Amen — need to get clearer contracting on the insurer-provider side plus rebuild claims systems to allow loc bills https://t.co/ACG5naEGfo
— Richard Mayhew (@bjdickmayhew) March 21, 2016
This was the tail end of a long discussion about how to systemically get surprise bills out of realm of the common and into the realm of myth. The current set of laws like the New York surprise bill dispute resolution law is a post-facto attempt to not completely screw over patients and their families. It eliminates some of the gold mine that doctors and hospitals can strip mine but the process is long and painful. It is a good attempt to treat a symptom without getting at the underlying root cause.
An emergency room visit is almost guaranteed to trigger two claims for the simplest possible visit. The first claim is the institutional/facility claim where the hospital charges the patient for using the space. The second claim comes from the doctor who sees the patient. This is the simplest ER claim. More complicated ER visits can generate even more unique claims including lab, radiology and surgery claims. If someone has surgery, there is a possibility of an out of network assistant surgeon plus a separate anesthesiologist charge.
This is too complicated. This confusion is how surprise medical billing can easily occur. An individual can think that they are doing everything right and drive past an out of network hospital to get to an in-network ER and still get hit with surprise out of network charges.
There are two long term fixes. The first is a significant change in contracting relationships between hospitals and insurers. Right now, every medical professional in an ER can be acting as an autonomous atom with no required relationship with a particular insurer. The hospital is mainly concerned about getting heads in beds to run revenue through their facility charges, room charges and then through whatever services the hospital directly provides. The hospital is merely a contracting entity and foci of high end medical care. It is not an active agent in managing care.
The relationship change is to move the hospital to that of a general contractor where an ER visit is a single bundle payment with appropriate modifications for complications and complexity of the visit. An asthma attach should be paid far less than a heart attack or a sucking chest wound. However that bundle payment will be split in whatever proportion that the general contractor so decides. That means if an out of network radiologist reads an X-ray, that is the hospital’s problem (and loss center) instead of the patient’s problem. The entire concept of an out of network specialist for an ER visit becomes obsolete. If the hospital is in-network, every claim associated with the ER visit is in-network. The same logic would apply to surgery. The surgeon would become the bundle recipient and general contractor. For that one particular instance, anyone who touches that particular patient would be considered in network.
The insurance side needs to change as well. Right now most insurers pay claims based on a combination of Tax ID Number (TIN), place of service (POS) code, National Practitioner ID (NPI), CPT-4 codes (procedure codes), modifiers, ICD-10 diagnosis codes and a few other boxes on a standard claim. There are a few claim payment systems that tie a claim to both an episode and a particular location but not many. Claims systems will need to be rebuilt or replaced so that every claim that is attached to a particular instance can be pooled together. From there, actually paying bundled payments to a general contractor is plausible. Until the systems are rebuilt, tying claims to instances is difficult which means paying for an instance with a single payment is difficult as well.
Soprano2
There are also bills for calling the paramedics but not going to the hospital. My husband got one of those after I called 911 because he had a low blood sugar incident while we were at the movies. He was assured that Medicare would cover it in January; then in September he received a bill for $800! Turns out this could have been fixed with a phone call to his Medicare Advantage provider the next day, but he didn’t know that. It happened again yesterday; he’ll be sure to call his provider today. It was maddening to be told it would be paid, only to receive a bill nine months later!
cmorenc
When I recently (end of January) had knee joint replacement surgery, I knew my orthopedic surgeon took my BCBS insurance, but it dawned on me that I didn’t know whether the anesthesiologist who I would meet (briefly) for the first time less than a half-hour before he/she put me under for the operation – would take BCBS, or indeed who they would be. The really HUGE bit of irony in this is that my older daughter is herself an anesthesiologist (in another state), and she doesn’t know either which patients she will be assigned to until shortly before serving on their case – nor whether the patient’s insurance coverage is within her practice’s network of insurers. She has nothing to do with billing patients or insurers herself.
japa21
This, of course, is a common sense solution. Some hospitals actually have those specialty adjuncts (radiologist, ER doc, etc.) as employees of the hospital. However, in most cases, they contract with an outside agency to provide those services and those outside entities do their own billings. Many contract insurance companies write with hospitals include a clause stating the facility will work with the insurance company to bring those outside entities into the network. However, most of those agencies balk at giving insurance companies any sort of a discount.
It is harder to do now as more states are requiring insurance companies to pay as in-network those claims arising from a visit to an in-network facility even if those providers providing the services may be out of network. What the payment is based upon also becomes an issue. Some insurance companies try to pay at a Usual and Customary basis, but defining that has become a real problem.
And even that would not eliminate all the additional bills a patient receives. So making the primary provider of care responsible for collecting an overall amount and then spreading it among all the providers make sense, but it would require those separate entities to agree to have that happen and, as you point out, major claim processing changes.
As I said recently, with all the changes coming in the near future, I am glad to be retiring. This old brain is getting to the point where any new rewiring may cause it to stop functioning completely.
