment

The Bitter Pill: The Times Article on Health Care Costs That You Need to Read

If you haven’t taken the time to read the new Times article on health care costs you should really do so. It is an expose on our nation’s health care system written by Steven Brill. I warn you, it is very long about 24,000 words (the longest article ever published by The Times, in fact). With tons of anecdotes and mountains of data it shows how for-profit hospitals and health care companies are practically robbing us blind. So you might want to set aside a bit of time to work through it. It will open your eyes…

Here are a few snippets from the article.

When we debate health care policy, we seem to jump right to the issue of who should pay the bills, blowing past what should be the first question: Why exactly are the bills so high?

What are the reasons, good or bad, that cancer means a half-million- or million-dollar tab? Why should a trip to the emergency room for chest pains that turn out to be indigestion bring a bill that can exceed the cost of a semester of college? What makes a single dose of even the most wonderful wonder drug cost thousands of dollars? Why does simple lab work done during a few days in a hospital cost more than a car? And what is so different about the medical ecosystem that causes technology advances to drive bills up instead of down?

If you are confused by the notion that those least able to pay are the ones singled out to pay the highest rates, welcome to the American medical marketplace.

The difference between the regulatory environment in the U.S. and the environment abroad is so dramatic that McKinsey & Co. researchers reported that overall prescription-drug prices in the U.S. are “50% higher for comparable products” than in other developed countries. Yet those regulated profit margins outside the U.S. remain high enough that Grifols, Baxter and other drug companies still aggressively sell their products there. For example, 37% of Grifols’ sales come from outside North America.

More than $280 billion will be spent this year on prescription drugs in the U.S. If we paid what other countries did for the same products, we would save about $94 billion a year. The pharmaceutical industry’s common explanation for the price difference is that U.S. profits subsidize the research and development of trailblazing drugs that are developed in the U.S. and then marketed around the world. Apart from the question of whether a country with a health-care-spending crisis should subsidize the rest of the developed world — not to mention the question of who signed Americans up for that mission — there’s the fact that the companies’ math doesn’t add up.

The article has many examples of the madness that is our health care system. Routine double billing and overcharges on basic items is the norm. Huge profit margins in non-profit hospitals and CEO and administrators making hundreds of thousands or even millions to run them. What you will read will undoubtedly have you wanting to beat your head in the wall about the sheer scope of what is considered good business in healthcare.

Here is Brill conclusion, that sums things up pretty well.

Obamacare does some good work around the edges of the core problem. It restricts abusive hospital-bill collecting. It forces insurers to provide explanations of their policies in plain English. It requires a more rigorous appeal process conducted by independent entities when insurance coverage is denied. These are all positive changes, as is putting the insurance umbrella over tens of millions more Americans — a historic breakthrough. But none of it is a path to bending the health care cost curve. Indeed, while Obamacare’s promotion of statewide insurance exchanges may help distribute health-insurance policies to individuals now frozen out of the market, those exchanges could raise costs, not lower them. With hospitals consolidating by buying doctors’ practices and competing hospitals, their leverage over insurance companies is increasing. That’s a trend that will only be accelerated if there are more insurance companies with less market share competing in a new exchange market trying to negotiate with a dominant hospital and its doctors. Similarly, higher insurance premiums — much of them paid by taxpayers through Obamacare’s subsidies for those who can’t afford insurance but now must buy it — will certainly be the result of three of Obamacare’s best provisions: the prohibitions on exclusions for pre-existing conditions, the restrictions on co-pays for preventive care and the end of annual or lifetime payout caps.

Put simply, with Obamacare we’ve changed the rules related to who pays for what, but we haven’t done much to change the prices we pay.

When you follow the money, you see the choices we’ve made, knowingly or unknowingly.

Over the past few decades, we’ve enriched the labs, drug companies, medical device makers, hospital administrators and purveyors of CT scans, MRIs, canes and wheelchairs. Meanwhile, we’ve squeezed the doctors who don’t own their own clinics, don’t work as drug or device consultants or don’t otherwise game a system that is so gameable. And of course, we’ve squeezed everyone outside the system who gets stuck with the bills.

We’ve created a secure, prosperous island in an economy that is suffering under the weight of the riches those on the island extract.

