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surprise medical billing ban nears


hegemony
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Some of this makes perfect sense, especially for emergency services.

 

It also makes no sense for a provider in the possession of someone's insurance information not to provide a written cost estimate prior to performing non-emergency services, and it would make sense to require insurance information at the time the appointment is made to ensure that this happens.  My dentist gives me a written cost estimate and breaks out my portion prior to performing services.

 

This would substantially solve the "surprise billing" problem for non-emergencies.  

 

Some of the rest of this.... yeesh, especially for people in rural / outlying areas where there my be no network specialist for what they need, so various specialists travel to a local clinic or hospital a few times a month.  These rules will reduce the incentive for providing this type of care in places where there are no other options.

 

Also, I didn't read what constitutes "emergency services," but in Southern California people pour into emergency rooms to get care for sore throats, fevers, etc.  And they also know that to avoid the hours-long wait, all they have to do is say "chest pain," and that moves them to the front of the line.  

 

A few years ago I picked someone up from an emergency room in San Diego and the waiting room was teeming with people filling out Medi-Cal applications on phones that were newer and nicer than mine.

 

Edited by cv91915
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55 minutes ago, cv91915 said:

Also, I didn't read what constitutes "emergency services," but in Southern California people pour into emergency rooms to get care for sore throats, fevers, etc.  And they also know that to avoid the hours-long wait, all they have to do is say "chest pain," and that moves them to the front of the line.  

 

It's like this everywhere.

 

55 minutes ago, cv91915 said:

A few years ago I picked someone up from an emergency room in San Diego and the waiting room was teeming with people filling out Medi-Cal applications on phones that were newer and nicer than mine.

 

It's funny you mention this. My sister, who is a nurse, says the best place to see the latest offerings from Apple and Samsung is the ER. The department that handles hardship cases is another good place. Can't pay the $500 bill, but the rug rats you brought with you have the latest Jordan's.

 

Now if you told me you got hit with a $50k bill, then I might turn on my sympathy spigot. 

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Expensive brand named shoes like Jordance are easy to identify but how can anyone determine whether someone has the latest offering of a Samsung or IPhone without asking the person? I have an inexpensive Android Tribute Monarch phone that I paid about $100 for it. I see my friend's phones and they look all the same. I usually ask them what they have just out of curiousity.

 

 

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3 hours ago, StarkRaven$ said:

Expensive brand named shoes like Jordance are easy to identify but how can anyone determine whether someone has the latest offering of a Samsung or IPhone without asking the person? I have an inexpensive Android Tribute Monarch phone that I paid about $100 for it. I see my friend's phones and they look all the same. I usually ask them what they have just out of curiousity.

 

 

 

I'm more familiar with iPhones, but if you can't tell the difference between a 4 and an 8 and a 12 Max Pro it's either complete indifference (which is fair, I'm not a phone aficionado either, but the generation is still pretty obvious to me), or you should have your eyes checked.  :)  

 

My current XR is vintage 2018, and it doesn't have eleven(?) spooky eyes on the back like the new ones do.  

 

Not as familiar with the Samsungs, but for some time the folding screens were a dead giveaway that you weren't looking at a Jitterbug that Grandma picked up at Radio Shack.  

 

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24 minutes ago, cv91915 said:

 

I'm more familiar with iPhones, but if you can't tell the difference between a 4 and an 8 and a 12 Max Pro it's either complete indifference (which is fair, I'm not a phone aficionado either, but the generation is still pretty obvious to me), or you should have your eyes checked.  :)  

 

My current XR is vintage 2018, and it doesn't have eleven(?) spooky eyes on the back like the new ones do.  

 

Not as familiar with the Samsungs, but for some time the folding screens were a dead giveaway that you weren't looking at a Jitterbug that Grandma picked up at Radio Shack.  

 

My eyes were checked last month and eyewear perscription is up to date.  However, if a stranger is sitting across from me say, 4 - 6' or so, and is looking down at their phone, all I see is a smartphone shaped in a rectangle.  I don't stare and and try and see the back of their phones, etc. to determine what type of phone do they have.

 

My husband just recently was forced to give up his 3G old flip phone for a 5G smartphone or he'll lose coverage next year but that's getting off topic.

 

 

 

 

 

 

Edited by StarkRaven$
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11 minutes ago, StarkRaven$ said:

My eyes were checked last month and eyewear perscription is up to date.  However, if a stranger is sitting across from me say, 4 - 6' or so, and is looking down at their phone, all I see is a smartphone shaped in a triangle. I don't stare and and try and see the back of their phones, etc. to determine what type of phone do they have.

 

My husband just recently was forced to give up his 3G old flip phone for a 5G smartphone or he'll lose coverage next year but that's getting off topic.