OzarkHillbilly
Oh yeah. When I broke my ankle in Dec, the Washington MO hospital that was 10 miles away was out of network so I drove 50 miles over Ozark backroads to the one I knew was in network (and 15 miles from home) and I’m still getting bills I have no idea who from or what they are for.
Not pay them until I do know.
amygdala
This is definitely a problem that needs real solutions. Patients who aren’t aware of the many possible pitfalls get slammed and folks who do know about them may fare only minimally better.
There are risks, however, to hospital-based fixes. It’s not unheard of for hospitals to pressure physicians who are their employees to do things that are not in the patient’s best interest. With the focus these days on so-called “disruptive physicians,” pushing back against the hospital can lead to loss of staff privileges. In some specialties that can be career-ending.
I would wonder if Kaiser, as a staff-model system, has come up with ways to manage these issues fairly.
Benw
From now on I’m paying my surprise medical bills in equivalent soccer cleats and dildos. Suprise, suckers!
CONGRATULATIONS!
Timely. I had to go to the hospital several times in the last month. I’ve got Gold Premium coverage. I definitely was not expecting to get hit with over a thousand dollars in bills. Lab, radiology, all kinds of shit. I’ll be the rest of the year wading through all of this, trying to run down what’s a valid charge, what isn’t, and what the insurer should be covering – I work fulltime and frankly don’t have time to be dealing with sons of bitches trying to nickel and dime every last cent out of me, so I’ll probably end up paying someone who I don’t owe money to. The system is even more fucked up than it was before, which I didn’t think was possible.
Anyone who has to deal with this who does not understand how hospitals work – and frankly, many who do understand it – are going to blame Obama and Obamacare. I think some blame is warranted. ACA was necessary but very poorly thought out and executed. Better than nothing for some of those who had nothing, but a bad deal if you already had insurance.
CONGRATULATIONS!
@amygdala: They have. They let all their patients die equally.
I’m fucking serious. I was on Kaiser for many years. They treated nothing that they could get away with not treating, and made getting anything outside of primary care so difficult most patients just end up giving up.
Lemme tell you a story that was the impetus for getting me off Kaiser.
Friend of my wife’s, her husband falls off a ladder three years ago. Hits his head. Serious head injury. Goes in to Kaiser, is in for six weeks. Released. Keeps complaining of pain in his neck. Is told it’s normal and is given pain meds. Several weeks later, at dinner, he turns to say something to one of his kids and collapses and dies right there on the floor.
He’d had a broken neck the whole time. Kaiser x-rayed his head…but not his neck.
When I tell this story, the only people who believe it could have happened are Kaiser patients. They don’t even question it, just nod their heads and say “yep”.
Lawsuit pending. Turns out one thing Kaiser is willing to spend money on is lawyers.
japa21
@CONGRATULATIONS!: Explain to me how this is to any degree the responsibility of the ACA. Seriously, I am curious as to what in the ACA contributes to there being bills from many different providers.
Bobby Thomson
OT: it’s official. Scalia’s death saved public unions.
amygdala
@CONGRATULATIONS!: Horrible. Terribly sorry for everyone’s suffering. This is why there are Level 1 Trauma Centers, to keep things like this from happening. Although errors can happen there, too.
The further I got into my career, the more I became convinced that the malpractice system doesn’t work for reducing errors. It exists for situations like this, where compensation is due. But the vigorous defense that most systems put up discourages getting to the root of problems. And it does nothing about near-misses, which, if caught and fixed, can prevent disasters from occurring in the first place.
Alain the site fixer
OT: The theme developer has solved the :”back” issue. So when the new stuff goes live soon, back will work again for navigating comments!
that is all
WereBear
@CONGRATULATIONS!: Dear heavens, that is so horrible.
And while I am not a Kaiser patient, I utterly believe it. Medicine has reached a point of arrogance that they tell you what is wrong with you and what you are feeling.
WereBear
@Bobby Thomson: Cite?
pseudonymous in nc
If you’re wearing a badge with the hospital’s name, you’re working for the hospital, and you don’t send a separate bill. Simple.
If you’re going to send a separate bill, you wear a different (larger) badge and your scrubs have a $ $ $ pattern on them.
Richard Mayhew
@pseudonymous in nc: I like this idea :)
Sister Rail Gun of Warm Humanitarianism
@CONGRATULATIONS!:
Because anything that’s wrong with healthcare today is obviously the fault of Obamacare.
Yeah, I’ve seen that.
And people don’t want to believe me that hospitals were doing this shit twenty years ago. Great Ghu, the bills my mother waded through after my father died.
