patrick.net

Well everything is negotiable. Try treating them like construction people: get 3 bids and then play the bids off each other "Dr. A will do this for $40 can you beat THAT?".

It seems like a 'cash up front' doctor who published reasonable rates online might get a lot of business?

Instead of going there, I tried calling Palo Alto Medical Foundation billing at 877-252-1777. Took a couple of minutes again to get a person, but again it was a pleasant and reasonable person.

Unfortunately, she said she could not begin to give me an estimate until I gave her a "procedure code". I assume that's the same as the billing code I just asked for when I made the appointment. So now I have to call back to the dermatology department and tell them yes, they can and need to give me a billing code.

I asked why even having the procedure code would just get me an estimate and not an exact cost. She said that there could be "modifiers" to the procedure code that would change the amount.

I asked whether I would get a discount for paying on the spot. She said that's up to the doctor, but even though my deductible is $8,000, I might benefit from filing with the insurance because their contracted rate is almost certainly lower than the rate I'd get without insurance.

PockyClipsNow says

It seems like a 'cash up front' doctor who published reasonable rates online might get a lot of business?

Yes, I would think so, but they probably don't want to compete with each other that way and drive down rates for every doctor.

Also, I can see that the low-cost doctor might think he'd be seen as inferior.

I was just talking about this with a friend of mine who is an NP (nurse practitioner) at a derm office. She said that it's hard to guess the cost until you see the mole, but for people with a deductible plan a biopsy can cost $500 (because it includes cost of pathology reading) so it's sometimes worthwhile doing an excision on something suspicious for cancer and having the path done on that rather than having biopsy then excision.

Sometimes the derm doc can look at something and say 'hey, that's not something I need to biopsy/excise' in which case there's a diagnosis code, not a procedure code.

Just fyi, my friend says people ask her this all the time, and it always takes her a while to figure out how much it will cost because insurers make it hard even for the doc/np to figure it out and deductible plans are the hardest.

Also, because potential cancer requires pathology eval and report, the charge will also involve payment to whichever pathology lab it gets sent to etc etc.

And she's right, the insurance contracted rate for each procedure code will be cheaper than the noninsurance rate.

So I call back to dermatology saying that the billing department needs a procedure code before they can tell me what it will cost.

They said sorry, they refuse to give me a procedure code because the doctor might do something else.

I said "OK, let's say I just get a mole checked. What's the procedure code for that?"

This is apparently very unconventional behavior, because I was transferred to her supervisor, who once again asked for my name and date of birth, and put me on hold, where I have been for a few minutes...

OK, the supervisor finally got back to me and said they best he could find was a diagnosis code from 2010 for a simple mole check, and that would cost $180 in 2010 before insurance, probably less with insurance.

He still didn't want to give me the diagnosis code though, saying it might have changed since 2010. I agreed and persisted and he finally said a simple mole check code in 2010 was 99201.

denyse says

I was just talking about this with a friend of mine who is an NP (nurse practitioner) at a derm office. She said that it's hard to guess the cost until you see the mole

Sure, I understand that the doctor might choose to do something more, but you'd think they could say up front what the simple exam would cost with nothing else.

So it's back to billing that I call now, hoping my diagnosis code (not a procedure code I assume) will enable them to tell me the current price.

OK, billing had to put me on hold a couple of minutes too, but said that 99201 is just "office visit" and that should cost $134, and that my insurer probably has a lower negotiated rate.

So I guess I answered the first question, assuming they actually do bill me that.

I'll try Blue Shield and see if they cover any of it, but I doubt it.

Patrick, I've had a few similar issues in the past:

Had a cardiologist who wanted to run a stress test - even though I was told from him that everything was great: EKG, low blood pressure, cholesterol, etc... In other words, they were padding the bill (I'm only 29 and workout routinely). So I asked them the cost of it with insurance and they said my COPAY would range anywhere between $200-1000. Meanwhile, I have really good insurance through my company, and thought that was insane.

After pressing the doc and office staff, they still couldn't give me an answer as to what my copay would be, or which specific stress test they were going to run. With all the run around I decided to ditch the test and spend a $25 copay with my regular physician who said there was nothing to be concerned about, and that a stress test was not needed.

I also went to a sports doc orthopedic guy for my knee. Copay was $30 - the bill in the mail said he billed insurance $325. I know insurance doesn't actually pay that amount - but it annoys the crap out of me that they list prices like that.. It's like buying a car MSRP, Invoice, and what the average person pays.

