Doctor Surprise Billing

This doctor is a bit much; but, he gets a point across which I have been making also. The issue(s) Dr. ZDogg  is describing about what commercial healthcare insurance, Medicare Advantage plans, hospitals, and now doctors are doing needs to be told over and over again. Schumer and the Senate have to release the portion of the House Budget bill that dealt with Surprise billing.

ZDoggMD reacts to ridiculous medical bills, MedPage Today, February 6, 2020

Going to her PCP located in Manhattan, a woman complains of a sore throat. Forget the Manhattan part of this as various versions (surprise billing)  of this situation are happening everywhere. The doctor swabbed the throat, sent it off to the lab, ordered some tests, and then gave her a prescription for antibiotics. She took her meds and went on vacation feeling better.

The tests came back negative. She later received a bill for ~$26,000.

The  lab was out of network which usually results with insurance only paying a portion of the bill and the patient the balance unless the insurance negotiates a lesser charge (hospital 3rd party employees) which they will pay. This is another version of Surprise Billing, not in a hospital setting, which we have heard so much about, and the patient gets screwed with the balance of the Surprise Billing.

More Information

The lab was out of network but it was a part of the employer the PCP worked for also. Usually doctors use the hospital they are affiliated with to run tests or do lab work which are also in network (today). I suspect more hospitals will relegate lab work to 3rd parties to cut costs and improve profits.

There was a time when I had catastrophic insurance which only paid 50% of costs. I had pneumonia and really could not afford to go to my PCP at $150 (then) as I was out of work. My PCP was not sympathetic and wrote me script to take to the hospital for imaging and another test. I called the U 0f M hospital and talked to a clerk there about cost. He finally told me to go to Quest (outside lab) and they would be half the cost in doing imaging, etc. U of M has some major Overhead to pay for today.

By the way, Blue Cross Blue Shield paid almost all of the bill for this lady with the sore throat.

Even More Information and a Hypothetical

The Insurance company must apply 80% of healthcare insurance premiums to actual care. and 20% to Overhead and Profit. Dr. ZDogg states most of the tests were not needed such as a Pan-Viral test when a rapid-strep swab would do. Dr. ZDogg contends this was a virus and the most one should do is the swab the throat or just wait to see what develops .  .  .   this sounds familiar to me as a patient too.

The hypothetical? Lets say at the most, what was done should be about $1000 or $800 to actual care and $200 to Overhead and Profit. Multiple this by 26 and see what it amounts to. In Dr. ZDogg’s words: “What if we make the pie bigger and 3% of a bigger pie is more money? What if we actually let people overcharge for procedures they don’t need? Then all we have to do next year is raise the premiums to cover the actual medical cost, which is now higher, and then we make a higher amount of profit.” That was the untoward side effect of the government policy on this, which, by the way, happens with many policies that are top-down. You can’t predict what happens and then it happens. ”

I would like to think doctors, hospitals, and healthcare insurance companies are not prone to this. Yet we have record of numerous surprise billing instances by hospitals, this is an example of one by a doctor. Medicare Advantage plans are over billing CMS for treatments running totals up to $10 billion per year. And what about Commercial Healthcare Insurance? I have not heard of insurance pushing back on over charges. Usually, they reject a bill or a portion of it and the patient pays the balance.

And what Happens as a Result?

Again Dr. ZDogg:  “Guess what’s going to happen to her insurance premiums next year? They’re going to go up by 10%, 15%, 20 percent. And what will happen at employers around the country who are paying most of the bill? They’re going to drop or keep wages flat (happening today). Healthcare becomes a financial albatross with collusion between healthcare providers charging a bunch of money and insurance companies paying it, hospitals overbuilding, overcharging, and doing stuff we don’t even need.  The results of these money games are a minority of people getting rich and everybody else’s wages staying stagnant. 1 in 5 Americans have collection agencies coming after them for medical bills that are inflated and unnecessary.

Dr. ZDogg recommended exposure to sunlight might cure the problem.

The patient; “I made it very clear [to the doctor’s office] that I was unhappy about it.” And told them I would report the doctor to New York state’s Office of Professional Medical Conduct. She also reached out to “Bill of the Month,” a joint project of NPR and Kaiser Health News. After a reporter started asking questions about the bill, Blue Cross and Blue Shield of Minnesota stopped payment on the check it issued and is now investigating.

The bottom line to this is, it should have never got this far or even happen.

Recently it was disclosed Michigan No Fault Accident Coverage was paying an ~289% of Medicare rates to hospitals and clinics to care for patient injuries suffered from car accidents or automobile accidents. No Fault coverage will die in a few years as the new legislation sponsored by Quicken Loans Dan Gilbert and Michigan Repubs have allowed people to opt out or take lesser coverage which will now pay hospitals and clinics 220% of Medicare rates. No Fault would not disclose what it was paying caregivers. Another surprise which should have never happened . . .

This story is from December 2019 and was in NPR For Her Head Cold, Insurer Coughed Up $25,865, NPR, Richard Harris.

Paperwork: Manhattan Specialty Care
$26,000 for a Throat Swab?!, ZDoggMD, MedPage Today, February 6, 2020
The Doctors Who Bill You While You’re Unconscious, The Atlantic, Olga Khazan, February 11, 2020