 

 

 

 

 

 

 

Then it's indifference, which is fine.  :)  

 

Just because you can't tell doesn't mean no one can. Plus, you asked and I was just answering, and the emoji I chose normally conveys some element of good nature, for clarity, when there is room for interpretation.

 

PS:  The woman that was sitting across from me here at the airport when I typed that was using an iPhone of the same generation as mine.  :) 

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23 minutes ago, cv91915 said:

 

Then it's indifference, which is fine.  :)  

 

Just because you can't tell doesn't mean no one can. Plus, you asked and I was just answering, and the emoji I chose normally conveys some element of good nature, for clarity, when there is room for interpretation.

 

PSI:  The woman that was sitting across from me here at the airport when I typed that was using an iPhone of the same generation as mine.  :) 

People make a lot of assumptions about others based on bias. My family has been lied about by someone who thought they were an expert but didn't know what they were talking about. They were wrong and simply were spreading hate that was false about us. It all had to do with what they assumed was entitlement and judgement. So yes people cheat but not everyone does. There lies the difference.

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5 hours ago, StarkRaven$ said:

Expensive brand named shoes like Jordance are easy to identify but how can anyone determine whether someone has the latest offering of a Samsung or IPhone without asking the person? I have an inexpensive Android Tribute Monarch phone that I paid about $100 for it. I see my friend's phones and they look all the same. I usually ask them what they have just out of curiousity.

 

 

 

It's a geek thing.

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This needs to happen for all services.

 

It is patently unrealistic for patients to not understand that if you have Xrays or lab work done (emergency or not) that there will be secondary bills from a radiologist or pathologist interpreting those tests to issue results to the ordering physician that generate bill(s).  It is also patently ridiculous that patients get hit with a shocking out of network charge for those contracted services when they have NO choice on who does the readings and whether it is a contracted service or not.  Especially in an emergency setting.  

 

If you are having chest pains and go to the ER and need emergency bypass and the only surgeon is out of network there are already policies and laws in place to prevent charging out of network costs when the patient has no options in a TRUE medical emergency.  However, if you need elective surgery and CHOOSE an out of network surgeon it is no "surprise" that the costs are more and you bear them for making that choice.  

 

The major issue isn't as much "surprise" billing as patients who make NO effort to understand their coverage and how to best use it for their health AND financial benefit.

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2 hours ago, CreditSucksNot said:

 

The major issue isn't as much "surprise" billing as patients who make NO effort to understand their coverage and how to best use it for their health AND financial benefit.

I agree but to be fair, reading the coverage benefits is clear as mud when it comes to costs. Also, I just went to my provider's website to find out where I can get blood work drawn while traveling and the site keeps crapping out when doing a zip code search.

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4 hours ago, CreditSucksNot said:

The major issue isn't as much "surprise" billing as patients who make NO effort to understand their coverage and how to best use it for their health AND financial benefit.

 

Sorry, but the major issue for us has been "surprise" billing ... occasionally because a hospital uses a radiologist or other in-house professional who isn't a "participating provider".  Little to do but grin and eat the bill.  Then you have a situation such as are currently dealing with an independent outpatient lab services provider who is "affiliated" (received orders and electronically reports results) with the hospital ordering lab work ...

 

First lab run is processed as an in-network provider by Blue Shield, but then the provider aggressively tries to balance bill us.  Net lab run, performed at the same location as the first, is run through a different affiliate and is processed as out-of-network by BS.  It's taking patience to get this squared away, but we're confident we'll only be on the hook for in-network liability.

 

There shouldn't be any guesswork about this stuff and I'm starting to think that a provider should be on the hook to provide a "good faith estimate" of cost and patient liability before services are provided.  There are no mysteries involved here and adequate systems should be place to produce such an estimate.  I'm not a huge fan of government regulation, but the healthcare system seems to be begging for intervention on this count.

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I reread my EOB's and EOC for my HMO Kaiser plan and when it comes to plan costs, all it provides is the meaning of out-of-network provider/non-contracting provider in its glossary. It does not address surprise billing but then I live in California where this is against the law for such a medical plan (praise God and pass the potatoes).

 

Medicare plans forbid surprise billing if you are provided care in a in-network plan facility. Currently 93% of primary doctors accept Medicare but only 70% are accepting new patients. Non-contracted speciality providers i.e. lab work and anesthesiologists are still allowed to balance bill patients in many states under emergency situations and this new law is trying to address this. I totally understand what @hdporter means about surprise billing. It's horrible and can be in the thousands of dollars. 

Edited by StarkRaven$
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While we are on the subject of surprise billing, bean counting etc.

