Hospital Fee Transparency More Cloudy Than Clear

Hospital Fee Transparency More Cloudy Than Clear

In the spirit of protecting patients, hospitals began posting their list of charges online in January 2019 (per the Public Health Service Act enacted by the Affordable Care Act). Sounds like a simple thing to do, but consider the numerous services and items hospitals provide: diagnostic procedures, physician consultations, surgeries, treatments, medication, and supplies, to name a few. It gets even more complicated when the scope of difficulty or duration of a surgical procedure or treatment is factored into the equation. Also, there are great variations between various hospital’s pricing—some may charge double what the others do for the same procedure. Imagine how this can affect the ability to have a good understanding of hospital bills. It is this issue, the disparity in hospital pricing, and a lack of desire to make charges known to the public before rather than after treatment which causes confusion surrounding hospital fee transparency and problems for the average consumer. Creating greater awareness of the issues about hospital pricing transparency could help individuals minimize or avoid unnecessary serious financial repercussions.

            Hospital fee transparency is meant to help consumers calculate medical costs to assess a treatment’s affordability. Sounds great in principle, but is it feasible in practice? Would you know what is needed in a surgical procedure and hospital stay? Most likely, you would not know. So how is the average consumer expected to calculate an approximate cost based upon reviewing a list of hospital fees? A hospital price list, known as a “Chargemaster,” can be as short as four pages, but more likely several hundred. On top of this, the information is often not alphabetized or categorized by subject. Some hospitals even use codes which are indecipherable to anyone but themselves. While the list of charges is meant to educate, more often than not, it is a confusing mess. Essentially, a Federal statute was passed—and hospitals complied. However, the statute neglected to mandate posting the information in a manner that is comprehensible by the patient. So, while there are Chargemaster posted, they are essentially useless—as the information they contain is not decipherable.

Advocates of fee transparency comment that the program is new and can be seen as a step towards informing consumers. However, according to a February 15, 2019, article in the Florida Phoenix: “Hospitals have some leeway in deciding how to present the information — and currently there is no penalty for failing to post.”

            With the mid-year mark having passed since the mandated public disclosure, it is possible to analyze the information being provided by hospitals. In its July 2019 issue, The National Law Review raised some problematic issues about the information released by medical facilities:

  • Patient specific variability affecting cost is not included
  • Variances in health plan coverage costs and out-of-pocket expenses and out-of-network bills are not provided
  • Nonexistence of requirements specifying how to format data for public consumption

 

            The success of hospital fee transparency is not just a matter of providing the consumer with clear and concise information, it is also about accomplishing specific goals. The New England of Journal Medicine (NEJM) Catalyst explored the topic of price transparency last year in an article which posited that the efficacy of price transparency depends on the success of meeting the following four goals:

  • Help patients make informed decisions;
  • Enable comparative price shopping;
  • Facilitate affordable care; and
  • Create pressure to reduce pricing.

 

                While the value of posting hospital fees online (in the current manner) is questionable, given the complexity of the pricing, it does expose the random variability and exorbitant differences in pricing among medical facilities. The embarrassment over these disparities could serve as a catalyst for change and motivate some institutions to reconsider their fee structure. Then again, one cannot shame the shameless into doing the right thing. The more light shone on this cloaked pricing information, the greater the benefit to the public. Many have called for further legislation concerning the form and manner in which such information is posted. This could then begin some momentum towards positive healthcare reform in pricing which might stimulate further useful change.

Human Health Advocates, LLC, located in Boca Raton Florida, serves clients both statewide and throughout the nation. It is a very highly reviewed entity, affiliated with the Better Business Bureau. Its members are Board-Certified Patient Advocates; specializing in medical debt reduction. If you are having difficulty understanding or managing your medical bills and/or health insurance Explanation of Benefits (EOB’s), reach out…..get help…..contact one of our Board-Certified Patient Advocates at Human Health Advocates. We review medical bills and health insurance determinations, locating errors in providers’ charges and processing.  We prepare insurance appeals for denied claims. We negotiate reductions in your medical debt from hospitals and other medical providers. If you have problems with your medical bills or health insurance, get in touch. WE CAN HELP!