Lastly, my right eye was really inflamed one day, and I went to my eye doc. A five minute office visit and I was referred to an eye surgeon.... Later got a bill in the mail from my eye doc for $175 (for the 5 minute visit which he referred me). I went back, and asked him if his time was actually worth $2100/hr... especially for just a referral. He conceded and dropped the bill to $75.

Some of these crackshots are like car salesmen - and you just have to be upfront and unwilling to pay ridiculous prices for simple procedures.

I know of a great dentist in Capitola that gives nice discounts for cash patients - they are pretty upfront about pricing as well. He does good work and I'd recommend him and his staff any day. Let me know if you want a name.

OK, after the usual rigamarole, I got a Blue Shield rep. Very nice person again, though with some foreign accent.

She didn't tell me the contracted rate, but did tell me that my portion for a 99201 code would be $50.39. Better than I expected actually. I expected to have to pay 100%

So it looks like I answered the second question too. All in under 2 hours.

joshuatrio says

the bill in the mail said he billed insurance $325. I know insurance doesn't actually pay that amount - but it annoys the crap out of me that they list prices like that.. It's like buying a car MSRP, Invoice, and what the average person pays.

Yes, it seems to be exactly like that. Not at all unfront and clear.

I think the real health care reform we need is immediacy, clarity, and consistency in billing.

joshuatrio says

I know of a great dentist in Capitola that gives nice discounts for cash patients - they are pretty upfront about pricing as well. He does good work and I'd recommend him and his staff any day. Let me know if you want a name.

Thanks for the offer, but I finally found another dentist I really like. Very straightforward about billing, said I didn't need all the random crazy stuff other dentists were recommending (like replacing all fillings, 3 crowns, etc) and seems quite competent: Dr. Tseng in Palo Alto.

My old dentist was great like that too, but he retired.

You guys and gals think we docs want this billing system? It is a nightmare. I have 4 full time employees just trying to work this crazy billing system established by insurance companies and government-- that is I spend about 200k a year to get paid by health insurance companies. When the exception comes along and wants to pay cash it does not work with the system established by the healthcare bureaucrats. Since you are the vast minority of patients the system does not accomodate you. I am glad you are starting to understand our pain-- 5 min with patient and 50 min with the paperwork.
I am losing the battle on my front and cant see myself here next year. Congrats BCBS, you win, I quit.

Yes, I know the insurance companies are hard to work with, but couldn't you, as a doctor, just set up an "express lane" in your office for people who choose to pay cash on the spot? Those people could then deal with their own insurance company if they want to try to get reimbursement.

I guess the insurance company would still contact you to confirm what you did, but at least then you'd have your payment up front.

Why not just go see your primary care doctor? That's part of the problem in America, especially those who are educated. The patient has a problem, and immediately they feel like they need to see the specialist.

As an FP in our office, we'll do a punch biopsy for cash $140-150. Pathology reading is about $50 if you pay cash. If it turns out to be cancer, then you get referred to a derm. If you go insurance, then we'll bill the procedure code which will be $200 plus. My guess for a lab through insurance will probably be at least twice the cash price. Note, not all doctors offices will accommodate cash pricing for patients nor will they necessarily have a cash arrangement with the lab they're dealing with. We feel that our pricing for cash patients are reasonable, so we never negotiate with patients for cash. They don't want to pay that price, they are more than welcome to seek care elsewhere.

[...]

curious2 says

Also, if you visit Mexico from time to time, medical services are 80% cheaper there, and all cash.

That and parts of Costa Rica are supposed to have really good medical care as well.

As an experiment one day, I priced out dental work (fillings, crowns, teeth implants) in Costa Rica at the "best" clinics, vs. what my copay is with my insurance company here in the states.

Turns out, my COPAY was about the same price as the regular price in CR - across the board for ALL procedures.

So my take? Cut out the middleman - the insurance companies. They are the ones raping the system, cutting a chunk out of your paycheck, and turning this entire thing upside down.

Hi Patrick,

The billing code depends on the location and size of the mole. Just the removal is a code from 11400-11406. There would be another code for the pathology report.

And the 99201 is the code for an initial consultation. 99211 would be the code if you've seen that Dr. before and are an established patient.

So the question is whether it is even possible in America to know in advance what a visit will really cost the patient.

Yes, you can... just call the front office for a quote.
Usually they go for $50-75.

This is exactly why we need single payer. Same price for everybody. No gaming the system.