 

My wife recently needed a prescription. Doctor told her most likely, from his experience, insurance would not cover it, or if they did cover some, the out of pocket would still be insane. When I went to Walgreens to have it filled, I kid you not I could almost see dollar signs of joy in the eyes of the tech I handed the prescription to. When she ran everything through the computer, she had a confused look, and had the pharmacist take a look. He shook his head in disbelief. Our out of pocket was $17 on a $1200 medicine.

 

I went home and shared the experience with my DW. She proceeded to school me on pharmacy profitability. She told me it's all about volume of sales, and why every Tom, Dick, and Harry pharmacy is constantly advertising to get you to bring your prescription business to them. Doesn't matter if it's Walgreens, Walmart, or a mom and pop. All the behind the scences contract, and pricing negotiations would drive the average person insane.

 

She works for a large grocery store chain. Grocery stores have it the worse when it comes to making a profit with their pharmacies, much less breaking even. The pharmacy at a grocery store is a loss leader 98% of the time. Only time a grocery pharmacy turns a profit, at any given location, is if they get lucky and get a customer needing cancer drugs, or some exotic drug.

 

So why bother having a pharmacy in a grocery store? It's like any other competitive business. If your competition down the street offers it, then you better offer it too.

 

Back to that $1200 medicine. That's most likely MSRP you would pay out of pocket if you had no insurance at all, not the price the pharmacy paid on the back end.

 

To borrow a line from @StarkRaven$ ...............(praise God and pass the potatoes) we have great insurance.

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While we are on the subject of surprise billing, bean counting etc.  

My wife recently needed a prescription. Doctor told her most likely, from his experience, insurance would not cover it, or if they did cover some, the out of pocket would still be insane. When I went to Walgreens to have it filled, I kid you not I could almost see dollar signs of joy in the eyes of the tech I handed the prescription to. When she ran everything through the computer, she had a confused look, and had the pharmacist take a look. He shook his head in disbelief. Our out of pocket was $17 on a $1200 medicine.

 

I went home and shared the experience with my DW. She proceeded to school me on pharmacy profitability. She told me it's all about volume of sales, and why every Tom, Dick, and Harry pharmacy is constantly advertising to get you to bring your prescription business to them. Doesn't matter if it's Walgreens, Walmart, or a mom and pop. All the behind the scences contract, and pricing negotiations would drive the average person insane.

 

She works for a large grocery store chain. Grocery stores have it the worse when it comes to making a profit with their pharmacies, much less breaking even. The pharmacy at a grocery store is a loss leader 98% of the time. Only time a grocery pharmacy turns a profit, at any given location, is if they get lucky and get a customer needing cancer drugs, or some exotic drug.

 

So why bother having a pharmacy in a grocery store? It's like any other competitive business. If your competition down the street offers it, then you better offer it too.

 

Back to that $1200 medicine. That's most likely MSRP you would pay out of pocket if you had no insurance at all, not the price the pharmacy paid on the back end.

 

To borrow a line from [mention=177795]StarkRaven$[/mention] ...............(praise God and pass the potatoes) we have great insurance.

 

PharmaHo (wife), works at one of the top 5 pharmaceutical companies in the world and gets their medication at production cost. We help a friend get Lipitor which retails, without insurance, for about $130 for 30 tablets. With insurance, it will probably cost you $35, assuming it's not generic. PharmaHo gets it for $0.90.

 

Production cost on almost every medication is under $0.05 per dose. There are exceptions, though, for some medications that are very new and rarely prescribed, but those are extremely few and far between. Even then, production cost may be as high as $0.50 per dose.

 

The real killer is R&D costs. Even then, they generally recover R&D costs within the first few years on the market. On your $1,200 medication, assuming it's relatively new on the market, the pharmaceutical company was making a 50% profit at $400. The rest went to the middlemen and the pharmacy.

 

Just think about it. PharmaHo's secretaries earn $65k a year. WTF does that money come from? The only enterprise more profitable than a drug company is a drug cartel. My secretary only earns $42k, and that's with the promotion after their leg got blown off.

 

For some, they'd need to tweak @StarkRaven$ quote to something like "Raise dogs, and pass on toes."

 

 

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2 hours ago, PotO said:

PharmaHo (wife), works at one of the top 5 pharmaceutical companies in the world and gets their medication at production cost ...

 

The real killer is R&D costs. Even then, they generally recover R&D costs within the first few years on the market. On your $1,200 medication, assuming it's relatively new on the market, the pharmaceutical company was making a 50% profit at $400. The rest went to the middlemen and the pharmacy.

 

First I recall mention of your wife @PotO  (Although a lot "gets by me" these days ... ;) )   My dearest, Bev, heads up the market research unit of the rare disease segment of her pharma firm (recently merged into a larger firm, nudging that firm into the "top 10").