And we’ve allowed those on the island and their lobbyists and allies to control the debate, diverting us from what Gerard Anderson, a health care economist at the Johns Hopkins Bloomberg School of Public Health, says is the obvious and only issue: “All the prices are too damn high.”

For a little more levity on the situation you can watch Steven Brill on a recent daily show. Daily Show (link for the full episode)

January 31, 2013 by Aaron Leave a Comment

How a cheaper health insurance plan can save you money

choosing an insurance policy — Choosing the best health insurance can be a tricky endeavor!

This article is mainly for those of us lucky enough to be self insured, but I think anyone who has any ability to pick their healthcare plan could possibly benefit from it. I am going to tell you how the cheaper insurance policy could be a much smarter way to go. This topic makes me think of the old adage “You don’t truly appreciate the value of something until you pay for it yourself,” or something along those lines.

Selecting an insurance policy for yourself or your family can be a daunting decision. While everybody wants to get the best coverage possible – the reality is that health insurance is really expensive. Expensive enough to make one think that: welI, I am hardly ever sick. What is the harm in not having insurance for a few months/years? I won’t lie, when I was between full time jobs, and doing some freelance work on my own I let my insurance policy lapse for a few months before my common sense dictated that I set up my own policy in the interim. In this day in age where a minor surgery will cost you 10-20k out of pocket without insurance, and something major could run you into the 100’s of thousands of dollars – it just doesn’t make sense not to have some kind of financial protection from what would be a veritable mountain of debt. A debt that could possibly haunt them for the rest of their life.

So there are a few things to consider when shopping around for an insurance policy. The main ones to look at are

Monthly premiums – how much money you will be spending each month to maintain your policy.

Deductible – how much money you will have to spend on medical bills before your insurance policy kicks in (note: having insurance will get you lower rates at any doctors that are in network for your policy).

Max out of pocket – the maximum amount you will spend in any plan year of your policy on eligible medical expenses. This is an important one! Why, you ask? I will get to that in just a second.

What it actually covers – AKA the fine print. What exactly is considered an eligible medical expense? Does the policy cover things like eye care? Or infertility treatment? The important thing is to be aware of any possible things that you will likely use the insurance for and if they are covered or not.

The main thing to think about when selecting an insurance plan is to figure out it will cost you. This is not quite as simple as multiplying the monthly premium by 12 and calling it a day, although, that is an important piece of information. You also want to consider what the cost to you would be if you got really sick, and needed to be hospitalized. I.E. what is the deductible of each policy you are looking at and what is the max out of pocket. If you are hardly ever sick and almost never go to the doctor, it doesn’t make much sense for you to pay extra each month for a low deductible policy. A policy that would save you a few buck if you went to doctors just a few times a year, but would end up costing a lot more in premiums. You want to think of what will be your total health care costs on each insurance policy.

The deductible can be an important piece of data to consider when figuring how a policy will impact your total health care costs. Lower deductibles mean that the insurance benefit will kick in sooner. If I had a $100 deductible on my policy and I went into the doctor for $300 dollars of care I would pay 100% of the first $100 and that would satisfy my deductible. The next $200 would be processed at my coinsurance amount. For example, if I had a 80/20 coinsurance benefit on my policy, it would mean that out of that original $200, I would be responsible for just $40. Sounds pretty nice right? The lower the deductible the more you will pay each month. So again you have to consider how often you actually use medical treatment. If you are not someone who goes to doctors very often it is not very important to have a low deductible when it is costing you more money in premiums each month. As long as the money you save by not having a low deductible is more than the money you will save by having a low deductible than you are better off not having a low deductible, and vice versa.

One of the most important things to look at is the max out of pocket costs section on your policy. This little piece of info tells you how much you will have to pay if things really hit the fan. If my policy has an out of pocket max of 5k, and I get into accident and need some serious care, I know I will not have to pay more than $5k. For me, someone who doesn’t need much medical care, but wants to have insurance to protect myself from the potential life-changing amount of debt that an accident could give me, this is a very important. I save a lot of money each year by going with a higher out of pocket max. You should look at your total costs though, and a lower max out of pocket could make sense for you if you have kids, or need more medical care.