You know Patrick, you've said you don't like Kaiser Permanente in the past but one of the big advantages is that its a single organization. Meaning there's no back-and-forth between the doctor, the hospital/clinic and the insurance co.

bdrasin says

You know Patrick, you've said you don't like Kaiser Permanente in the past but one of the big advantages is that its a single organization. Meaning there's no back-and-forth between the doctor, the hospital/clinic and the insurance co.

It also means that if you have an emergency out of network you are uninsured, also the rates they charge to the uninsured with the misfortune to need treatment in one of their centers is as bad as anyone else. That Kaiser may look from certain angles 'better' is a sad reflection of our sick profiteer based healthcare. They are not the answer, rather they are one of the originators of our twisted system.

Zlxr says

I would rather go back to the idea of paying them for their time.

Good idea, time and materials seems like a decent way to go. However, any system can be rigged and abused.

drxrayman says

You guys and gals think we docs want this billing system?

Xray, would you be happy with time and materials?

I realize such a system is not a simple as it sounds, because there is nurse time, doctor time, etc that have to be timed carefully, and one cannot have a simple and regular N*15min (N=1,2,3,....) patient schedule if everything is timed in detail.

Then there is operating room rent, hired OR nurses, whether materials can be marked up, whether you are actually buying materials at a good price, etc etc etc.

Could also be somewhat complicated but worth a try.

burritos says

As an FP in our office, we'll do a punch biopsy for cash $140-150. Pathology reading is about $50 if you pay cash.

I remember once I had some moles removed/biopsied, and my primary doctor did give me the option that he would do them rather than send me to the dermatology department. Because I had some other questions for dermatology I chose going there, but I think right now I'd just let the primary do it, because I have a high deductible.

General comment: I think PPO plans (not HMO) with a high deductible is a minefield because they give direct access to specialists, but on the other hand you may end up going to expensive specialists for stuff you do not need and/or the primary could take care of, and end up paying a lot of it out of pocket.

I think billing codes exist for two primary reasons:

1. A billing code represents a bundle of time, skill level and materials/costs, and hence is relatively simple accounting tool.

2. The code also gives the insurance company a simple way of determining whether a procedure (there is that word again) is covered or not.

Of course, the consumer does not get access to the system of billing codes, which is a big problem.

bdrasin says

You know Patrick, you've said you don't like Kaiser Permanente in the past but one of the big advantages is that its a single organization. Meaning there's no back-and-forth between the doctor, the hospital/clinic and the insurance co.

Can they tell you costs in advance?

justme says

Of course, the consumer does not get access to the system of billing codes, which is a big problem.

Perhaps an opportunity for Patrick.net! Are the billing codes on your bills? Yes, looking through old bills, it seems they are.

So maybe if everyone entered their billing codes, description, the provider, insurance, and what it cost and what was covered, then we would all finally have the info we need to fight back.

Kind of like gasbuddy.com tracks local gas prices. Doesn't change the fundamentals, but at least tells you which of your bad options would be the least bad.

If people enter the data anonymously, then privacy is protected too.

Huge pain to type all that in though. Too bad you can't get digital medical bills.

bdrasin says

You know Patrick, you've said you don't like Kaiser Permanente in the past but one of the big advantages is that its a single organization. Meaning there's no back-and-forth between the doctor, the hospital/clinic and the insurance co.

Kaiser is the original HMO. It is designed to deny benefits and limit treatment. Single payer system would be different, in that it would be designed to actually treat people and help them.

Zlxr says

You'd think that after Doctors spend all that time going to school learning how to treat us - that they would be able to come up with an easy way to bill.

People go to medical school because they want to be physicians. You're crazy if you think that they're focused on how to get paid while they're attending school. When they graduate and begin practicing, they learn the billing systems. Insurance companies created the system.

The billing systems, coding and such, are crazy as evidenced by Patrick's odyssey getting a mole check. It should be simple - but it's not. New patients are billed at different amounts, and everything requires a code. Insurance pays according to the code, procedures & surgeries depend upon the codes that have already been submitted. For example, cardiac surgery won't be approved until the stress tests are all completed.

Sure, some tests seem redundant or unnecessary - but sometimes they're the only way a health condition can be detected. They can run tests for a couple of days straight and find nothing until the very last results come in... it's not just liability that they're worried about when they run these tests - they're actually trying to diagnose someone.

curious2 says

Why not just take a photo with a ruler next to it and check it again in a few weeks to see if it's changed? Also, if you visit Mexico from time to time, medical services are 80% cheaper there, and all cash.

