Thursday, July 20, 2006

THE MEDICAL/INSURANCE COMPLEX(ITY)

I read with interest in the Portland, Oregon newspaper this morning that Legacy Hospitals has agreed to settle a class action suit concerning the higher prices paid for services by the uninsured. As a recent surgery patient, I am witnessing first-hand the intricacies and complexities of the Medical-Insurance Complex.

As a consumer of medical services, I have several problem with the billing procedures of the medical providers and the insurance companies. My three main concerns are the following:

1. Consumers should know the cost of the services they are buying prior to purchase. I have made a point of asking what the cost of a medical procedure or service will be when I check in at the reception desk. I have never gotten an answer, except a couple of times when the receptionist did me a favor and called someone to ask. Medical services might be the only commercial enterprise for which consumers agree to a purchase without knowing the price they will be paying.

2. I won't pay for something without first seeing an itemized bill. The typical process for the expenses related to my surgery has been that I never get a bill from the medical service provider (there have been 1 or 2 exceptions). Instead, I get an Explanation of Benefits from the insurance company showing how much was charged, how much the insurer will accept as a charge for the service (see number 3, below), how much the insurer will pay, and the balance left for me to pay. Then I get a statement from the medical provider for the amount the insurance company didn't pay. In many cases, I have received statements from medical companies (doctor groups or laboratories) that I have never heard of, and I have no idea what they did to or for me. After some investigation, I find that doctor so-and-so read an MRI, doctor such-and-such looked at my freshly removed tumor, and company xyz ran the CT scan. My message to these folks: "Send me an itemized bill so I know what you did and I'll think about paying you."

3. The pricing agreements of the Medical-Insurance Complex are amazing! My understanding is that every insurance company negotiates a price list with the providers on their list. This is truly amazing stuff. Here are some examples gleaned from the Explanation of Benefits documents I have received:
- Legacy Emanuel Hospital semi-private room (2 days, 1 night): $1,171; Great West Insurance "covered expense" (the amount they have negotiated): $175.
- Legacy Emanuel Hospital "hospital extras": $12,872; Great West Insurance covered expense: $1,225.68.
- Oregon Anesthesiology Group "anesth inpatient": $780; Great West Insurance "covered expenses" $572.
- medical supplies and equipment: $156; "covered expense" $69.11

The medical providers list the reduction in price on their bill (if you get one) as a discount or insurance allowance. I assume that patients without insurance pay the full meal deal, hence the class-action lawsuit.

Here is what I would like:
1. When I go for a medical service, I am told prior to receiving the service a) the cost to me of the service, and, b) the names of all providers who will be providing service and then billing me. The cost I want to see is the amount negotiated with my insurance company; this information is certainly in the medical providers computer databases.
2. An itemized bill from every medical service provider who provides services to me, not just a statement of the balance after insurance payments.

These are simple and reasonable requests for a consumer to make, and it would help get the Medical-Insurance Complex into line.

1 comment:

Guillermo said...

Today it was announced that the nations largest hospital chain will be acquired by a group of "leveraged buyout firms." It is curious that these firms are not monitored by the SEC when their primary source of revenue in this case will be government payments for various health programs. More disclosure is needed all around.

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