Sunday, July 13, 2008

My Sunday Feeling

I am fortunate to have really good health insurance. I have stayed with the same provider for the last 20 years or so, mainly because the numerous doctors I maintain on the payroll all really like my provider and I have never had a minute's worth of trouble with them.

At least not until last week.

My doctor scheduled me for a certain diagnostic procedure at a local hospital. He made the referral because he felt it was medically necessary to get some answers really fast based on some rather interesting symptoms that had popped up out of the wild blue yonder.

My provider sent a fax: Coverage Denied.

This particular physician is quiet and almost sphinx-like in his demeanor. Jim is gentle and kind. He is the kind of doctor who has this almost Svengali-like power over elderly patients who are drawn to his unassuming ways. Think Fred Rogers with an Ozark accent.

Ray, his nurse, called me the day before the procedure to give me the happy news. He said that a peer to peer teleconference between Jim and the provider's review physician had been scheduled for the morning of the procedure. One more thing. Ray told me Jim was pissed.

Wow. Guys like me uncork over any of a number of slights and injustices, most of them imaginary. You have to go some to light Jim's fuse.

OK. I wasn't real happy at this news. I mean, it's not like I didn't have the money. But it was earmarked for repairs to my deck. Not for a medical procedure. But it wasn't the end of the world. At least I could come up with it.. Little did I know that the screwed up way we finance medical care in this country would inure to my benefit in any event simply because I happen to be reasonably solvent.

The insurance lady at the hospital called me the morning of the test to tell me that the decision by my provider not to cover the procedure was under review. I told her that I knew that. And just so I would know, I asked her how much the procedure cost.

" Ummmmmm....generally around $3000.00," she said.

" Great," I said sarcastically. "OK. I guess I'll just wait for the bill to get the final amount." I hadn't planned on shelling out 3 grand this month on anything other than home projects and airfare to Chapel Hill. But then again, I hadn't planned on that trip to the ER earlier last week either. Stuff happens. Again, I am fortunate. I had $3000.00 that I could shell out if I had to. Lots of folks can't say that. You got to look at the big picture sometimes. You have to count your blessings.

" Well," the insurance lady said. " If you can pay cash today, we'll give you a 58% discount on the charge."

" Huh?"

" Yes."

I was dumbfounded.

" Let me get this straight," I said. " If my provider changes its corporate mind and decides this thing is indeed medically necessary and not the equivalent of a face lift or something, y'all charge them the full rate and my copay is 700 bucks. "

" Um-hmmm"

" But if I just make an appointment, and show up to get a CT Scan of what passes for my brains, y'all will back off to (I did the math in what passes for my brains) around-what?-$1200 bucks?"

" Yeah. Something like that."

" No disrespect but that's insane."

" I don't make the rules, sir. I'm just reading off the screen here."

Think about it. Even if insurance covered the procedure, it would only pay what was reasonable and customary. So it wouldn't pay the quoted rate if it didn't want to. I wouldn't be charged the quoted rate if I could pay cash on the barrel head. And how did they come up with a number like 58 per cent anyway? Surely they meant that's all I would have to pay up front and they would bill me the rest later. But that's not what she said.

I've seen a more straight up pricing system on used car lots in Louisiana.

The hell of it all is that the only people that get charged the full rate are the uninsured. And they can't pay. But I guess that the hospital can then write off the full amount charged as bad business debt.

The good news is that Jim evidently beat the provider down. They covered it. My eventual hit is "fixed and liquidated" by the terms of my insurance policy and not governed by some arcane internal accounting practice which prices a procedure not based on what is worth but rather upon who is paying.

Like I said, I am fortunate and I know it. However this was going to shake out was not going to bankrupt me. But there's a whole lot of people out there who don't have insurance and some of these people typically can't come up with 3 grand either.

Surely to God there is a better way to manage medical care in this country.

Because, like I said to the insurance lady at the hospital, this is insane.


Anonymous said...

Welcome to the world of the review board. Don't even get me started on the GED dropouts who determine which tests BC/BS will pay for my son and which ones I just have to wonder about for all eternity because I don't even have a deck to upgrade, much less the funds stashed to pay for it.

Ask your Miracle League parents about insurance. Then write a book on the abomination called health care in this country.

And go watch Michael Moore's movie again, too...


Polycarp said...

Your hospital won't admit it, but regardless of what it bills, it(and everyone else in the business of health care) will generally accept a greatly reduced negotiated rate from large health insurers. The larger sticker price, which almost no one actually pays,is used to justify the enormously larger co-pays, which are in turn designed to discourage expensive procedures like MRIs. The hospital takes a $700 co-pay from the patient, then bills the patient and his or her insurer the "remaining" $2,400; the insurer cuts a check for $1,200 (its negotiated rate) and the hospital accepts it as payment in full. The real function of the $3,100 price tag is to hide the fact that your co-pay amounts to 40% of the cost of the procedure, not 20%, as your health plan advertises in its promotional materials and would like you to believe.

Still and all, some sort of oversight by someone seems to be warranted. Health care costs are far higher in the United States than in other "developed" countries, and our health care is not any better. This is in part because American doctors are far more likely to order expensive tests than their European and Japanese counterparts, in part because they're afraid of being criticized for not performing them if something goes wrong, which is due in part to our sue-happy culture.

tmfw said...

And when the patient involved is a lawyer who hit the deck under mysterious circumstances, then the docs really start sweating like whores in church.

The ER doc asked me what I did for a living. I told him. He asked me what type of law I practiced. I was tempted to say that I was a plaintiff's lawyer. After I told him the far less interesting truth, he told me that he had never been sued before.

Which I found odd.