I work with many people who have self-diagnosed and, as a practitioner of end-of-life care I'd like to thank you in advance for this advice. I'll be working with the people who take this delightful medical advice over the interwebs. However, please remember that being treated out of the country can kill you and shipping your body back is expensive. Followup treatment is also expensive, due to the need for fixing the shit that non-trained physicians can do to you. But I don't mean to discourage my future patients - mama needs a new pair of tenny-runners (shoes).

justme says

General comment: I think PPO plans (not HMO) with a high deductible is a minefield because they give direct access to specialists, but on the other hand you may end up going to expensive specialists for stuff you do not need and/or the primary could take care of, and end up paying a lot of it out of pocket.

PPO's give you the freedom of choice and the opportunity to see a specialist - something not always offered with an HMO. You can't be treated out of town except in case of emergency - meaning going to City of Hope for cancer treatment isn't an option. Considering that they specialize in such treatments, do you really want your life decided by suits rather than lab coats?

Dermatologists leave smaller scars, if any. There's a reason this is a specialty.

elliemae says

Dermatologists leave smaller scars, if any. There's a reason this is a specialty.

Yes, now that you mention it, that was one of my concerns, too. I think the dermatologist did leave a visible scar, too, though. I think she used some sort of small triangular shaped loop knife, about 4-5mm at the base, to "deep shave" the mole off, for a lack of a better term.

Patrick.

when I designed http://www.treatmentreport.com I originally wanted to include price information for "treatments" and procedures with codes. After doing a pilot with price information, I realized that there were very few people in the same situation as I am (high deductible HSA PPO). It was difficult to collect price information because most people still don't care. Anthem has all of their negotiated rates in the database. It would not take much for them to make that info public, but they don't. Maybe when more and more people are forced onto high deductible plans, they will demand more pricing info.

treatmentreport says

when I designed http://www.treatmentreport.com

Good idea, I will definitely take a look at that one.

We used to have the price information as a field but since so few people entered it, now it's just in with the treatment description Here is an example: http://www.treatmentreport.com/cases/everything-you-need-to-know-about-knee-arthroscopy/1352/

treatmentreport says

Patrick.

when I designed http://www.treatmentreport.com I originally wanted to include price information for "treatments" and procedures with codes. After doing a pilot with price information, I realized that there were very few people in the same situation as I am (high deductible HSA PPO). It was difficult to collect price information because most people still don't care. Anthem has all of their negotiated rates in the database. It would not take much for them to make that info public, but they don't. Maybe when more and more people are forced onto high deductible plans, they will demand more pricing info.

I like treatmentreport.com. So it tells people how the various treatments panned out?

I hope you'll put that price field back in. I certainly care about price, but then I'm one of those self-employed people with a high-deductible HSA PPO.

elliemae says

Kaiser is the original HMO. It is designed to deny benefits and limit treatment. Single payer system would be different, in that it would be designed to actually treat people and help them.

Not designed to deny benefits, but yes to reasonably limit unnecessary procedures and evaluations within standards of medical care. Do you believe that any patient for any reason is entitled to see whatever physician and get whatever test they want at any time? Most patients do, but this way of medicine is sustainable. Do you know how many how many 20 year old's I see every week who come in with chest pain and shortness of breath because of anxiety and stress?. Of course these patients google their ailments and think they need chest xrays, stress tests, echo cardiograms, and chest CT scans to make sure they don't have heart attacks, pulmonary embolus's, cancer etc... Do you think I'm limiting their care if I don't do these tests that the internet told these patients to get or not sending them to the specialist ASAP?

burritos says

Kaiser is the original HMO. It is designed to deny benefits and limit treatment. Single payer system would be different, in that it would be designed to actually treat people and help them.

Not designed to deny benefits, but yes to reasonably limit unnecessary procedures and evaluations within standards of medical care.

Yes. And of course also countries with single payer systems have to put in these kinds of limits. Do you really think that in Canada, Sweden or Cuba people get any kind of procedure or test they can imagine? No, doctors follow standards set by administrators that consider both costs and benefits.

In general I would say US health care is so expensive for two major (and many minor) reasons. The two major reasons are

1) The administrative nightmare of government - individuals - hospitals - insurers

2) The use of any number of high cost, small (but not zero) benefit tests and procedures that are not used in other developed countries.

I don't see much hope of reform because very few are willing to challenge 1) and nobody is willing to challenge 2).

[...]

curious2 says

elliemae gets those who are unlucky enough to be dying slowly

No, not all of them.

I have no problem with people monitoring their healthcare condition - if a mole isn't itching, not growing and not disclored, probably not necessary to have it seen right away. Maybe never, everyone has moles.