By Guest Blogger: Mary Ann Mace

You Can Fight Facility Fees

You Can Fight Facility Fees

Lawmakers have placed pressure on healthcare providers and institutions for transparency with medical fees, however, the information posted online by hospitals is difficult to understand. Assessing an approximate cost for procedures, treatment, and hospital stays remains guesswork, which makes it difficult for consumers to calculate medical expenses in advance. For the time being, consumers might only be left with a defensive strategy as it concerns fighting facility fees.  

How can consumers combat against inflated hospital and physician costs? In a June 2019 Consumer Reports article, there is a choice of actions you could take either before or after incurring facility fees, and it could prove helpful to you:

Medical

Primary Care Doctor: We are all tasked with managing our own healthcare and can no longer expect our doctors to do this for us. However, developing a relationship with your doctor remains an important part of your self-care. This way, it becomes easier for you to ask some of the difficult questions unrelated to treatment. Schedule appointments often, especially if you take medication, and the next time you schedule an appointment, ask the front desk if the practice charges a facility fee. If so, get information on fee structure. Remember, it’s your money and you have the right to know where your dollars go.

Diagnostic Services/Specialists: It’s no secret doctors have a network of other physicians and diagnostic centers they refer to their patients. It’s a lot easier for your doctor to provide a name of a preferred provider he or she has used for years than to look up someone new. Plus, it’s human nature to refer a patient to a resource that has some commonalities. So, if your doctor is associated with a medical center or healthcare services-owned facility, chances are the referral will be too. You’ll need to do your homework and find out the referral’s facility fee, if there is one.

As an added note, in the 2019 article from Consumer Reports, hospitals were mandated in 2016 to notify patients if their doctor, or outpatient facility, had changed ownership to a hospital. Estimated facility fees were also supposed to have been included in these notices. Keep this in mind when speaking with your doctor’s office.

Additionally, you can conduct your own online search if you want to inquire about hospital fees, hospital facility fees, or facility fees. In your browser, type the name of the relevant hospital followed by the keywords “chargemaster” or “billing.” This may help with your hospital bills.

Insurance

Insurance Provider: Uncovering whether there is a facility fee and verifying it’s covered by your insurance provider are two different things. If you’re able to uncover the facility fee charge, then contact your medical insurance provider and ask if the excess fee is covered by your policy. If it is, confirm the amount the policy will reimburse. It might even be worthwhile for you to have a conversation with your insurance provider in advance of any medical care. This way, if you decide to change doctors because of facility fee practices, better to do this in advance of any treatment.

Negotiation: If you find yourself in a situation where you require immediate care and incur facility fees, then you might be able to negotiate the fee with the healthcare provider. Even suggest their waiving the expense, but if this isn’t possible, discuss reducing the amount. As well, you can negotiate with your insurance provider regarding their coverage of the charge. If you don’t feel comfortable negotiating fees, you could consider turning to the services of a medical billing advocate to help you.

Appeal: Additionally, you have the right to appeal an insurance decision. The appeal process can be lengthy and complicated. While you can manage your own appeals, retaining an advocate with medical debt specialization could be advantageous to you. Specialists like Human Health Advocates could not only relieve you of the stress of an appeal, but also offer negotiation expertise.

Keep in mind it’s your decision whether or not to proceed with specific medical care, and you have a choice with where you receive your treatment. Electing whether to proceed with recommended care or go to another provider is your decision. Knowing in advance about any additional costs you might incur can help you to plan financially.

Are you ready to fight facility fees? Contact Human Health Advocates today for a free consultation.

