The story starts, like all great stories, with a nasal endoscopy.
There I was, sitting in an otolaryngologist’s office, complaining of copious mucus, sinus pressure, and occasional headaches.
In my state of sickness, I didn’t have the bandwidth to do more research than simply figuring out that this particular doctor was in-network. I figured it would be a typical investigation to assess what was wrong, so I didn’t check pricing beforehand. (“It’s one office visit, Michael, what could it cost, $250?”)
Before I knew it, I had a tube up my nose, figuring that this was simply a standard part of the investigative process during the office visit.
As we were wrapping up, the doctor mentioned that he would be giving me a Neilmed Sinus Rinse bottle to take home, as they had them lying around the office. I panicked: “Is that going to be an extra charge?” He looked at me like I was insane. I persisted: “This has happened to me before, you get something to take home, like crutches, and then you figure out that the front office has billed you way more for something you could have gotten on craigslist for a couple bucks.” He assured me it was free.
Imagine my surprise when I received the bill from my insurance. The sinus rinse bottle was a red herring. The real issue was that my procedure was billed not as an office visit, but as “nasal endoscopy”. Because he used an implement for less than a minute to perform the diagnosis, I had the pleasure of paying $450 on top of the standard office visit.
After discussing the story with a few friends, I learned that I wasn’t alone: they recounted similar stories from a variety of surprise procedures. I started doing research: unexpected bills are a common customer complaint, and my $450 upcharge pales in comparison to some of the billing horror stories I’ve read online.
In order to figure out how to fix it, let’s illustrate how things should work by using the complete opposite of a nasal endoscopy: delicious Indian food.
The paneer tikka masala analogy
Say I want paneer tikka masala. Currently, I can go to Yelp, find all Indian restaurants near me, consult their menus, verify that they do in fact have paneer tikka masala on the menu, and consult the price. Then, taking the price into account, in conjunction with other factors like rating, location, and opening hours, I decide which restaurant to go to.
Once at the restaurant, the waiter might inform me that they’re out of paneer tikka masala, but they have lamb biryani instead. I can easily consult the menu right then and there, verify the price of lamb biryani, and decide whether I’d like to have that.
While I’m eating my lamb biryani, the waiter might try to upsell me on garlic naan. I can quickly and easily ask him if there will be an extra charge, receive the exact amount, and decide whether the upsell is worth it.
Replicating the paneer tikka masala analogy within our current system
Here’s what happens if I try to replicate this within the medical system:
Say I want an office visit with an otolaryngologist. Because I live in New York City, I can go to Zocdoc, find all providers near me, verify that they take my insurance, and see when their next available appointment is.
To get pricing, my insurance, United HealthCare, contracts with Rally, who can tell me exactly how much I’m going to pay for each procedure. The problem is that the data isn’t complete and not all procedures are listed. A nasal endoscopy isn’t on the list, for example.
If I can’t find pricing, I have to call the office and speak to the front desk. In my experience, the front desk will almost never tell you how much you’ll pay out of pocket with your insurance. They’ll claim you have to call your insurance company to find out. However, one time I was told by a front desk worker that this was BS, and if you gave them your insurance member ID they could look it up for you. In any case, you’re likely just going to get cash prices, and even then it’s hard to get this information out of them. I’m often told “oh, it depends on which procedures the doctors do” or “we can’t tell you that up front”.
I arrive at my appointment. There’s no menu at the front desk which explains the pricing. I undergo the exam blind, completely unsure as to which billing code I’m currently operating under. Often, I just forget entirely about billing, because I’m distracted by questions the doctor is asking and the fact I’m apparently about to have a tube up my nose. At no point am I stopped to explain that this is a different procedure than a routine “office visit”.
I go home, get the bill a week later, and freak out.
How we can fix it – short term
Barring any longer-term legislation changes, it seems patient self-advocacy is the only way out:
- Compare providers using your insurance website, Zocdoc, and phone calls to find the best price/quality ratio
- Before the visit, ask the front office staff which billing codes are typical for the requested procedure, and what they generally entail
- When the provider brings out an implement or suggests a procedure that does not sound like standard operating procedure, stop him or her and ask if there will be an additional charge. Do not be shy about doing this multiple times during the visit.
- If you get a bill that has unexpected services performed that were not correctly explained to you, appeal it with the provider or through your insurance and explain that you’re refusing to pay unless the billing code is changed or they negotiate down in price.
How we can fix it – longer-term
The first clear issue I can see is that there are four parties involved, not all of them communicate with each other, all have different incentives, and the only one that has your best interest in mind is YOU.
- You – decides which provider to go with
- Provider – performs the work, doesn’t really care about billing
- Front office – figures out which billing codes apply to the work performed, bills insurance
- Insurance company – processes the claim, figures out eligibility, sends you the bill
The longer-term solution would involve getting these parties on the same page and forcing them to be more transparent/communicate with each other:
- Offices should be forced to display cash-pricing on their websites and in their facilities (like a restaurant menu)
- Insurance companies should do a better job of getting complete procedure information from providers
- You should be shown the “menu” before the visit and explained what your likely billing codes will be before you agree to service
- Providers should have checkpoints where they stop and explain that such-and-such procedure will bump you up into a different billing code before performing it. You should be able to have a “time out” during the visit where you are free to debate the pros and cons of undergoing the additional procedure with them, taking the additional price into account.
- You should leave the office with an exact idea of what you will be billed for, not be surprised when you receive the bill a week later.