Blue Cross and Blue Shield of North Carolina invites you to learn how we’re fighting to rein in medical costs, and how you can too.
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Let's Talk Cost
from Let's Talk Cost 2011
April 26, 2011
How well do you understand the fees you pay for a doctor’s visit?
Heather L. commented on April 26, 2011
How can you know what your Doctor charges when they will not tell you. I recently asked the cost of a visit before making an appointment and not a single person could tell me. I spoke with four different people. Finally I just cancelled the appointment and said forget it. I wanted to have a physical. My husband went for a physical at the same practice that was supposed to be covered at 100%. It cost us $206.00. The office people just don't have a clue how much anything costs.
Hanna B. commented on April 26, 2011
That is because if you have private insurance the charges will be determined by the contracted allowed amount. This amount is negotiated with the provider and the private insurer.
Heather L. commented on April 29, 2011
How can people be "good healthcare consumers" when they do not know what things cost?
Contributor commented on December 31, 2012
Steve F. commented on April 26, 2011
All doctors and their staff should be aware of or have access to their standard charges for the most common services and procedures performed at that office location.
Here's is a perfect example of a facility that discloses their standard charges online (http://www.avancecare.com/uninsured.asp). These are also clearly posted at their office.
With insurance, each patient's liability might be reduced to a different extent, but at least everyone is aware of what they might have to pay in the worst case scenario that the claim is denied (like in Heather L.'s case).
Lew B. commented on April 26, 2011
The only time I have a vague sense of what a doc charges is an office visit--and through health reform, the patient will soon not incur charges to see a doc for a wellness/preventive visit.
However, that said, we recently had a serious family emergency requiring ER visit, hospitalization, follow up. None of this was spelled out at any time, in any way.
We need some kind of frank transparency so folks know what they are being charged or will be charged. And we need to recognize that our insurer stands behind us in these times of crisis.
Thanks to BCBSNC, our most serious concerns were taken care of. Health issues are often an unexpected roll of the dice. We should have a better sense of what the costs are--upfront, during and after. That would be a remarkable change.
Laura B. commented on April 26, 2011
Lew, I agree. There is no "menu" that shows us what each thing costs. For example, how many people would opt to bring their own tylenol to the hospital if they knew how much the hospital was charging for it?
Each medical procedure or item has a code that is used to bill insurance companies. I think we should be able to see that code and exactly what that code means (for example, what is the difference between a level 1 and level 3 visit and how do I know I'm being charged for the right one?) We should be allowed to view these charges before we have any procedures if at all possible (of course, there would have to be exceptions when someone comes to the ER and cannot physically commit the exercise of reviewing anything).
I know for sure that I would have spent $15 in Rite Aid for a cane vs. $150 for the same one in the hospital if I would have known upfront about the cost - even if my insurance had to pay for it.
L M. commented on April 26, 2011
I shop for the best price if I'm buying a television. I look for coupons to save if I go out for dinner. I get three estimates if I'm getting work done on my house. But it is very difficult to "shop" for healthcare. Luckily I'm healthy and generally just go in for physicals or routine care. And I always go to an in-network provider, knowing that BCBSNC has negotiated a rate that at least caps my costs.
Phyllis I. commented on May 13, 2011
This is a perfect example of pricing not being the only issue. Would you take the lowest estimate even if the workmanship was going to be poor. Money is not the only reason to select any professional service, and performance is the main reason I make such selections. It does not matter to me what the cost, if I am getting my money's worth.
The fact of the matter is, there are many poor doctors and many offices where the doctors are more "businessmen" than "practitioners" and I would pay more for better care as opposed to paying less because I could shop for a better price.
A big part of keeping costs under control for both patients and insurance companies is being an informed consumer and selecting the best care for yourself and not just doing as you are directed by the professionals. I have been so involved in my own care that I have left practices for reasons of poor care which lead to higher costs, and managed to work with better practitioners to resolve medical issues and save money in the long run.