By Guest Blogger: Mary Ann Mace

Don’t Pay A Medical Bill Until You Do These 6 Things

Don’t Pay A Medical Bill Until You Do These 6 Things

Medical bills are an inevitable expense and often times patients are ripped off because of mistakes or errors in the bill itself which they failed to recognize beforehand. It is estimated that more than 80% of medical bills contain errors. Additionally, health insurers routinely deny claims erroneously. This only adds to the confusion when trying to decipher your medical bills, explanation of benefits (EOB’s), and how much you should pay your health care provider. However, there are some steps you can take in order to avoid paying a hefty medical bill that you don’t fully understand.

  1. CHECK YOUR INFORMATION

There are many billing errors that occur due to a slight clerical error entered on the claim form submitted to your health insurance company. Even if there is one digit missing from your insurance ID number or your name is misspelled, it can result in your claim being denied- and you being billed prematurely. Many times, claims are submitted to the incorrect insurance carrier. To avoid the hassle, make sure your insurance information on the bill is correct and that the bill has been processed by your insurance company.

  1. COMPARE THE INVOICE TO YOUR INSURANCE EXPLANATION OF BENEFITS (EOB)

When claims are processed by your health insurance company you should receive a statement called an Explanation of Benefits (EOB). The EOB will provide details on how your claim was processed including any deductible and coinsurance amounts, as well as any services that have been denied. Always compare your medical bill to the EOB to verify that the amount on your invoice reflects the amount your insurance company says you owe.

NOTE – Some providers and billing entities are very aggressive. They will send you a bill requesting payment while your insurance company is still processing your claim. Many people pay these bills without realizing that the amount they owe might be substantially less once processed by their insurance company. Look out for phrases such as “Due Now,” “Estimated Amount Due” or “Amount You May Owe.” Don’t get tricked by this sleazy tactic. Call the provider and ask for an invoice showing the insurance processing information. Verify with your health insurer whether you should pay the bill at that time.

  1. REQUEST AN ITEMIZED STATEMENT

It is very common for medical bills to only show a grand total of all items and services without providing a detailed breakdown of them. Errors are often made by the hospital or billing entities that can lead to duplicate or inflated charges– such as $20 for a box of tissues or $75 for a warm blanket.  Therefore, it is important to ask for an itemized statement of the medical so that you can make sure that you are only paying for the services and items provided to you.

  1. CHECK THE CODES

There is billing code (HCPS/CPT) for every medical procedure that is performed by the provider, as well as, diagnosis codes (ICD-10) for every medical condition. These codes are used nationwide in order to inform the insurers directly of what was done and how much it cost. They may appear on your invoice or EOB. There are some instances where coverage may be denied based upon the codes submitted. At times, the insurer may deem the procedure unjustified based on the diagnosis code submitted. Other times, the provider may have submitted the wrong code. Sometimes it is a combination of both. In all cases it is important for you to research the code(s) independently. If it is an issue with insurance coverage, you can request a reconsideration or file an appeal. If it is a provider error, contact them immediately and ask that they review, recode, and resubmit the claim to your health insurer.

Reviewing the codes on your medical bills from practitioners, hospitals, testing centers, laboratories, and other providers is a great way to be sure that your insurance company (and you via co-pays, deductibles, and coinsurance) is only paying for services you received. If you receive statements from either your provider or health insurance without the HCPS/CPT codes, contact them and request an itemized statement with codes.

  1. NEGOTIATE A REDUCTION

Once you have determined that there are no errors in the invoice and that your insurance company has paid its proper share, you might still have a bill that is larger than you can afford to pay at once (and, in many cases, that is just too large PERIOD)! You might try to negotiate a reduction in your medical debt or payment terms that are workable for you.  You can find resources on the internet (Health Care Blue Book, State websites, etc.) that will help assign a value to the services provided that is most common—and thus determine if you were overcharged. This information can be a valuable tool when negotiating with medical providers. Make your financial constraints known to them and ask for a discount. (Typically, paying a lump-sum is more likely to result in an adjustment to the bill. Generally, discounts are not given on accounts with a payment plan).

