Friday, August 15, 2014

Kliff Diving with Sarah

Recently, longtime foil Sarah Kliff (she who couldn't understand her own Explanation of Benefits) set out to enlighten folks in flyover country on how to negotiate better prices for their health care:

She then goes on to offer five steps one might take to entice the provider to offer a price break.

As someone with many years of first-hand experience actually running medical practices, here's my take on her efforts.

First, Miss Kliff is “surprised” that, after visiting a medical provider, having been provided medical services, and receiving a statement after each visit outlining all the various codes and associated costs, she received a bill that somehow she was not expecting. I have dealt with many, many patients who are just as “surprised” as Miss Kliff that the doctor actually billed them for services rendered, and who actively seek ways to avoid paying their share. There’s nothing inherently “wrong” about asking for a break; the problem is that there are a lot of sound reasons why they’re generally not available.

And as a Medical Healthcare Executive, let me say that this is an extremely selfish attitude to take about your financial responsibility for medical care. The medical provider whose valuable services you received has bills to pay and he/she can only pay those bills by charging individuals for the care they provide. Was Miss Kliff forced to have the medical care or did she enter into a contract with the medical provider to pay for services rendered based on the guidelines of her insurance policy? This is why “negotiating down a medical bill” is nonsensical; by being in an insurance plan the price has already been negotiated down. When I set my fee schedule, I account for a discount based on the contract that I signed with the insurance company to treat their patients. That discount can range anywhere from 5% to 60%, depending on the usual and customary charge set by the provider and the amount negotiated to be paid by the patient/insurance company.

Miss Kliff outlines five steps that I would like to refute:

Step One, “stay in network,” is only viable for primary care. For specialty care, finance should not rule your decision, your medical care should.

Step Two, “negotiate beforehand,” is impossible:  the doctor cannot tell you what he is going to code in regards to your injury or illness until he has examined you and made a diagnosis. He then sets up a plan for care that is reviewed and modified at each appointment during the treatment. A treatment plan is individualized for each patient, so a provider is unable to quote the charge before treatment begins.

As to the suggestion of asking the provider to accept what an insurance company would pay, which insurance company price should apply? Each carrier pays a different amount for any service rendered. I received as little as $33.00 for a 99213 (mid level exam) and as high as $65.00 for the same code. If you want to pay the negotiated insurance price, buy an insurance policy; if not, pay your bill.

Step Three, “check your bill for errors.” If I’ve heard this once I’ve heard it a million times from patients unhappy that they had to pay for their medical care. The most common refrain was “my insurance company said you coded wrong”. In today’s electronic billing to clearinghouses this cannot happen. Any incorrectly coded claim is kicked back to be corrected before it even reaches the insurance company. In my years as a medical practice manager, I can attest that 98% of all problems were the fault of the insurance company, not the provider.

Step Four, “ask for a prompt pay discount.” This does not exist. When you sign a contract for an insurance policy you agree to pay your provider as soon as you are notified of your responsibility, thus you have already agreed to pay promptly. Why should I reward you for following the guidelines of your policy and hopefully the financial statement you signed when you entered into care with your medical provider of choice?

Step Five is “don’t be an asshole.” While this is always good advice, she does admit that, in the end, the doctor does not have to negotiate. In fact, she finally gets to the crux of the article, that “your bill isn't wrong, … you just think it’s too expensive.”

Here’s a news flash, Sarah: medicine is expensive. 
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