As long as we only think about money, we are not focusing on the real issue of care. Good care is worth any amount of money, and bad care is not worth a red cent.
Kristen L. commented on June 28, 2011
L.M. There definitely IS a menu of prices. All you have to do is be informed and ask your doctor for them. Know your benefits and be aware of what you are agreeing too. All doctors have a fee schedule that they can provide you with that gives you a full price for any procedure. Just Ask!!
Also, it may appear that healthcare reform is going to make all preventiative care "free" this is actually not the case at all. Your insurance company will be taking the biggest hit, paying for your wellness visits at 100%. And don't expect to have more than one wellness visit in a year, because payment on that will be denied for sure!! And then it's your responsibility.
Eddie C. commented on April 26, 2011
Receptionists and billing clerks at a doctor's office are often hesitant to tell you what a visit will cost (or more accurately, what you will be "billed" for the visit). There's too many variables. How many questions are you going to ask the doctor? Are you going in with simple symptoms that turn out to be a more complicated problem than you anticipated?
For example, if you had a bad cold that turns into a nasal infection that won't go away, you might go in, explain what happened, be prescribed antibiotics, and it might be billed as a "limited" office visit. If while you're there you say, "By the way, the low-dose insomnia medication you prescribed has helped me sleep. I'm only using it about once a week, but on those sleepless nights I find it takes two pills to get to sleep. Is that okay?" Your yes/no question just took you from a "limited" office visit to a "moderate" office visit.
Thus, you often cannot get a direct answer when trying to ask about the cost. There are other times that you can get a list of fees ahead of time, but if you're using insurance, it doesn't matter because there is another huge transparency issue--negotiated rates.
For example, my primary care physician charges $210 for a comprehensive physical. The contracted amount with my insurance company is $110--discounted 48%. They "bill" $210 but they actually "cost" $110. My co-pay is $25 and insurance pays the remaining $85.
A recent visit to a specialist for a consultation about two separate issues resulted in a charge of $245. The contracted amount with my insurance company is $195--discounted only 20%. My co-pay is $50 and insurance pays the remaining $145.
Yet another specialist visit for a "new patient visit" and consultation about one issue resulted in a charge of $100. The contracted amount with my insurance company is $55--discounted 45%. My co-pay is $50 and insurance pays the remaining $5.
So, even if you know what a doctor or specialist will charge for a certain type of appointment, you have no idea how much they actually cost your insurance company. Each have their own negotiated rates, so you cannot simply go doctor shopping for the lowest billing price, because it doesn't reveal their negotiated rate with the insurance company. This type of transparency should be provided, so that we can opt for doctors that actually "cost" less, and maybe then we can collectively get insurance premiums to drop.
Unfortunately, as has been stated already, most people are blind beyond their co-pay, so they do not realize it costs more than $25 to visit their doctor monthly about the smallest of symptoms. The result is higher insurance premiums for everyone, simply because so many simply do not care to know how much appointments truly cost, beyond their co-pay.
Ultimately, every medical practice has a fee schedule, and some of them may even have it posted online. But knowing the contracted rate with our insurance company for each item on the fee schedule is what we truly need to become smart shoppers.
Laura B. commented on April 27, 2011
Eddie, I hear you about there being too many variables for a receptionist to tell us what our visits will cost. And, I agree. However, there should be a clear fee schedule REQUIRED for any medical visits, whether in a doc office or ER. The fee schedule should be clear enough so that anyone can understand that if they ask other questions, they will be charged a level 3 instead of level 1, and what that will cost them. I'd be willing to bet that people will begin to be more responsible about going to the doctors if they have that available. Especially in the hospital where the charges are outrageous for everything.
Let's Talk Cost commented on April 27, 2011
Eddie, thank you for your thoughts. Do you have any ideas for solutions to this problem?