TIP- Many hospitals and some other providers offer a “Prompt Pay Discount,” if you pay at the time of discharge from the hospital.  They also have financial aid personnel to analyze whether you might be entitled to a discount based upon your income. However, even without a discount, a payment plan can be very helpful— allowing you to spread the payments out over a longer period that is more budget-friendly. If you are negotiating a payment plan remember to ask for zero interest. Also, remember that a medical provider can still report you to any of the three Credit Bureaus (Equifax, Experian, and TransUnion) while you are making payments. This is a detestable practice and should be avoided by having the provider state in writing that it will not report provided you are current in your payments.

  1. TAKE ACTION QUICKLY

Regardless of the size of the bill, it is very important to take care of it as soon as possible. The longer it remains unpaid, the more likely it is to be sent to a collection agency. New laws require hospitals to wait until six months from the date of service before you can be reported to any Credit Bureau. However, if that does occur, it can remain on your credit report for years- likely increasing your costs of buying a home, car, or increase credit card interest rates (nearly anything on borrowed credit).

TIP- You are entitled to a free credit report from each of the Credit Bureaus each year. We recommend that you obtain a credit report every four months. It should be reviewed for erroneous items or incorrect information. If you notice any errors on your report, you can dispute them with the Credit Bureau to have to removed. Learn more here: https://www.consumer.ftc.gov/articles/0155-free-credit-reports

If you are having difficulty understanding your medical bills and/or health insurance Explanation of Benefits (EOB’s), contact one of our Board-Certified Patient Advocates at Human Health Advocates. We review medical bills and health insurance determinations. We negotiate reductions in medical debt from hospitals and other medical providers. We prepare insurance appeals for denied claims. If you have problems with your medical bills or health insurance, get in touch. WE CAN HELP!

Preparing for an emergency

Preparing for an emergency

Did you know that you can save yourself a lot of time, frustration, and MONEY by being an informed patient? You may be asking yourself “how?” The healthcare system, especially medical billing and health insurance is extremely complex and confusing. However, with a little advance planning, you can reduce or eliminate endless phone calls to medical billing or health insurance representatives that are unwilling or unable to help you resolve your problem. Advance planning is also very likely to help you save money on medical expenses, as well. In a series of blog posts, we will give you many of the tools necessary to help you make informed decisions that ultimately save you money.

Be prepared for an emergency. When you need medical attention quickly, you have to make several decisions at once. Knowing which in-network Hospitals and Urgent Care Centers are closest to your home, workplace, or places you visit most often can save you hundreds, even thousands of dollars.

EMERGENCY ROOM VS. URGENT CARE

If possible, start by assessing whether the situation could be handled effectively by an Urgent Care Center, or whether your condition is serious enough to warrant a trip to the emergency room.You could spend a few minutes researching this as part of the planning process. If you are unsure, try calling your primary care physician for help determining which facility you should go to. An Emergency Room visit can cost as much as 10 times that of an Urgent Care Center.

BE PREPARED – PLAN AHEAD

In order to protect yourself from unnecessarily high medical bills, you should know which hospitals and which urgent care centers are in-network with your health insurance plan.

 These simple steps can help you save thousands of dollars:

  1. Locate one or two in-network urgent care centers near your home. Be sure to note the address and hours of each. Remember, some Urgent Care Centers are staffed by MD’s—others not.

 

  1. Next, locate one or two in-network urgent care centers near your workplace;

 

  1. Locate one or two in-network hospitals closest to your home. Note the entrance to the Emergency Room.

 

  1. Finally, locate one or two in-network hospitals near your workplace.Note the entrance to the Emergency Room.

 

  1. Document the information in a way that you can access it at any time, especially in an emergency.

It’s not always possible to be fully prepared for an emergency. However, knowing which Hospitals and Urgent Care Centers are in-network with your health insurance plan literally can save you thousands of dollars.