Barbara
I have to be circumspect, because this is a true story. A hospital based practice refused to contract with any payer and a particular insurer ended up paying close to $900,000 in additional fees to just this group at a single hospital. So very big insurer went to hospital and said, we are going to deduct $900,000 from whatever increases in fees you are expecting. Because said hospital refused to pressure said group to contract with insurers. Putting a price on it galvanized hospital to change the situation. People rail against insurers, I get it, but in reality, what really separates American health care from other countries is just how much providers are paid compared to the average citizen. The relative cost of medical items and services is much higher in the U.S. than in other countries. More than once I have negotiated discounts and refused to pay (when my father had cancer) because I know stuff about how reimbursement works and was able to write letters that persuaded providers to back off. But overall, it’s just a nightmare scenario for the average person.
WereBear
@Barbara: And, I might add, something we are supposed to wrestle with when we are sick.
Ang
@pseudonymous in nc:
I like the scrubs. They should also be required _at any and all times_ to be able to tell me if they accept my insurance and if they are an in-network provider. And make their answer legally binding. If they can just walk into my hospital room and provide services that I will be required to pay for then I should be able to ask at that moment if I am covered or not.
Or we could just use some common sense and require that services provided in the hospital’s footprint be billed through the hospital.
Last time my kid went to the local emergency room we were billed by a separate staffing company for the doctor. This wasn’t an on-call specialist or anything like that, just the regular doctor who was on duty in the e-room.
Feathers
Did a recent gig at a healthcare company. What amazed me was that these folks pay each other by putting checks in the mail. I’m at the front desk, answering the phones, giving badges to visitors, handling complaints about the candy machine, and … opening the mail to find six figure checks from various hospitals.
It is truly amazing how healthcare has been able to avoid the computer revolution. It’s almost as bad as the Pentagon.
Mnemosyne
@CONGRATULATIONS!:
Let me guess — Kaiser Northern California? They got so bad that they lost their privilege to do transplants at one point. Kaiser So Cal is much better, in my experience.
bemused senior
@Sister Rail Gun of Warm Humanitarianism: Absolutely true that this has been going on forever. My husbands grandmother had a heart attack while visiting us 30 years ago. She had BCBS from New York (we are in California). She was taken to our local hospital by the paramedics and died a few hours later. BCBS tried to deny payment because she didn’t need to go to the ER. They also denied the ambulance charge. It took months to straighten this out. I couldn’t figure out whether they felt we should have just let her die at our house, or we should have driven her ourselves, or what their theory was.
bemused senior
@Mnemosyne: Don’t know about their surgical chops, but the Kaiser fertility center on the SF Peninsula is number one in the state, and when my grand twins were born, the maternity care was outstanding. I’m so glad my daughter had Kaiser. (Of course the fertility treatments weren’t covered. :-( )
Mnemosyne
I mentioned a couple of days ago that I’m wrestling with a slightly different issue — the medical group my doctor now belongs to decided that I should go to their preferred facility 20 miles away for a procedure rather than the one less than 1 mile from my apartment. Both places are in my network, so I suspect it’s the difference between what the medical group owns and what they don’t.
To make it even more fun, they informed me of this decision the day AFTER I had the procedure done with my doctor’s verbal approval, which means that they dragged their feet for 3 weeks before making a decision.
Luckily, the insurance company for the Giant Evil Corporation I work for are mere managers for our program and not the final arbiters, so the insurance company assured me that we’ll work it out. Still, it’s a stress I did NOT need to deal with, particularly since the procedure found something that now needs to be biopsied.
Mnemosyne
Also, I know California now has a Surprise Bills law, though I don’t know the details.
CONGRATULATIONS!
@Mnemosyne: Nope, SoCal. I have dealt with Kaiser NorCal when my girlfriend’s mother had a stroke. I’m tempted to say that no medical care at all, or on the spot euthanasia, would be preferable to Kaiser North. Incompetent doesn’t even begin to cover that experience.
My personal experience with Kaiser SoCal is that they hew to the mantra “if you can’t medicate it ignore it”. Ever since I left them I’ve been in my doc’s office every month at a minimum, dealing with issues that should have been dealt with years ago.
Prescott Cactus
@amygdala:
We have the equivalent of a mini Kaiser in my area. Unknown person (cardio surgeon) walks in hospital room, says they were referred and tried to get my 80+ year old Dad to get his carotid arteries operated on. Said risk of harm was 1% to 3%. Dad asked “It’s an operation? NO ! ” Turns out actual serious harm had ranges from 7% to 10% for my Dad per his regular Doc. . .
@Mnemosyne:
May all go well and your path be smooth and uneventful.
John
See Medical Associates LLP in Indianapolis for an example of this mess. Attorneys with a group of medical professionals on staff that they rotate into area hospitals as an excuse to balance bill since they aren’t “in network”.
justsomeguy
@Mnemosyne:
Kaiser is just as bad in the Denver metro area.
Procopius
@CONGRATULATIONS!: It’s not so much that Obamacare was poorly thought out. It’s that, in order to get votes from the damned Blue Dogs and DLC New Democrats and the Loathsome Cryin’ Joe Lieberman, minor changes and tweaks were made that broke the original design. Thanks Max Baucus.