E. W. commented on May 16, 2011
One solution would be a massive education campaign with a simple premise: costs beyond your co-pay do not simply disappear...they turn up in your premiums and your taxes in ways you'd never expect (or perhaps even believe!).
HSA is a great educational tool...prior to it, I was just as guilty of not particularly caring about the costs beyond what came out of my pocket. Faced with the first $3,000 coming out of my pocket before insurance pays one dime changed the nature of the game for me.
I now track every expense very diligently and question providers before I agree a service or to their billing. A lot of times, providers can be persuaded to waive the usual amount collected at time of service given the uncertainty of when one goes from paying deductible to paying co-insurance which gives you additional time to ensure the claim and the billing are correct before you pay any money (very nice when most provider reimbursement processes are hideously slow and inefficient at best...after all, what is *THEIR* incentive to return *YOUR* money that was over-collected?).
Steve F. commented on April 27, 2011
Ever since I switched to a high-deductible plan, I have been a lot more aware of the amount charged by doctors and amount discounted by my insurance as I directly see the impact on my medical bills.
Copay plans shield the consumer from true medical cost as it is very easy to pay the copay for each visit and forget about it, not realizing that the additional cost is built in to the premium.
I suggest that more people try high-deductible insurance plans, which in my case comes with the benefit of lower premiums.
Agreed 100%. I also have a HDHP, and that makes me much more aware of every medical cost. However, it would certainly be better if it was made clear what my bill is going to be before I incurred a cost. I'm sure it wouldn't be easy, because there are tons of medical procedures, but I think as people, we should be able to make decisions up front. Without a menu of costs, how can we? Yes, our insurance will cover some of it, but I believe we are responsible for finding out what that amount is. If the docs/ERs could tell us the base cost and let us figure the rest, I'd be more satisfied.
My son needs a renal bladder ultrasound. The town I live in only has two choices for this service. I called both places for pricing the first was over seven hundred and the secod was $369.00. For the same service. The real kicker is if I had no insurance and paid the day of my appointment it would only cost $276.75. So having an HSA that it all comes out of my pocket I am better off to not file with insurance. This does not seem right.
Laura B. commented on April 29, 2011
The benefit of the HSA is that it is tax-deductible, and once you meet your medical deductible, your co-insurance kicks in. It's interesting that there is such a cost difference for non-insurance, and that the cost for no insurance is less than the negotiated rate with the insurance company. I wonder if this is a rare case, or if the huge cost difference is the norm in the industry.
Steve F. commented on April 29, 2011
It does seem odd. However, even if you dont use your insurance at the time of the service, you should still be able to file the claim yourself. That way your expense of $276.75 will still be applied to your deductible.
Amy M. commented on May 6, 2011
Now that we have an HRA plan, our employees see what the actual cost is of the procedures / doctor's visits. What makes us all so upset is that doctors will charge patients for TWO office visits if a patient comes in for a physical and then asks any questions about their health. The physician says that the questions about their health take the patient out of the wellness visit and make the appointment a "sick" visit. So we can't ask questions about our health during a wellness exam???? That's just unreal!!
Laura B. commented on May 12, 2011
Amy, good points! This is why I think we should have the "menu" so we can understand all the potential costs before we incur them. We'd likely make different decisions at the doctors office (or about when we visit) if we knew what was going to come out of our pockets.
Aaron D. commented on May 12, 2011
Now that I have horrible insurance through my work, I am VERY well aware of what healthcare costs. My child's two year checkup cost me $130 recently. What makes me so very angry is that I can't pay in cash the same negotiated rate that the insurance company gets. They didn't pay a dime of my child's visit, yet, if I had gone in without insurance, I would have paid $245 cash! What I would like to see is the same discount for cash patients as for insurance companies. That way the office does not have to do the 'paperwork' (computer work) to bill insurance and it cuts everyone's cost down. Just like in every other business, cut out the middleman, and everyone benefits.