 

Finally, there may be several invoices in connection with an Emergency Room or  Urgent Care Center. Don’t assume that your medical bills or health insurance explanation benefits are correct. Its estimated that 85% of medical bills have erroneous charges or health insurance processing mistakes. If you are having difficulty understanding your medical bills and/or health insurance Explanation of Benefits(“EOB’s”), contact one of our Board-Certified Patient Advocates at Human Health Advocates. We review medical bills and health insurance determinations. We negotiate reductions in medical debt from hospitals and other providers. Get in touch. We can help!

Navigating the Medical Billing Process

Navigating the Medical Billing Process

Kenneth Klein, manager of Human Health Advocates, was recently the featured guest on WLRN Public Radio’s popular Topical Currents show. There was an excellent discussion of many aspects of patient advocacy as it relates to medical billing and health insurers. Give a listen.

(3-7-2017) It’s a common assumption that if one has health insurance; the company routinely covers the bulk of medical charges.

Correct? The answer is only a “maybe.”

Today’s Topical Currents looks at the confusing aspects of navigating the medical billing process, with patient advocate Kenneth Klein, Founder/Manager of Human Health Advocates, LLC, in Boca Raton. He provides assistance to patients with medical bill and health insurance related concerns.

Click here to listen to the full interview.

www.humanhealthadvocates.com

CBS12 Investigates: Cash vs Insurance

CBS12 Investigates: Cash vs Insurance

There are times when it is less expensive to pay cash for medical procedures than submit claims having your doctor/medical provider seek payment from your health insurer.

Health Insurance AdvocateWEST PALM BEACH, Fla. (CBS12) — When you go to the doctor, do you ever think about not using your health insurance?
Some patients are now negotiating the price and paying in cash. They say cutting out insurance is like cutting out the middle man.
As a consumer, when you think about negotiating costs, you probably think about buying a car or a home – not negotiating with your doctor.
But, as we found out, paying out of your pocket instead of going through insurance could save you money.

PAID THE CASH PRICE
When James Tow needed to pay for a tonsillectomy, he knew it would be expensive. Instead of just handing over his insurance card and trusting that would be the best price, James asked the doctor’s office if they had a cash price. “If I go through insurance, I’m going to have to pay the insurance price,” said Tow. “Whereas if I do the cash price, I pay less.”

That’s right. For example, if he went through his insurance, the anesthesiologist would have charged $656. James’ insurance would only pay $136, leaving him with an out-of-pocket bill for $520. While just paying cash, the anesthesiologist would only charge $464. So, by paying cash and not going through his insurance, James saved $56.

PATIENT ADVOCATE
So why would the doctor’s price vary depending on whether or not a patient has insurance?
We took our question to patient advocate Kenneth Klein. He said one reason doctors charge more for insurance is that it costs them money to file the paperwork, and that can run as much as 20% more. “If they are presented with a situation where they can get cash up front and not do anything else, file any papers, that is great,” added Klein. Klein said there’s nothing in state law that requires you have to use your insurance. “In many situations, it may be disadvantageous to submit this through your insurance,” Klein explained. Although, paying cash isn’t a guarantee that you will always save money.
You will have to decide on a case by case basis. It can vary based on your level of insurance coverage, whether the provider is in or out-of-network and your deductible.

Klein said it pays to treat going to the doctor like any other consumer transaction, and ask, “How much is this going to cost?’ “You are not locked in, and one can always try to negotiate. The worst thing that can happen is the person on the other side says, ‘No’. You are no worse off than you were. In many cases, you may be surprised,” said Klein.

WHEN TO CONSIDER CASH
According to Klein, the best places to ask for a cash price are hospitals, imaging centers, sole practitioners, eye doctors, surgical centers and pharmacies.
James said he’s learned from this experience to always ask the doctor for both the cash price and the insurance price and to not assume using insurance is the financially prudent way to go.

“Just paying cash, it seems to me it’s far better,” said Tow. If you decide to negotiate a cash price, get it in writing with the full agreed upon price.
Also, ask for an itemized bill for your records. Klein suggests submitting that bill to your insurance. Some companies may apply it towards your deductible at a reduced rate.