Accountable Care: Transparency of Fees Is Mandatory

thcbA personal account of a transaction that went very badly, and rules of Health Reform were not followed.

Accountable Care and associated transparency have not made it to Florida, at least not in this physician’s office.

I made an appt with an ENT (ear nose and throat doctor) for ear wax.  When I get there, I need to fill out 5 papers (EMRanyone??), and I’m told there is a $35.00 copay, which she says I can pay on my way out.

The 5 page HIPAA form says they can share my info with other providers who are trying to collect fees. But you only learn this, among other clauses, if you read the form that is tacked on the wall–it’s not in the form the patient signs.

I asked the receptionist how much the office visit is, and she said, “On your insurance there’s a $35.00 copay.” Yes, but is there an additional fee for removal of ear wax? How much? “We can’t tell you that until after the doctor sees you and marks what is done. And besides, we don’t know if you have satisfied your deductible.”  I tell her I have not, but because I have to guarantee payment if the insurance company denies anything, I’d like an estimate of charges.  She repeats the deductible statement and I say yes, I understand, but that’s a problem, as I haven’t satisfied my deductible so I need to know how much this will be. She tells me she will get the Office Manager (OM).

The Office Mgr (who is disguised in a clinical suit) tells me, “You have to sign this financial form before the doctor sees you because after, you will have received the services so you or the insurance company owe the money.” No problem say I, but I need an estimate, and I can’t sign a financial responsibility form that allows you to bill me if my insurance company doesn’t pay you in 45 days AND that tacks on a 30% interest fee, when I don’t know if I can afford it.

Two visits into the doctor’s lair, she comes out and says, “Dr M is more than willing to provide the services you need but he cannot be interrupted to tell you the costs of the services.” BOOM.

In my surveys and seminars, physicians tell me they want responsible, accountable patients.  I’m calm, I’m rational, I’m doing my best to be proactive and ensure they get their money.  But I can’t promise an open-ended checkbook, and I’m not on Medicare (which, if you read the financial form attached, seems the gateway to payment nirvana).  I’m a firm believer in people being paid according to contracts and promptly upon receipt of services.  But OM keeps telling me that they just don’t know what all this will cost.

So, I say, “How about if, when I get into the exam room, the doctor and I chat and then he tells me, before he does anything, what estimated costs will be billed?”  Note, I’m not asking negotiated fees, even, just retail pricing.

If you know me, you know I tried every which way to get some inkling of an estimate, including sharing my dermatologist’s willingness to tell me the price of the lab review for a specimen.

OM goes back once more and comes out with this:  “Dr M will gladly provide you the services you need but he is not responsible for knowing the prices of the services so he cannot provide those, and he doesn’t want to be interrupted with a patient.”

I left.  What would you have done??  BTW, I’ve attached the financial guarantee with my name blacked out so you can see what I was I told to sign.

11 replies »

  1. I too am a responsible, rational consumer who has read these unilateral agreements and took issue. I am now self-pay because I am so frustrated with insurance companies and doctor’s offices and hospitals. I refuse to use any provider that doesn’t have reasonable policies. One doctor asked me to electronically sign that I had read his forms but he hadn’t provided them. His office manager said that no one had ever asked to see the forms before signing the ipad! Dishonest and sloppy practices.

  2. Trish, you are so very correct. My goal is to seek the equilibrium between patient and system engagement. That means rewarding the patient for improving lifeskills and health mgt, including choice of care. For the system it means paying for Better, Smarter, Healthier, the HHS mantra and a great riff on value-based payment reform. It’s also why I’ll be speaking at a conference in May for the Specialty Health Orgs (dental, vision, hearing) because we can’t fix health outcomes without those folks. It’s also why I’m restating: we need the costs. Any costs. Negotiated? fine. Billing? fine. Because we, as patients and consumers, must make purchasing decisions that impact our whole life now–each of us has higher deductibles and more responsibility. OK, then share the info.

  3. I believe this is how most dental offices survive. Patients actually know the cost of procedures before having them, and most dental fees are collected at the rate they are billed. With medical care, is the “rack rate” ever actually collected from any patient in offices that accept insurance?

  4. Just an approximation. I knew I had a deductible. But it’s unconscionable betrayal of my trust to tell me you don’t know the billing amt BUT I’m responsible for all.

  5. Agreed. When told they may need a bunch of services, I asked for a range. Nope, they wouldn’t reveal. Pls don’t miss the paragraph on Medicare: they are DELIGHTED to bill for the patient, no worries

  6. This is an example of failure of the patient agency role of physicians. When we began to see patients treated so shamefully like this in the mid-80’s (this is @ when the world decided to jump into health care), we should have marched to the insurers office and protested “We can’t treat patients like this! We both have to work together so that we can figure out ways to quote prices! and total oop obligations”

    We should be doing the same thing now with respect to deductibles and co-payments. They are so high that the insurance product appears as a diaphanous filmy veil without substance. We should be howling and screaming. “You and we cannot treat our patients like this””Help”.

  7. Even if there are a number of different issues at different costs that the doctor would need to treat depending on what the examination reveals, he/she should at least be able to provide a cost range or an upper limit, which, if too expensive, the patient could decline and try to have done somewhere else for less or hope it resolves itself.

    Separately, a friend is undergoing a series of dermatology treatments to resolve a skin issue. The insurer was billed $500 per treatment and the allowable charge was $172.50. My friend told the doctor he has a $5,000 deductible and was told to just pay us $35 per treatment and let it go at that! If car insurance covered oil changes, Jiffy Lube would probably bill $500 instead of $25 or $30. What a system.

  8. Excellent commentary…and so true. As an oral and maxillofacial surgeon, I see patients with diagnoses and procedures that are billed medically and those with issues and procedures that are covered by dental benefits. I find it interesting and consistent that most patients expecting medical coverage to be responsible, have no interest in knowing their expected fees while most patients using dental benefits predictably do. The writer of this commentary would be an outlier in my office, but a welcome one. I have always appreciated, and accommodated all patients who want to know what my fee will be. I may not know what their benefit company will pay, but I know what my fee is. I also find that those with the interest to request that information are more often than not the kind of patient that will participate actively in their care, a trait we all appreciate. We need those that seek our care to have some knowledge of the cost of that care, and have the ability to use that in their healthcare decision making process.

  9. There is at least one dermatologist in NYC Manhatten who financially rapes patients, telling them that their health insurance will cover her fees, and goes aggressive on them when she does many extras that insurance does not cover.

    One of the problems is that insurance carriers do not disclose what they cover without lengthy tedious wait times.

    In elective care situations, doctors should disclose their fees, but they may not know what the insurer will pay, even with their expensive EHR systems.