Another thing is that instead of paying high premiums for health care, insurance should just be for catastrophic problems. Everyday health care checkups should be taken care of out of pocket by everyone, at the same discounted rate that the insurance companies get.
Also, everything healthcare should be tax-deductible. It's not fair to me that my company doesn't offer a HSA or a FSA but yet the guy next door can take pre-tax money and pay the same bill that I'm paying after taxes. I have to wait until I have more than 7.5% of my adjusted gross income before seeing any tax breaks from healthcare. Another possibility is to offer EVERYONE FSA's instead of just limited people through their work.
Great ideas, Aaron!
If your employer offers a high-deductible health plan (HDHP) compatible with the IRS requirements for the HSA (for 2011, minimum deductible $1,200 indiv./$2,400 family, out-of-pocket max $5,950 indiv. /$11,900 family), then you might want to consider selecting that plan option and opening your own HSA through the HSA vendor of your choice using that plan as the qualified HDHP.
You wouldn't have the pre-tax deductions/employer reimbursements that an employer-offered HSA allows but if you're reasonably healthy or you have a family of frequent flyers, you might still end up paying far less in premiums/deductibles/co-insurance and tax (even after tax) than you would on your employer's PPO plan.
It might be worth your while to run the numbers both ways and see which way is best for your situation.
Another option would be showing HR the benefits to the employer to add a HDHP/HSA to their benefit offerings. They're typically much cheaper to the employer than traditional PPO for healthy employees and/or those who are frequent flyers.
Juan P. commented on May 17, 2011
I have an idea of what the doctor charges, but can yo please share with us how certain items have increased over the past 10 years? And how premiums have increased over the past 10 years?
Amy D. commented on May 22, 2011
I was a health care consultant, so I do understand how negotiated fees work. I am absolutely amazed since my husband went on Medicare, how many of the physicians and other providers balance bill us. It is not huge amounts, but how many people to end up paying the $20, or $40 dollar "balance due" because they do not understand that the providers cannot balance bill the patient? I send the provider a copy of the EOB and advise them that they were paid the contracted amount and CAN NOT balance bill us. I never hear from them again. I think it would be a great service if BCBS would make the EOBs more easily understood, and perhaps even had some seminars around the region.
Let's Talk Cost commented on June 8, 2011
Amy – Thank you for sharing your idea. We’re working to make our EOB’s more understandable for our members. What other ideas do you have that can help lower costs?
Rita W. commented on May 30, 2011
my doc charge $120 Only check my blood pressure.
Amazing , money printing machine
Laura F. commented on June 1, 2011
Rita - you made me think of something - an idea to share. There are really good blood pressure machines that are small, portable, and relatively in-expensive (my husband got his on sale for $40). They even have ones that talk to you! These are available at most drug stores like Kerr Drug, CVS, Rite-Aid, and Walgreens. A pharmacist can recommend a good brand, and there is lots of research online (and also coupons!) $40 at one time is much less than $120 at each visit! Of course you should make sure your doc is OK with this...disclaimer!
Let's all share ideas and suggestions because if we lower the need to spend so much at each doctor visit, we ultimately can contribute to lower medical costs for us all :-)
Let's Talk Cost commented on June 2, 2011
Laura, thank you for the great idea. If you have any other ideas to share, we would love to hear them.
Kathie S. commented on June 10, 2011
I have no health insurance. I pay for everything out of pocket. I recently went to my Dr's office. When I asked how much the cost would be for the visit. I was told $244.00 and up. The reason you ask??? Because I haven't been to the Dr. in a year. Really???? I have to be penalized for NOT going to the Dr's enough?
(ranting tirade coming! )
After sitting in the waiting room for an hour and a half, then repeating for the 3rd time why I was there in the first place. I was taken to the exam room, only to wait another hour. When the Dr did grace me with his presence,I had to repeat for a 4th time why I was there. He listens to my lungs, my heart rate, takes my blood pressure again... then asks me again, why I was there. Finally, he prescribes 4 medications, then sends me off for blood work. My total time with the Dr. was a whole whooping 15mins.