I agree that the plural of anecdote is not data. But I also don't deal with data. I deal with people who are dying. My client population has a prognosis of six months or less if their disease runs its normal, natural course. I don't see healthy people, other than the family members or caregivers. Sure, my view is skewed.

However, many of the cancer patients I see either chose to ignore the symptoms when they first presented themselves or chose to treat them holistically. IMHO, that simply doesn't work.

Like the guy (?) who said he's healthy and doesn't need insurance, people need to treat their bodies better all the time. Limit the crap they eat, load up on fresh foods and veggies, drink water and exercise. That's one of the secrets to a better life as you age - but it doesn't guarantee that you'll live longer or without the need for doctors. I'm always impressed when someone who has a cold takes vitamin C, believing that it will cure them. The time to take vitamins would be all along, not when you're symptomatic.

burritos - HMO's work, in theory. No, people don't need every test under the sun that the interwebs introduces to us. It's good for patients to be educated but not to believe that they're experts. It's a positive thing for them to document their symptoms and how they're treating them (ice, hot baths, yoga, etc) in addition to the treatment prescribed by the MD. It's important that patients follow the treatment plan set by their doc to see what works.

However, HMO's limit patient choice. For example, if a patient requires rehabilitation, the HMO might contract with 2 facilities even though there are 20 in the area. This means longer drives for family members at the very least. Since HMO's contract rate is often substantially less than the Medicare rate. Using Las Vegas for example, some of the nursing homes (aka skilled nursing facilities) that contract with HMOs are the crappiest ones with histories of below average care.

Specialists out of town are out. Receiving care from the expert in the field is out. For people who are "snowbirds," that live in the North in the summer and the South in the winter, they aren't able to see a doctor unless there's an emergency. I've witnessed procedures that were denied more often than approved - even tho the primary physician believes it to be necessary.

Medications are limited according to the formulary the insurance company has chosen - doesn't matter what the MD prescribes.

Medicine should be left to the practitioners, not to the pencil pushers. It shouldn't be for-profit. I don't mean that practitioners shouldn't be paid - they should. However, insurance companies and more specifically HMO's make their huge fucking profits by denying benefits, limiting benefits, and treating patients like numbers who don't matter.

Gonna hop off my soapbox now.

Dr. Kirk A. Churukian (http://www.drchurukian.com)
one mole removal goes for $250

elliemae says

However, HMO's limit patient choice. For example, if a patient requires rehabilitation, the HMO might contract with 2 facilities even though there are 20 in the area. This means longer drives for family members at the very least. Since HMO's contract rate is often substantially less than the Medicare rate. Using Las Vegas for example, some of the nursing homes (aka skilled nursing facilities) that contract with HMOs are the crappiest ones with histories of below average care.

HMO's do limit choice. The limiting step is the amount of money available. There just isn't an infinite amount of resources to supply all the care that all patients want. I don't work for Kaiser, but have many friends and family who are physicians who do. These physicians are getting killed. And I take umbrage of the characterization that they are there to deny care. The are a non profit organization that works as hard as they can to follow evidence based medicine I know for a fact that Kaiser's CEO/chief is an MD, who make maybe 25-50% more than your fellow MD, but not like the Health Net and Aetna CEO's who make 10's of millions of dollars a year which are dollars that could go to patient care. British Medical Journal ranked them as delivering a higher quality care compared to Britain's NHS. If people want "PPO" care they should just pay for it. I take care of "PPO" patients. If they want disjointed care where the specialists only want to take care of them solely based on the fact that they have "PPO" insurance, then have at it, but believing that it's superior care without limits is a fallacy.

curious2 says

burritos are working with unrepresentative samples of the population.

Yes, but unrepresentative experiences can and do skew the way medicine is conducted. I have a colleague who once encountered a 20 year old college student who had flu like symptoms. She had fever, chills, bodyache, and some cold like symptoms. She treated her with anti virals. That patient came back the next day and say me. She looked a lot more ill and I sent to the ER. She ended up having meningitis, she seized in the ER, was on life support system for a week. She lived but suffered brain damage and went from college student to life time 10 year old IQ. My colleague was sued and settled(because she was caught changing the patient records, not because of quality of care). Nonetheless, to this day, that colleague of mine, sends a disproportionate of her flu patients to the ER. The point is, when you base care on what "your" doctor thinks is best, it may deviate from the standard of care based on what that individual doctor has experienced.

[...]

curious2 says

Why not just take a photo with a ruler next to it and check it again in a few weeks to see if it's changed?

I was going to say that the code would also depend upon the size of the mole. The bigger the mole, the more expensive it is.