Yesteday I got to play hookie because my daughter had a follow-up visit with the orthopedist. Our appointment was at a different location then the original visit. Her appointment was at a suburban strip mall. There was one event that illustrates a significant problem with consumer driven medical decision making. No one knows what the bill will look like due to the vagaries of medical billing.
She was happy and excited as she told the receptionist that her broken wrist was no longer broken, and that she wanted to go on the monkey bars that afternoon. As soon as we got called in, the med tech told me that my daughter needed new comparative x-rays. I was handed a form that was an authorization for a hospital to come after me in case my insurance did not pay. This looked wierd to me. I asked the tech if this office was considered a hospital clinic. If it was a hospital clinic, I would be paying more for the X-ray as well as paying a facility charge. She did not know.
I then called a friend of mine in claims and asked for a favor.
“Sally, could you look at Site 19821, Dr. Doe, and see if there are any radiology claims in the past year with POS that is not 11 and were there facility fees?”
“Dick, you’ll owe me a coffee tomorrow… give me a minute to get the SQL written…. how is your little one …Yes, South Suburban General was running their radiology until 3/31/15 and charging a facility fee, but after that every POS indicator is 11 and all claims are in-house claims….”
That coffee that I owe her as soon as I get off my bus will have been well spent.
Sally told me that the form I was given was out of date/useless, and I would be charged normal office rates and normal office co-insurance. The forms that I was given authorized facility charges. I would have not been surprised by a big facility charge bill on Labor Day. I am an extreme outlier in my knowledge of medical billing plus my access to relevant claims data to make informed decisions. Most people would have no idea that a facility charge was possible as they signed their forms.
No one knows to ask if Room 14 is considered an in-network office location while the doors immediately to the right and left of Room 14 are out of network doors or hospital clinic doors. No one can make an informed decision, and people are stuck at getting the X-ray at the place the doctor wants the X-ray as they would still be on the hook for the full specialist visit cost even though the specialist would need a foll0w-up visit to actually read the X-ray. So the price of shopping would be a second specialist visit payment that totally destroys any costs savings from shopping.
Thankfully, it worked out, but the office staff had no clue that they were previously charging facility fees and now no longer were. They were just told to get people to sign a form before X-rays.
I lucked out, and my daughter saw the orthopedist for five minutes. He gave her the okay to do whatever she wanted and made a very helpful suggestion that taking a right at the second set of lights and following that street for half a mile would lead to an awesome playground with four sets of monkey bars. So that is where we went for two hours after the appointment and she monkeyed around for most of that time.
Problems with consumer driven healthcare (Part 765,221)Post + Comments (72)