My bill was $244.00 for the office visit, plus they charged me $7.00 to check my pulse ox. $156.00 for my blood work. The cost of my follow up visit was $130.00 for one hour of waiting to see the Dr. and $156.00 for blood work again. I am frustrated by this.
It would seem to me that if a person is paying privately out of pocket, there would be more discount, and incentive to come back. And how do you figure charging $7.00 for a piece of machine to be on your finger for less than 30 seconds is a good price?
Laura F. commented on June 10, 2011
You may want to shop around for a new doctor... There are lots of doctors out there that will give you much more of a discount for being without insurance. It also doesn't seem that your doctor is giving you the right attention for the price. Remember, regardless, we are the consumer and we have choices on where we go and how much we'll pay.
Also, I would look at the codes circled on your chart (you get a copy when you check out) and ask specifically what those codes mean. You can even ask your doctor what codes they are circling during your visit, ask they why, and get information real-time. The more knowledge you have, the more power you have to make decisions on your care.
I think it's important that we begin asking more questions and holding our doctors accountable for what we are charged. Going to the doctors should be no different than purchasing a shirt. You should know what you are getting, for what price, and be able to walk away if you don't agree before-hand. But it's up to us to demand information before our care and accept nothing less than full disclosure.
The power is in your hands!
Michelle L. commented on August 30, 2011
I guess that I'm fortunate. I go to a therapeutic practice. The encounter form lists all of the types of visits (medication management, therapy for 50m minutes, extended telephone calls, providing testimony or medical opinions -- among others) and their fees. At my primary care physician's office as well, when I check out, the staff member writes down the cost of the visit, as well as the costs of any labs or procedures. I have Medicare with a BCBSNC supplement. These two practices give me my copy of the forms so that I know what my insurance providers will be billed. The interesting thing, though, is that I also read my EOBs, and so I know what my doctors are actually being paid for their services. My doctors participate in the Medicare-provider network, which means that they must accept the Medicare allowable rate for the services they provide. The BCBSNC supplement must pay their percentage portion for anything that Medicare pays, and BCBSNC is not obligated to pay for any service which Medicare does not cover. My doctors aren't paid by Medicare for the full fees that they charge. I think that doctors also have agreements with other insurers, in terms of accepting certain fees for in-network patients. I am grateful that my doctor's accept the Medicare rates; otherwise I might not receive the quality of care that I do. There are increasing issues related to rising co-pays, though most patients with insurance do have access to information regarding their co-payments. The patients most at risk are those who are uninsured. There may be larger issues at work here, though. When I was working at a small medical center in New York State in the mid-1990s, a law was passed that prohibited medical providers from charging self-pay patients less than they charged insurance companies for the same procedures or visits. (Question to BCBSNC: Is this true? Is it, or was it, ever true in NC? If so, how did these sorts of legal policies come about? To what extent is the insurance industry responsible for the elimination of sliding scale fees and self-pay rates?) This generated some bad situations. Since our ER was also legally obligated to provide care to anyone, regardless of insurance status, many people were seen, charged the same amount as if they had insurance, put on payment plans, and then defaulted, as the cost was so high. The defaults cost the hospital more than charging a self-pay rate below that of the insurance rate would have cost. The laws that were passed regarding charges to self-pay patients were not initiated by hospitals or other providers. I believe that they came from pressure from insurance companies and other large corporate interests. On the one hand, if 'fair' means 'exactly the same,' then I guess it's not 'fair' to charge insurance companies more for the same service provided to one of their beneficiaries than is charged to a non-insured person. However, given that insurers don't even pay the stated rates and have agreements with providers and hospitals, then there is an unevenness all around, and 'fair' payment should be proportional -- as it is, a self-pay patient could end up paying more for an office visit than Medicare itself pays the provider or than BCBSNC pays the provider, as the medical practice has no agreement with individual self-pay patients. They can charge full fees and, as when I worked in New York State, sometimes must legally charge the officially stated fee. Perhaps an organization could be formed that negotiated an in-network fee for self-pay patients, just as Medicare and the insurance companies do, so that self-pay patients are not at a disadvantage -- at least until we can find a way to get things under better control for access to affordable health care all the way around. Things are not going to change soon, and those of us with insurance are paying higher and higher premiums and co-pays. The best short-term solution to create a temporary equality between the insured and uninsured, it seems, is to find an organized way to help uninsured patients receive care at reasonable fees.
