Patients lost in the maze

Millions of patients are paying medical bills they don’t actually
owe after being confused about the practices of "balanced billing," according to a recent Business Week report.

The story goes onto discuss how it’s illegal for doctors, hospitals or labs to bill patients for the difference if they deem the insurance payment too low, but that it happens routinely to the tune of $1 billion each year.

Around the time that story first ran, THCB received this email from distraught reader, Paul Evans of Arizona:

I recently went into an emergency room at a local hospital in Scottsdale, Ariz. The doctor asked several questions and diagnosed kidney stones. To confirm this, he ordered a Cat scan and X-rays. While there I was given morphine for the pain. Two hours later, I was discharge with a prescription for pain pills and a strainer to examine my urine for the stone I would pass. I am insured by Aetna. Aetna received a bill for $6,000 and paid $4,000. I am now receiving bills for the remaining $2,000. All this for two hours in the emergency. Do I have to pay these bills? This is balance billing I think. What are my rights?  Help!!

This isn’t balanced billing. Paul’s health plan required him to pay a share of cost and he was unaware of how much. This lack of understanding traps consumers in balanced billing practices.

Paul’s lack of understanding of his health benefits is far from an isolated case. As Jane Sarasohn-Kahn wrote here a few months back, one survey found that only half of the respondents reported understanding their benefits.

The health care system remains a mystery to most people even the
well-employed and highly educated. Many insured people don’t know the
details of their health plans until it comes time to use it — often in
emergency situations.

I e-mailed Paul back to see if he knew he had a share of cost, and how great of a burden the $2,000 bill is for him. Here’s what he wrote:

You are correct I was unaware that I would have to pay such charges. I have the savings to pay, but so many others do not. Also my concern is that when you are in pain, you don’t discuss treatment and costs with the doctor. Was a Cat scan really necessary? X-rays? I think that the hospital takes advantage of pain and ignorance to run up the bill. As I say, I can pay these charges, but what about others who can’t?

Just as Paul’s shock at his high ER bill isn’t unique, neither is his combined mistrust of the hospital, doctor or health plans’ motives.

8 replies »

  1. “You can get a CT scan to check for calcified arteries for about $200 (a good preventative care but not covered by insurance).” – I don’t think that is accurate price, and why are you talking about calcified arteries in this context?

  2. I’m a pre-med student. From shadowing a nephrologist I recall that x-rays are a bit of a lucky catch to find a kidney stone (which may be improper recall, as could the rest of what I’m about to state). CT Scan should be a good bet. You can get a CT scan to check for calcified arteries for about $200 (a good preventative care but not covered by insurance).
    It sounds like the doctor was acting as a salesman and took the appropriate first step–qualify your sale. Good insurance, solid job = bill, bill, bill!
    Go to a nephrologist next time. And ask how good of a radiologist would you need to determine the presence of kidney stones on whatever imaging he orders. It’s my understanding you have to get a view in which the stones position themselves nicely so you can say that bright spot shouldn’t be there!
    If the strainer looks like the same one your wife uses in the kitchen, just use it. You can put it in the dishwasher anyhow and so long as you don’t have Urinary Tract Infection, your piss is cleaner than most of what you eat.

  3. The question I have is, where does the responsibility lie for educating patients about their insurance coverage? Insurance companies? Employers? The patients themselves? If we want patients to be effective consumers, we have to figure out how to get the education right.
    Transparent pricing is already starting to happen. The problem is, each doctor/hospital’s price for each service is different for each insurance with which they have a contract. Posting the full charge is only a worthwhile exercise for those patients that have no insurance, or an insurance that is not accepted by the doctor/hospital (in which case, balance billing is permitted).

  4. One of the big issues is the over use of labs and tests. Physicians are forces to test and scan for everything because God forbid they miss something and the patient is then suing for millions.

  5. Sarah,
    Interesting to learn that at Brigham and Women’s Hospital in Boston, the price of a medical test shows up on the ordering doctor’s computer. Glad to know they have a CPOE system. It’s a good idea, too.
    But remeber, retail price [charge] is an economic artifice. It has no relation at all to actual [wholesale] cost.

  6. Alanna, I think you raise a very interesting point and one that doesn’t often get discusses. I have a doctor friend that works at the Brigham and Women’s Hospital in Boston and each time he orders a test, the price shows up on the computer. It’s a good reminder for him and other doctors that price is important — it’s important to the hospital’s bottom line, the government’s bottom line and the individual’s bottom line. Yet, as you say, many individuals feel uneasy, afraid or maybe don’t even know they can talk about costs with their doctors.

  7. I believe the term is correct in Paul’s note – “balance billing” rather than “balanced billing.” It refers to the fact that the institution/provider bills for the balance remaining.
    Notwithstanding, ER bills remain astronomical.

  8. Americans (and maybe other countries, I don’t know) tend to feel awkward and embarassed talking to doctors about price and cost. Considering how cloesly prosperity and health are linked, it hurts us. Why don’t doctors just post price lists? And how can we get more comofortable asking cost questions?