A major discussion these days is the cost of health care. Everyone from patients to politicians lament the cost of services charged to them by providers, hospitals, clinics… you name it, there’s a complaint.

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Over the past 10 years one of the biggest discussions revolves around something known as “price transparency”. This concerns the demand that hospitals and other medical providers should post their prices so patients can shop around for the best cost of services in their area. It’s believed that this would reform health care because it would hold hospitals and physicians accountable for keeping their prices lower.

There are two fallacies to this argument. The first is that hospitals would lower their prices based on this model. Without a proper understanding of hospital and physician costs and insurance reimbursement works, physician’s privileges with specific providers and referrals, and often the lack of competition in an area, it takes more than knowing what the prices are to get them lowered.

The second; most facilities already have to give patients this information, and most physicians offices are willing to do the same.

As a matter of fact, both have tried, but patient apathy killed the initiative. About 7 years ago a number of hospitals decided to put their charge masters online where anyone who wanted to could see what they charged for services, pharmacy and supplies. One hospital went so far as to hire and train someone to take patient calls and answer these questions for them.

What happened? The hospital that hired someone received 3 calls in six months, and all the other hospitals reported that the page where their charges could be accessed had fewer than 10 visits a month. Some hospitals still have their charge masters online but see very little traffic. There are no statistics on physicians but most of the time their staffs report that few people ask how much their visit is going to be.

This tells us that when it comes to medical services, the consumer has to learn how to take charge and at least ask providers about pricing, and then contact their insurance companies to verify coverage and payment. Here are some details on how patients should proceed as it pertains to outpatient services.

1. Contact Your Insurance Carrier To Verify Covered Procedures And Possible Payments

Unless you live in a very small town, your first call for primary (first time visit or first time with new insurance coverage) services should always be to your insurance company if you have coverage. Once you reach someone, you should tell them the type of physician or service you’re going to have, ask them if your physician (if you already have one) or clinic is a participating provider (your hospital should always be unless you have a small or out of area insurance plan) and what your liability would be if you have an appointment.

You always want to go with a participating provider because your out of pocket costs will always be relatively low. If you go to a non-participating provider it means they won’t accept payment from your insurance company as payment in full. If there are no participating providers of service in your area your choices will be to either see a physician further from where you live or pay for your visit or services in full.

2. Call Your Service Provider

If your insurance company has told you that your service provider is participating, you’re pretty safe in not having to ask them how much their services are. You’re not done though; keep reading because something else will be coming your way.

If your insurance company has told you that your provider isn’t in their network, or you don’t have insurance, then when you call you need to ask them how much a visit or service is going to cost. You need to know that there are ambiguities when it comes to things like office visits.

First, there are 5 levels of office visits for new and existing patients so you’ll probably be given a range. Also, there are things physicians groups do within their office and things they send out, and the degree of work they do on each of these fronts is different.

This means that you won’t know until you see your physician if they’re going to request extended services like lab work or x-rays. Almost no physicians have x-ray equipment in their office so you can assume you’ll be going elsewhere for that. When it comes to lab work, some types are done within the office while other types are either sent to a lab or you’re told where to go for these services.

If there’s even the possibility that you might be going elsewhere for services or that your physician might do part of it (such as draw the blood) and sent it elsewhere, you need to ask who they work with in providing these services. This way you can call your insurance company to find out if those outside providers are participating providers as you did with the physician.

Second, if your services are at the hospital or even an outside clinic, you need to know that there’s a possibility you could receive even another bill. Some hospitals contract with outside physicians to interpret things such as x-ray scans, and if they’re not paid by the hospital then you could receive a bill from the physician’s group. This means that if you’re having any services at the hospital you need to find out if there’s a possibility that you’re going to be billed by someone else.

Third, if you’re being sent to a specialist for services you need to find out if you need an approved authorization from your insurance company. Your primary physician might not know this information but your insurance company will, which is why, after you have this other information, you’ll need to contact your insurance company to find out if these other physicians are part of the network, whether you need an authorization (for instance, if you’re being sent for physical therapy you might need an authorization for multiple visits) and what your possible liability might be.

3. Surgical services can be unpredictable

If you need to have surgical services, getting an exact price can be difficult. If you need to have something removed that’s a fairly standard process and you can get a pretty fair approximation of what you’ll owe. If it’s something like a knee surgery or anything to do with the heart, it’s going to be more problematic for multiple reasons.

One, all physicians don’t work at the same speed. Many surgical procedures are based on time, and often pre-surgical x-rays or scans might not tell the whole story once a physician gets inside the body.

Two, it’s hard to be definitive on which supply items a physician might need to use in your case. There are literally thousands of medical supplies, thousands of different body types and thousands of things that could go wrong during a surgery. Things like screws, stents, and pacemakers come in all different sizes and work in many different ways, and prices can range anywhere from under $100 to upwards of $20,000 or more.

Three, if there are complications sometimes physicians might need to call in another physician to assist, or might have to do something that’s out of the ordinary and that will drive costs up even further.

Therefore, the best you can do is ask for an estimate based on a physicians norm for time and supplies. You should also ask about pharmaceuticals that are normally used, although once again physicians might change these things up after they see what they’re working with.

Not all procedures require an anesthesiologist but you need to ask because that’s a bill you might not be expecting. There’s also the physician’s bill as well as a bill from either the hospital or surgery center you might encounter. Sometimes you’re told this up front but you should never take it for granted.

This is the one time where you need to ask two more questions that might help you on the back end when you call your insurance company. The first is the expected procedure code for the service you’re having; the second is the diagnosis code leading into the procedure.

Most insurance companies pay based off fee schedule which takes into account both the procedure and diagnosis codes. Sometimes insurance companies won’t cover a procedure performed one way but will pay if it’s done another way based on the diagnosis.

You need to be prepared to give your insurance company extra information if they try to tell you that your procedure isn’t covered if they don’t believe the severity warrants the procedure. Physicians don’t always give you complete diagnosis codes that cover all your symptoms leading into a procedure, so be prepared to ask questions as to why the insurance company might not be covering the procedure and tell them what you’re going through. Sometimes they’ll give you a secondary diagnosis code that your physician must have on the bill for it to be covered.

4. What if you don’t have insurance?

If you don’t have insurance then obviously your first step is to call around to see who might offer the lowest price for services. Your best bet most of the time will be some type of clinic, many of which can provide the basic services for you.

Your second step is to ask them if they offer either charity care or payment arrangements. Every non-for-profit hospital in the nation must offer some type of charity care for those who can’t afford to fully pay for hospital services, but sometimes they forget to tell you and patients forget to ask. It’s possible that you qualify for Medicaid services based on your income, which is your best bet, but sometimes you might qualify for a discount on services anywhere from 20% to 80% which could be a big help.

Whether you get discounted services or not, hospitals and clinics and most doctors will accept payments from you over time if you agree to a payment arrangement. Depending on the amount of your services the arrangements could be anywhere from a few months to a few years. Sometimes they’re affiliated with an outside debt processor that will pay your claim and allow you to pay someone else over time.

The common theme here is that if you’re either a patient or potential patient you need to take charge of your medical costs. Don’t be afraid to call either your providers or your insurance company to ask the important financial questions you need to know. You not only could end up saving money but you’ll have more peace of mind.
 

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