Amanda F. commented on January 18, 2012
I'm sure the reason that no one was able to tell you how much a Dr.'s visit was going to cost was because there a few different factors to take into effect when trying to figure it out.
1) do you have a deductible on your insurance? If you have a $1,000 deductible, that's the same as if you didn't have insurance at all. You'd have to meet your deductible before your insurance stepped in and covered the visit at 100%. So pretty much, you'd have to have enough Dr.'s visits to total up to the $1,000 deductible and once that was met, you'd either pay your co-pay, which may be $0 or upwards of $50 per visit. Or you'd have to pay your co-insurance, which is usually something like the insurance company would cover 80% of Dr visit and you'd be responsible for 20% of the Dr. visit.
2) Depending on what insurance you have also would indicate what you're covered at. Some insurance companies cover a physical at 100%, while others may pay a portion of that. And if you are to see a specialist, that would be a different price. For example, to see your Primary, it may cost you a $15 co-pay but if you were to go to an orthopedic surgeon, it would cost you a $35 co-pay instead. And also, a physical and say a woman's wellness exam MAY be covered at 100% but again, it is all dependent of what insurance you have.
3) The Dr.'s office may have told you that they didn't know because they were going to bill the insurance company first to see what they would cover, then they would write off a portion of what wasn't covered and then have you be responsible for the remainder of the bill.
Ex: You had an extended office visit and the cost of that was $95
you also had an xray done for $15 and you had a splint put onto your wrist at $35.
Insurance would come in and pay $50 towards the office visit. The Dr.s office would then write off $30 towards the visit and the remaining $15 of the visit would be your responsibility. And the same goes for the rest of the charges.
Before getting upset at the Dr.'s office, call your insurance company and see what your deductible is (if you have one), if you've met it, what it would cost to have the exam done, etc. Then you are informed and don't have to rely solely on the people in the office.
Let's Talk Cost commented on January 20, 2012
Thank you for sharing your insight and examples, Amanda. What resources have helped you be better informed about your health care costs before going to the doctor’s office?
Don R. commented on May 15, 2012
I can't believe Doctors can charge you without stating the cost. For example I recently seen a back specialist for about a half hour and received a bill for $360.00. I was not impressed with his service and did not physically benefit from his consultation. It really seems like an expensive roll of the dice to see a doctor. I also checked with the doctors office and my insurance company before to get a cost. Neither was able to give me a firm answer. It just seems wrong, I would never be able to provide a service at my business and then bill later for services that where never discussed. People would become upset and I would lose future business. Our healthcare system is a cash cow and a joke on the American people. We may have good doctors, but the cost of seeing one could bankrupt you. It is unfortunate .
Janice F. commented on October 20, 2012
I go to a "low cost " healthcare clinic as I do not have health insurance. Through the HIll Burton Act. I qualified for Copa Care3. Through this I pay $ 50 copay for a doctor visit and any balanced billed at Medicare rates.
After receiving a itemized statement for my visits I found out that this "low cost " clinic is charging me $236.00 for level 2 and $ 278.00 for level 3 visits. Some visits I get charge twice as they apply both a level 2 and level 3 charges for the one visit.
This seems very out rages and unethical to me.
Can anyone tell me who to contact about this?
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