Also factor in any regular care that you need, and if it is covered or not. For example, I wear contacts and every year I need an eye exam and new contacts – about a $250 annual expense without insurance. I would then factor that in when looking at the total cost of the policy. If the policy covers that expense 100%, cool, I know that will save me $250 bucks a year. However, if this policy costs an extra $500 from a similar policy I am looking at and there are no other differences that matter to me (think long and hard about this) then I am basically losing $250 bucks a year by going with the additional coverage. You then take these numbers and see how they affect your total health care costs for the year.

You should take all these factors into consideration when selecting your insurance policy and go for what you think will end up costing you less money in health care expenses. As with many financial decisions, it is much more important to look at the long term costs and go with whatever makes the most sense. I went with a high deductible, moderate out of pocket max because I am not often sick or needing medical care. I figured that the amount of money I save each month on premiums to be well worth the cost of a few minor doctors’ visits, if I for some reason I needed the additional care. I can bank the addition costs and spend/save them for something else. If I was someone who went to the doctors on a regular basis, then it would be more important to have a lower deductible.

I hope I shed some light on the things to think about when shopping around for a health insurance policy and why a cheaper plan can save you money, and be the smart choice. If you have any questions about any of this don’t hesitate to ask! Happy healthcare shopping!

Cheers!

January 26, 2013 by Aaron Leave a Comment

Coding and IVF Health Insurance Coverage

fertility coding and billing — It is very important that your fertility treatments get coded correctly

Correct coding is important for you—the IVF patient—as well as your medical providers and their accounting staff. While ICD-9 codes relate to diagnoses, CPT codes denote specific procedures. In order not to receive a denial on a health insurance claim, the CPT codes entered on each insurance claim must correctly correspond to the ICD-9 codes. Clinicians and billing staff sometimes make errors in coding, and a health insurance claim may be denied simply on that basis. The stated reason by the insurer for denial of payment is often that the procedure was “not medically necessary”. If you think you have gotten one or more claims denied by one of these errors your should contest them.

For in vitro fertilization, the coding can get especially complicated, and errors are not uncommon. Therefore, understanding the most common codes utilized in IVF health insurance can enable you to check if a claim denial was based on a coding error—and notify your clinic to re-submit the claim. According to an article in the Journal of the American College of Radiology, physicians correctly coded only 42% of interventional radiology patients. In a 2010 article by Skelly and Bergus, they found that family physicians’ frequently under-coded their visits as well as made errors in CPT coding.

Some infertility-related ICD-9 codes (as of 2012) include:

628.0 = female infertility, associated with anovulation
628.2 = female infertility of tubal origin (e.g., fallopian tube blockage)
256.4 = polycystic ovaries
752.19 = other anomalies of fallopian tubes and broad ligaments
617.1 = endometriosis of the ovary
617.2 = endometriosis of the fallopian tube

Typical CPT codes related to IUI and IVF include:

58322 = insemination
58974 = intra-uterine embryo transfer
58970 = oocyte (egg) retrieval
89280 = intra-cytoplasmic sperm injection

While ICD-9 coding can be exasperating and labor-intensive—especially for clinicians—it serves an important purpose in medical and healthcare research as well as governmental rate-setting departments. For public health researchers, the ICD-9 codes in electronic medical records can provide an indication of changes in the prevalence of specific health conditions (e.g., pediatric asthma, pediatric Type 2 diabetes, and HIV ). By searching on specific ICD-9 codes, researchers can acquire data to gain a better sense of emerging trends in health conditions. The relationship of IVF to multiple births was acquired in part as a result of research utilizing codes in medical records.

On the other hand, the complexity of coding presents an administrative challenge to reproductive health clinics requiring a sizable billing staff—and may be a factor in the increased costs passed on to patients.

Many insurance companies include nurse case managers as essential staff whose primary role is to review and seek ways to deny claims. The inclusion in most health insurance policies of a clause specifying that treatment be “medically necessary” provides a convenient loophole to deny treatment—especially high-cost treatment. Even those insurance companies that cover in vitro fertilization are focused on finding ways to deny claims to reduce their expenses. By maintaining narrow parameters for CPT codes to correspond to ICD-9 codes, they can limit their coverage. Therefore, your diagnosis as entered in ICD-9 codes is very important in terms of payment by insurers for procedures and tests by your clinicians.

Being aware of the implications of coding on the actual costs covered by your health insurance plan can enable you to ensure that you are not being short-changed in the claims approval process. After all, IVF is expensive enough without receiving a bill from your clinic for something your insurance should have covered.

Cheers!