Friday, May 3, 2013

Healthcare and Billing Practices


I just got my tonsils out two days ago and will be graduating dental school in a couple weeks, so I've been thinking a bit about healthcare lately. I just got a bill today from an ENT. I had gone to the ENT to have her look at my tonsils. In the process of the exam, she checked my ears (not my chief complaint). She said something along the lines of "Hold on, I'm going to just get a bit of earwax out," swung some sort of scope over, and within a minute the earwax was removed and the exam continued.

At the time I thought to myself, "That's a nice gesture. She saw something that needed taken care of that I wasn't really aware of, and she did it." Then the skeptic in me thought, "I wonder if I am going to be billed for that." Sure enough today I got a bill showing that $179 was billed to the insurance, while only $55.03 was allowed. Since I hadn't met my deductible, my portion was $55.03.

Alexia and I were just talking the other day about how odd it is that providers bill a large amount and then it always seems to be adjusted to a "contractual discount." So is the insurance shortchanging the provider by reimbursing less or only allowing a lower amount to be billed? Or is there fee inflation going on causing uninsured people to subsidize the contractual "discounts" insurance companies have?

Furthermore, should you as a provider inform patients of every fee they are going to get charged with? I struggle with this as a dental student. Do you inform the patient about the cost for radiographs and give them an option as to whether they want to get them or hold off for another six months, or do you make your opinion and perform the procedure? Will you be stuck with indecisive patients, who may be unable to understand and weigh the cost/benefit of a preventative radiograph vs. a possible cavity? Should a patient be financially counseled before all billable procedures? And what about billing not for service, but for complexity/time spent plus materials like a mechanic? My procedure to me did not seem like a $55 ear wax removal, certainly not a $179, but then again, I can't judge ENTs, the cost of equipment, cost of schooling, and complexity of procedures.

I guess overall the question is, what level of autonomy and trust should patients be given in their health care? As a patient, I feel capable with my medical knowledge, and the resources available to me, to be fairly autonomous in my cost/benefit analyses and to largely decide what I should and shouldn't have done if given the appropriate diagnoses and professional opinion. Many others may feel differently and may prefer to have the provider take the wheel. However, overall I am in favor of more transparency on pricing, procedures to be performed, potential risks, and especially complications that happened during the procedure, so that the power is in the patient's hands. If the patient decides that they would like to be less involved in the process, at least they were informed.

The difficulty with this is the implementation. I've heard of providers posting prices online, which sounds like a good idea. I feel like there needs to be some informed consent from a financial aspect where the patient either agrees that he or she will either not be aware of every billable procedure before it is performed, or where they are provided with prices and indicate that they would like to be informed of what procedures will be happening and that the onus is on them to get involved if they have a concern. Ultimately, providers shouldn't be expected to unreasonably compromise care because a patient wants to apply their Slickdeals mindset to their healthcare, but I think patients are currently losing a battle against autonomy, confusing medical codes, and convoluted insurance practices. What do you think?