 

She's impressed upon me just how much R&D is spent on drug prospects that end up circling the drain.  (Only about 10% of drugs under development make it into the marketplace.)  The drug marketplace is extremely competitive with every company not only striving to develop the next "Lipitor", but also now delving into treating illnesses that affect a tiny segment of the population.  We're not talking "orphan" drugs here (those for which the market is so tiny that drawing a profit is next to impossible).  But instead ones for diseases that impact only a handful of people for every million in population (rare diseases).

 

There are no guarantees in drug development that you'll end up with a drug that is both effective and the most attractive among alternatives in terms of administration, side effects and cost.  On the surface, there are many measures on which it's appears easy to criticize pharmaceutical companies.  But when you're the beneficiary of a life saving medicine, the balance starts appearing to be more evenly weighted.

 

The perverse thing about Bev's illness, CIDP (Chronic inflammatory demyelinating polyneuropathy), is that the medicine with which she's now being infused for 4-1/2 hours a month is one developed by her former employer, and one for which she was involved in the primary market research several years ago.  She talks about how, when engaged in that research and talking with study patients she remarked, "I feel so bad for these people!"  She never dreamed she might be one of them!  (FWIW, the incidence of CIDP in the population is approx 3 in 100,000.)

 

 

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First I recall mention of your wife [mention=136067]PotO[/mention]  (Although a lot "gets by me" these days ... )   My dearest, Bev, heads up the market research unit of the rare disease segment of her pharma firm (recently merged into a larger firm, nudging that firm into the "top 10").
 
She's impressed upon me just how much R&D is spent on drug prospects that end up circling the drain.  (Only about 10% of drugs under development make it into the marketplace.)  The drug marketplace is extremely competitive with every company not only striving to develop the next "Lipitor", but also now delving into treating illnesses that affect a tiny segment of the population.  We're not talking "orphan" drugs here (those for which the market is so tiny that drawing a profit is next to impossible).  But instead ones for diseases that impact only a handful of people for every million in population (rare diseases).
 
There are no guarantees in drug development that you'll end up with a drug that is both effective and the most attractive among alternatives in terms of administration, side effects and cost.  On the surface, there are many measures on which it's appears easy to criticize pharmaceutical companies.  But when you're the beneficiary of a life saving medicine, the balance starts appearing to be more evenly weighted.
 
The perverse thing about Bev's illness, CIDP (Chronic inflammatory demyelinating polyneuropathy), is that the medicine with which she's now being infused for 4-1/2 hours a month is one developed by her former employer, and one for which she was involved in the primary market research several years ago.  She talks about how, when engaged in that research and talking with study patients she remarked, "I feel so bad for these people!"  She never dreamed she might be one of them!  (FWIW, the incidence of CIDP in the population is approx 3 in 100,000.)
 
 


If I've said it once, I've said it a million times -- listen to Bev!

Each pharmaceutical company has a different strategy. Pharmaho's company uses what I call either "The Pimp Strategy" or simply "Ho, Ho, Ho". They look for smaller companies that are on the verge of breaking through with a blockbuster and then simply gobble them up.

R&D is exceptionally expensive and even though you have what will ultimately become the miracle cure, it takes a gazillion bucks to make it across the finish line. So Pharmaho's company simply buys them out, rides that horse across the finish line and wins the race.

If you look at the biggest hits the company has had, almost all of them were acquired from companies that were incapable of bringing the drug to market on their own. They very recently used the Ho, Ho, Ho strategy to wind up with one of the leading COVID-19 vaccines and earning a gazillion bucks in the process.


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Off topic but the manner in which [mention=31973]hdporter[/mention] [mention=164649]TheVig[/mention] and [mention=136067]PotO[/mention] speak about their wifes demonstrates good marriages. I admire that.

You need to define "good".


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Definitely! But not too much.

I mean, if she thinks I love and respect her too much, she will then start asking me to help clean the house, do the laundry and do the grocery shopping. Can't have that!

So every once in a while I have to find something to disagree with her over.


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21 minutes ago, PotO said:


Definitely! But not too much.

I mean, if she thinks I love and respect her too much, she will then start asking me to help clean the house, do the laundry and do the grocery shopping. Can't have that!

So every once in a while I have to find something to disagree with her over.


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Ha! I do the same thing. Don't want to be mansplained to death.

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Ha! I do the same thing. Don't want to be mansplained to death.

Six of one, half dozen of another.

I never explain anything to PharmaHo because by not explaining it makes her think that I think she's smart enough to understand everything. In reality, I don't explain because she won't understand and I really don't care whether she does or not as long as she just listens and STFU.

On the flip side, she never explains anything to me because she thinks I won't understand anyhow. The reality is that I do understand and I just don't GAF.

Marriage is all about give and take.


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